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K0918
F

Generator Maintenance and Testing Deficiency

Briarcliff Manor, New York Survey Completed on 03-20-2025

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 conduct all required tests on its emergency generator in accordance with NFPA 101 and NFPA 110 standards. During a life safety recertification survey, it was observed that the generator logs were missing documentation for weekly visual inspections for the week of the 29th of one month and the first week of the following month in 2024. Additionally, the monthly load tests for two consecutive months were not conducted or documented. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the missing documentation.

Plan Of Correction

Plan of Correction: Approved April 10, 2025 K918 I. Immediate Corrective Action: 1. Missing Generator Test Records: - The Administrator educated the Maintenance Director on proper Generator testing as stated in NFPA 110. - To address the missed load and run tests, a load bank test was performed to simulate the expected load on the generator for (MONTH) and (MONTH) 2024. - The generator was started and operated under load for the appropriate duration, as specified by NFPA 110. 2. Review and Verification: - There were no other discrepancies or missing records. The documentation was updated to reflect accurate and complete test results. II. Identification of Others: - All residents have the potential to be affected. - A full audit of the generator maintenance logs was conducted to verify that no other load tests or maintenance records were missing or incomplete. - No additional missing records were identified. III. Systemic Changes: 1. The Director of Maintenance in-serviced all maintenance staff on the updated procedures for documenting generator testing and inspections, emphasizing the importance of timely and complete record-keeping. IV. Quality Assurance: 1. An audit tool was updated to track the completion and documentation of weekly visual inspections and monthly load tests for the generator. - Audits will be conducted monthly for six months to ensure compliance with NFPA 101 and NFPA 110 and verify that all test logs are completed and properly documented. - The results of the audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance

See complete original report
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