Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system, as evidenced by the absence of documentation for several required tests and inspections. During a document review on December 30, 2024, it was found that the facility could not provide records of weekly visual inspections and battery checks for December 2024. Additionally, there was no documentation of a 4-hour load test being performed within the last three years, which is a requirement for ensuring the generator's reliability. An interview with the Facility Administrator and the Maintenance Director confirmed the lack of documentation for the emergency generator. This deficiency affects the entire facility, as the generator is a critical component of the essential electrical system, designed to provide power in emergencies. The failure to maintain proper records and conduct necessary tests indicates a lapse in the facility's adherence to NFPA standards, specifically NFPA 101, NFPA 110, and NFPA 111, which govern the maintenance and testing of essential electrical systems.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the weekly NFPA generator inspection requirements and the 3-year, 4-hour load testing. The 3 year, 4-hour load testing is scheduled on 1/23/2025. NHA/Designee will audit the weekly generator inspections monthly x 3 months. NHA/Designee will educate the Maintenance Director/Maintenance staff on the weekly NFPA generator inspection requirements and the 3-year, 4-hour load testing. The 3 year, 4-hour load testing is scheduled on 1/23/2025. NHA/Designee will audit the weekly generator inspections monthly x 3 months.