Missing Generator Fuel Quality Test Documentation
Penalty
Summary
The facility failed to ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110 standards. During a Life Safety recertification survey, it was observed that the documentation for the current fuel quality test of the facility's generator was missing and not provided at the time of the survey. The last recorded fuel quality test was conducted in 2023, indicating a lapse in compliance with the testing schedule. This deficiency was confirmed during an interview with the Corporate Regional, who acknowledged the oversight and mentioned that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K918 – Essential Electrical Testing and Maintenance I. Immediate Corrections The facility engaged the Emergency Generator service provider to perform fuel quality testing. Testing completed (MONTH) 7, 2025. II. Plan of Correction to Identify Other Areas Potentially Affected It was determined that all residents have the potential to be affected by the facility not ensuring that the required emergency generator fuel quality test is completed. The Director of Plant Operations will review all record and log reports to ensure required systems testing and inspection are completed as per the required code and regulations. Work completed: (MONTH) 12, 2025 III. Systemic Changes The facility maintenance record and log policy were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will review all required records and logs to ensure periodic testing, inspections, and services are completed as per schedule. All maintenance staff will receive in-service education, and all participants will understand the life safety issues identified, with a focus on the annual fuel testing requirements for the Emergency Generators. The Director of Plant Operations has been assigned responsibility for the education of staff. Work completed: (MONTH) 13, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that required generator annual fuel tests are completed in accordance with NFPA 101 and NFPA 110. 1. Audits will be completed by the Director of Plant Operations quarterly x 2 quarters, then complete annually thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to the QA Committee Quarterly x 2 Quarters then annually thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee