Failure to Document Weekly Generator Battery Testing
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 January 23, 2025, it was discovered that the facility could not provide documentation of weekly battery voltage testing for the emergency generator. This lack of documentation indicates a failure to adhere to the required maintenance and testing protocols as outlined by NFPA standards. An interview with the Administrator and Maintenance Director on the same day confirmed the absence of the necessary documentation. This deficiency affects the entire facility, as the emergency generator is a critical component of the essential electrical system, designed to provide power in the event of an outage. The failure to maintain proper records of testing and maintenance could compromise the facility's ability to ensure a reliable power supply during emergencies.
Plan Of Correction
1. The voltage battery of the generator was inspected and noted to be in proper function. The weekly inspection report has been revised to include the voltage battery check of the generator. 2. Education was completed for the maintenance director to ensure they inspect generator battery voltage weekly. 3. NHA/designee will audit the weekly check report weekly x 4 and then monthly x 3 to ensure compliance with the generator battery check. Report on Audit will be reported in QA.