Generator Documentation Deficiency
Penalty
Summary
The facility failed to meet the electrical system requirements for its generator, as evidenced by the absence of necessary documentation. During a document review on January 29, 2025, it was found that the facility could not provide records for the monthly battery-specific gravity or conductance test. Additionally, the facility lacked documentation for the three-year, four-hour load test, which is a critical component of ensuring the generator's reliability and compliance with NFPA standards. An interview with the maintenance supervisor on the same day confirmed that the required documentation was unavailable at the time of the survey. This deficiency indicates a lapse in the facility's maintenance and testing protocols for its essential electrical systems, which are crucial for ensuring the safety and functionality of the generator in emergency situations.
Plan Of Correction
4-hour full-load Generator run was completed on 11/3/2024. This was in response to a power outage that lasted 16 hours. The Nursing home administrator educated the maintenance director on ensuring the Generator testing to be completed timely. The NHA will monitor system compliance monthly. Results will be reviewed at the QAPI meeting. The generator at Cranberry Place is a battery specific gravity. The maintenance department was educated on where the battery read out is and record it as per regulation. The testing was completed until August 2024, then was missed. The battery specific gravity test has been recorded. Audits will be weekly for 4 weeks. Results will be reviewed at QAPI for further recommendations.