Facility Lacks Essential Generator Spare Parts
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the facility did not have generator high mortality spare parts on the premises. This deficiency was identified during an inspection conducted at 4:24 pm on April 22, 2025, with the Maintenance Director present. The Maintenance Director acknowledged the absence of these critical spare parts during a staff interview conducted at the same time. This acknowledgment indicates that the facility was aware of the deficiency in maintaining the essential electric system generator as per the required standards. The deficiency was further discussed and acknowledged by the Administrator during the exit conference. The lack of generator high mortality spare parts suggests a failure in the facility's preparedness to maintain the essential electric system, which is crucial for ensuring the safety and well-being of the residents in the event of a power outage.
Plan Of Correction
Findings will be taken to QAPI. Spare parts were purchased by the Plant Operations Director on 05/15/2025 and is currently located on site. No residents were affected by this deficient practice. The Plant Operations Team was educated by the Regional Director of Plant Operations on 05/15/2025 on Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Quarterly audits will be conducted by Plant Operations Director or designee to ensure there is adequate supplies of mortality spare parts per NFPA 111. Results will be taken to QAPI. Spare parts were purchased by the Plant Operations Director on 05/15/2025 and is currently located on site. No residents were affected by this deficient practice. The Plant Operations Team was educated by the Regional Director of Plant Operations on 05/15/2025 on Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 113. Quarterly audits will be conducted by Plant Operations Director or designee to ensure there is adequate supplies of mortality spare parts per NFPA 111. Results will be taken to QAPI.