Emergency Generator Maintenance Deficiency
Summary
An emergency generator at the facility was not properly maintained, as evidenced by the lack of documentation for required inspections and tests. The facility failed to provide records verifying that weekly inspections of the emergency generator were conducted prior to April 23, 2024. Additionally, there was no documentation that the generator was run under load for at least 30 minutes monthly before March 12, 2024. The absence of these records indicates that the facility did not adhere to its policy and procedure titled 'Generator Maintenance - Emergency Power Use,' which mandates weekly spot checks and monthly load testing to ensure operational status. Furthermore, the facility did not have documentation of an annual inspection of the building's electrical system main and feeder circuit breakers for the years 2023 and 2024. This deficiency affected the entire first floor, including all resident units, the second-floor administration area, and the basement. The Maintenance Director confirmed the lack of documentation during an interview, highlighting the facility's failure to comply with the relevant codes and standards, including the 2012 NFPA 101 and 2010 NFPA 110, which require regular maintenance and testing of emergency power systems.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. Administrator and Maintenance Director reviewed past year worth of testing and lack of documentation including weekly inspections of the generator. Maintenance Director has been running generator tests per policy since he started. An Annual inspection of the buildings electrical system main and feeder circuit breakers was completed by outside vendor. 2. All residents are at risk for deficient practice of not having generator run on full load for 30 minutes monthly and annual inspection of buildings electrical system main and feeder circuit breakers. 3. Administrator educated Maintenance Director and Maintenance Tech on Generator policy and procedure. 4. A monthly audit of generator will be conducted by Maintenance Director and brought to QAPI for review. Any deficient practices will be corrected immediately. Person Responsible: Maintenance Director
Penalty
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