Failure to Maintain and Inspect Emergency Generator System
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system, which is crucial for ensuring the safety and functionality of the facility during power outages. During a document review, it was found that the facility could not provide documentation for several required tests and inspections, including weekly inspections of battery electrolyte levels or voltage, a December 2024 test of battery electrolyte specific gravity or conductance, monthly 30-minute under load tests, evidence of wet-stacking, an annual 90-minute load bank test, a 3-year 4-hour load test, and an annual fuel quality test. These omissions were confirmed during an exit interview with the Facility Administrator and Maintenance Director. Additionally, observations revealed further deficiencies in the emergency generator system. The emergency generator annunciator panel, located on the second floor at the 2 B Well Nurses Station, had multiple trouble lights illuminated when tested, indicating potential issues with the system. Furthermore, the emergency generator set location on the second floor lacked battery back-up emergency lighting, and the manual stop station was located inside a locked room, obstructing access to emergency equipment. These issues were also confirmed during the exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The following inspections have been scheduled/ conducted for the Generator: a. Weekly Visual inspection b. Battery electrolyte levels/ or battery voltage c. Battery Electrolyte specific gravity or conductance d. Monthly 30-minute load test e. Evidence of Wet Stacking f. 3 yrs., 4 hrs. load test g. Annual 90 min. Load Bank h. Monthly Load Test i. Annual Fuel Quality test j. Monthly testing and recording of battery specific gravity or conductance testing Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0918 Electrical Systems- Essential Electric Systems. The maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in monthly QAPI.