Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on December 11, 2024, it was found that the facility did not complete the weekly inspection of battery electrolyte levels or voltage. Additionally, the monthly testing under load for 30 minutes was not conducted as required. These deficiencies were confirmed during an exit interview with the Administrator and the Maintenance Director. The lack of proper maintenance and testing of the emergency generator and its components, as outlined by NFPA standards, indicates a significant oversight in ensuring the facility's readiness for emergency situations. The failure to adhere to these standards affects the entire facility, potentially compromising the safety and well-being of residents and staff in the event of a power outage.
Plan Of Correction
The Battery testing is being completed weekly as required. The Generator Load test was ran for the 30 minute month load test and will continue to be ran monthly as required. An Audit will be conducted to ensure the testing is completed monthly. Audit results will be reported to QAPI committee.