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K0918
F

Failure to Document Weekly Generator Inspections

Newtown Square, Pennsylvania Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on April 17, 2025, it was discovered that the facility could not provide documentation proving that weekly inspections of the battery voltage were performed. This lack of documentation indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator as outlined by NFPA standards. An exit interview with the Administrator and the Director of Maintenance confirmed the absence of the necessary documentation. This deficiency affects the entire facility, as the emergency generator is a critical component of the essential electrical system, designed to provide power in the event of an outage. The failure to maintain proper records of inspections compromises the facility's ability to ensure the generator's reliability and readiness in emergencies.

Plan Of Correction

The Maintenance Manager or designee will check the battery voltage weekly on the emergency generators and document on the respective generator log. This will be added to the generator logs by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.

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