Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for several critical tests and inspections. These included the monthly testing of battery electrolyte specific gravity or conductance testing, an annual 90-minute load bank test or a report indicating the unit meets 30% of the nameplate, and an annual fuel sample report. This lack of documentation was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations. Additionally, an observation revealed that the emergency generator set location in the basement, specifically the transformer room, lacked battery back-up emergency lighting. This deficiency was also confirmed during the exit interview with the facility's leadership team. The absence of these critical components and documentation indicates a failure to comply with the necessary maintenance and testing requirements for the emergency power systems as outlined by NFPA standards.
Plan Of Correction
1.) A. Upon observation on April 15, 2025, the Maintenance Director and/or Designee performed the monthly testing of battery electrolyte specific or conductance testing. B. Annual 90-minute load bank or report indicating unit meets 30% of name plate - was not due for annual testing; however, it was completed. C. Annual fuel sample report although not due was completed. D. In the basement, the emergency generator set location (transformer room) a battery back-up emergency light was installed. 2.) The Maintenance Director and/or designee although not due had the Annual 90-minute load bank and Annual fuel sample reports completed. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all reports are completed timely and available for review. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit both the monthly and annual testing reports and ensure the back-up battery operated emergency lighting is in place and operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.