Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, as evidenced by a documentation review conducted on December 19, 2024. The review revealed that the generator was not tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a routine maintenance report from August 6, 2024, indicated potential issues with the fuel system, suggesting that the injection pump and injectors might need rebuilding. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. During an interview, the facility representative confirmed the findings and acknowledged that repairs had not yet been made. Furthermore, the representative admitted that there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one to facilitate repairs to the onsite generator. This deficiency had the potential to affect all residents, as it compromised the reliability of the emergency power source.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, [R] was contacted and came to assess the generator on 1/6/2025 and performed a four-hour generator load test on 2/11/2025. 2. The Maintenance Director added the required 4-hour load test every 36 months to the facility maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing and maintenance was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.