Failure to Maintain Emergency Generator System
Penalty
Summary
The facility failed to maintain its emergency generator system, which is crucial for ensuring the safety and functionality of the facility during power outages. Document review revealed that several key maintenance tasks were not performed after July 18, 2024. These tasks included weekly visual inspections, weekly battery voltage inspections, monthly battery conductance testing, monthly generator exercises for 30 minutes, and monthly operation of transfer switches. Additionally, an annual fuel quality test was not conducted, and a generator inspection from March 21, 2024, indicated issues such as wet stacking and fuel injector warnings. During a follow-up visit on February 5, 2025, it was confirmed that the monthly operation of transfer switches and the annual fuel quality test had still not been completed. The generator continued to exhibit problems with wet stacking and fuel injector warnings. The facility acknowledged the lack of documentation and stated that they were awaiting the delivery of parts necessary to complete these tasks.
Plan Of Correction
The facility will comply with emergency generator weekly visual checks, weekly battery voltage checks, monthly battery conductance testing, 30-minute monthly exercise, monthly operation of transfer switch, and annual fuel tests. The facility completed a fuel analysis on 1/22/2025 and failed the analysis. The facility requested for fuel to be polished to successfully pass analysis, and this work was completed on 2/13/2025. A TLW was requested on 1/24/2025 to fix the injector warning to address the deficiency from the 3/21/2024 inspection. The facility ran a monthly exercise on 2/13/2025. The facility corrected the wet stacks on 5/13/2024. All residents and areas have the potential to be affected. The Maintenance Director will be educated on the importance of conducting weekly and monthly inspections and scheduling the yearly test. LNHA will monitor all weekly, monthly, and yearly tests. LNHA will monitor future generator inspection deficiencies for appropriate and timely corrections. LNHA / designee will audit weekly inspections, weekly x4 then bi-weekly x2 then monthly x2. LNHA / designee will audit monthly inspections x3. LNHA / designee will audit yearly tests, yearly. LNHA / designee will audit generator inspection deficiencies quarterly.