Generator Testing Documentation Deficiency
Summary
The facility failed to ensure that all required tests for the generator were conducted in accordance with NFPA 101, NFPA 110, and NFPA 99 standards. Specifically, during a life safety recertification survey, it was observed that the monthly generator logs for the years 2024 and 2025 were missing documentation of the time power was transferred to the generator during the monthly test for the transfer switch. This omission was noted for the months of May, (MONTH), and (MONTH) in 2024, and (MONTH) in 2025. The Director of Facilities acknowledged in an interview that the generator was serviced by a vendor during those months and committed to ensuring that the time of power transfer would be documented in the future.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will develop and implement a standardized log for generator load tests that includes transfer switch timeframes by 4/1/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 4/1/25 the Director of Facilities or designee will audit the Generator Log monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Penalty
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