Emergency Generator Maintenance Deficiency
Penalty
Summary
During a Life Safety Code survey, it was found that the emergency generators at the facility were not properly maintained, as required by the facility's policies and procedures. Specifically, there was no documentation of the required monthly load tests and weekly checks for the generators since November 2023. These generators are crucial as they provide emergency backup power to all resident use floors in both the front and rear buildings of the facility. The facility's policy, revised in February 2020, mandates regular maintenance and testing to ensure compliance and functionality of the backup power system. However, the records reviewed during the survey showed a lack of documentation for these critical maintenance activities. Interviews conducted during the survey revealed that the Assistant Maintenance Director believed the former Maintenance Director was performing the necessary checks and tests, but there was no documentation to support this. The Assistant Maintenance Director mentioned that they had taken over the maintenance tasks after the former Maintenance Director left, but they only started documenting their observations recently. Despite claiming to have performed generator load tests and communicated the results to the corporate maintenance department, the Assistant Maintenance Director could not provide any logs or records during the survey. The Administrator also confirmed that they had not received any documentation regarding generator maintenance, only verbal updates, and acknowledged the expectation for maintenance activities to be documented.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Both backup generators were run on full load for 30 minutes each to ensure working order. The run was documented, including automatic power transfer in under 10 seconds. Additionally, the Maintenance Director visually inspected both generators and documented the results of the inspection. All residents had the potential to be affected; however, no loss of power actually occurred at the facility. Subsequently, both generators were run under full load for 30 minutes, and a visual inspection was performed, with both generators found to be fully functional. The Administrator, Maintenance Director, and maintenance staff were educated on the requirement to perform 30-minute load tests every 20 to 40 days and weekly inspections of all generators, and to maintain written records of all the maintenance, inspections, and load tests performed, ensuring that those records are readily available. An EES Generator documentation audit tool will be utilized by the Administrator to review documentation for both the monthly 30-minute load test and weekly inspection. The Administrator will scan and email the Corporate Regional Administrator the audit log every month for review. The Corporate Regional Administrator will review all generator documentation in-person each quarter. The Administrator will audit the EES generator documentation weekly for 4 weeks and monthly for 4 months. The Corporate Regional Administrator will review the EES Generator documentation audit tool monthly for 6 months and review the documentation in person quarterly for 2 quarters. Responsible Party: Corporate Regional Administrator