Generator Maintenance and Testing Deficiency
Summary
The facility failed to ensure that the emergency generator was maintained and tested in accordance with NFPA 101 and NFPA 110 standards. During a life safety recertification survey, it was observed that the facility's generator logs documented a 2-hour load bank test instead of the required 4-hour load bank test. Additionally, documentation for the 4-hour load bank test was missing and not provided at the time of the survey. In an interview, the Director of Plant Operations acknowledged the issue and mentioned that the vendor would be contacted to address the discrepancy.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Facility contacted the Generator company to conduct the 4-hour load test. ò Visit is scheduled to be completed on (MONTH) 7th, 2025. Residents at Risk ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes ò Re-education to the Director of Plant Operation on the importance of running the 4-hour load test once every 36 months. ò Ensure facility is maintaining a schedule for when test comes due with an audit. ò If not in compliance, vendor will be contacted immediately. Monitoring of Corrective Action ò The Director of Plant Operations or Designee will complete audit to ensure each testing is within compliance with the NFPA 101 Electrical system monthly x3 months or until 100% compliance. ò If non-compliance is found, this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented. ò All findings and results will be submitted to the monthly QAPI meeting. ò QAPI committee will determine if further information is required. Responsible: Director of Plant Operations or Designee
Penalty
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