Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator for one of its two generators, specifically the 80GS60 generator. During a document review on December 18, 2024, it was revealed that this generator did not pass the required three-year, four-hour load test due to a malfunctioning breaker. This failure indicates that the generator was not capable of supplying service within the necessary 10-second criterion during the test, as required by NFPA standards. Furthermore, the facility did not provide updated documentation after the breaker was replaced, which is a critical oversight in maintaining compliance with NFPA 101 and NFPA 110 standards. An interview with the administrator and maintenance director confirmed the deficiency, highlighting a lapse in the facility's documentation and maintenance processes for its emergency power systems.
Plan Of Correction
1. Maintenance Director will ensure the breaker was replaced on the 80GS60 generator, allowing it to pass the three-year, four-hour load test by 1/14/2025. 2. Education will be provided to the maintenance department by Administrator or designee on the importance of maintaining the emergency generator. 3. Maintenance Director or designee will audit monthly x 1 month. 4. Results will be discussed with QA committee with monitoring if applicable.