Failure to Maintain Generator and Document Testing
Penalty
Summary
The facility failed to maintain its generator, which is essential for the entire facility's electrical system. During a document review on January 27, 2025, it was found that the facility did not provide documentation for several critical tests and inspections. These included weekly battery voltage or electrolyte levels testing, monthly specific gravity or conductance testing, monthly 30-minute under-load testing, monthly operation of transfer switches, and weekly visual inspections. Notably, the deficiencies in weekly battery voltage or electrolyte levels testing and monthly specific gravity or conductance testing were repeat deficiencies from the previous annual survey conducted on March 13, 2024. An interview with the Administrator and Maintenance Director on the same day confirmed that these tests had not been completed, and no documentation was logged for the past 12 months. This lack of documentation and testing indicates a failure to comply with the maintenance and testing requirements outlined in NFPA 101 and related standards, which are crucial for ensuring the reliability of the facility's essential electrical systems.
Plan Of Correction
1. All required tests and inspections were immediately scheduled. 2. A log was created to ensure proper documentation of all tests and inspections. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of tests and inspections will be conducted to ensure proper documentation and compliance. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.