Deficiency in Generator Maintenance
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the generator room lacked high mortality spare parts, which are crucial for the maintenance and quick repair of the generator. This deficiency was identified during an inspection conducted at 2:00 pm on March 11, 2025, with the Maintenance Director present. The absence of these critical spare parts indicates a lapse in the facility's preparedness to ensure the generator's functionality in emergencies. The generator is required to supply power within 10 seconds, and regular maintenance and testing are mandated by NFPA 110. However, the lack of spare parts suggests that the facility may not be able to meet these requirements consistently, potentially compromising the safety and well-being of the residents. During a staff interview, the Maintenance Director acknowledged the deficiency, and this finding was also discussed with the Administrator during the exit conference. The report highlights the importance of having necessary spare parts readily available to maintain compliance with safety standards and ensure the reliability of the emergency power system.
Plan Of Correction
1. What corrective action will be accomplished? The following spare parts were ordered for our two on-site generators: 200 KW Generac Generator and 50KW Kato light Generator: * All engine filters: oil & air * All cooling system hoses & block heater hoses * All engine belts * Engine oil * Engine coolant 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: This deficiency could affect the occupants of the facility in the case of a loss of power. However, no residents have been affected by this practice. 3. Measures/systematic changes put into place: Once the supplies have been delivered, the Maintenance Director will establish a monthly inspection log to monitor all high mortality spare parts in the Generator Room. 4. How corrective action will be monitored: The Maintenance Director will ensure that all high mortality spare parts stored in the Generator Room are maintained in good working order and are available for use as needed. The inspection log will be reviewed at the monthly QA meeting until compliance has been determined. 1. What corrective action will be accomplished? The following spare parts were ordered for our two on-site generators: 200 KW Generac Generator and 50KW Kato light Generator: * All engine filters: oil & air * All cooling system hoses & block heater hoses * All engine belts * Engine oil * Engine coolant 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: This deficiency could affect the occupants of the facility in the case of a loss of power. However, no residents have been affected by this practice. 3. Measures/systematic changes put into place: Once the supplies have been delivered, the Maintenance Director will establish a monthly inspection log to monitor all high mortality spare parts in the Generator Room. 4. How corrective action will be monitored: The Maintenance Director will ensure that all high mortality spare parts stored in the Generator Room are maintained in good working order and are available for use as needed. The inspection log will be reviewed at the monthly QA meeting until compliance has been determined.