Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator as required, which was identified during a documentation review and interview. Specifically, the facility did not provide documentation for the weekly visual inspection of the emergency generator. This deficiency was noted at 8:50 a.m. on February 10, 2025. Additionally, the facility failed to provide documentation for the monthly conductance testing of the emergency generator, as noted at 8:52 a.m. on the same day. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director at 12:30 p.m. on February 10, 2025, affecting the entire facility.
Plan Of Correction
1. The Maintenance Director/designee will conduct the weekly visual inspection to ensure the facility is in compliance. 2. The Maintenance Director/designee will conduct the monthly conductance testing to ensure the facility is in compliance. 3. The Nursing Home Administrator/designee will educate the maintenance staff on visual inspection and conductance testing on the generator to ensure the facility is in compliance. 4. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure all generator testing is completed. 5. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.