Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 99 and NFPA 101 standards. During a record review conducted with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not have evidence of weekly visual inspections of the generator prior to February 2025. Additionally, the facility lacked documentation of the monthly load testing of the generator for the same period. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. The findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference. The absence of records for the required inspections and testing indicates a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA 99 and NFPA 101. This oversight could potentially impact the facility's ability to ensure the generator's readiness and reliability in providing essential power during emergencies.
Plan Of Correction
1. The Maintenance Director in charge of oversight of generator weekly and monthly testing in 2024 is no longer with the facility. The new Maintenance Director is in compliance with weekly and monthly testing of generator. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 on maintaining the generator in accordance with NFPA 99. 4. Results of the weekly and monthly generator testing will be reported to the QA&A committee and reviewed monthly.