Emergency Generator Maintenance Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for the maintenance of its emergency generators, specifically regarding the requirement to exercise the generators once every 36 months for four continuous hours. This deficiency was identified during an observation on December 19, 2024, at 9:35 a.m., when it was noted that the facility lacked the necessary documentation to confirm compliance with this requirement. During an interview conducted at the same time, the facility's administrator confirmed that the documentation for the emergency generator exercise was unavailable for review. This lack of documentation indicates a failure to adhere to the maintenance and testing protocols as outlined by NFPA standards, which are critical for ensuring the reliability of emergency power systems in the facility.
Plan Of Correction
The Haven will test the 2 facility generators for at least 4 consecutive hours. The 4 hour test will occur at least once every three years. The Haven did lose power on 3/25/2023 for 8 hours and 15 minutes. The generator did run for the entire time and functioned accordingly. The Administrator will monitor testing of the facility.