Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and test its generator system in compliance with NFPA standards, specifically the requirement for a 3-year, 4-hour load test. During a document review on February 10, 2025, it was discovered that the facility could not provide documentation to confirm that this critical test had been conducted. This deficiency affects the entire facility, as the generator is essential for ensuring the safety and functionality of the electrical systems during power outages. The absence of this documentation was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
3 year, 4 hour load test was completed on 2/26/25. All generator tests will be scheduled in TELS for timely completion. Maintenance staff will be in-serviced on timely completion of generator tests and documentation. The maintenance director/designee will do a random audit to ensure that generator tests and documentation are completed timely, findings reported to QAPI.