Emergency Generator Maintenance and Inspection Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which affected the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide documentation for an annual fuel quality test and a 3-year, 4-hour load test. Additionally, an observation on the same day revealed that the newly installed generator was in alarm for 'over-cranking.' These findings were confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance. A follow-up onsite revisit conducted on February 11, 2025, confirmed that the facility still could not provide documentation for the annual fuel quality test. This was verified during an exit interview with the Maintenance Director. All other deficiencies listed under this tag were corrected, but the lack of documentation for the annual fuel quality test remained unresolved.
Plan Of Correction
The annual fuel test is scheduled to be completed on 2/26/25. Results take up to 2 weeks to receive, so they will be available to us by 3/12/25. Maintenance will keep the date and the results logged in our Generator Binder and will ensure the fuel quality test is completed in February every year ongoing.