Failure to Maintain Required Annual Generator Maintenance Documentation
Penalty
Summary
The facility failed to maintain its emergency generator system in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. During a record review conducted on March 26, 2025, it was found that the facility did not provide the required annual generator preventative maintenance report. The last available report was dated 3/20/24, indicating that the annual maintenance had not been documented for the current year. This deficiency was confirmed through an interview with the facility Maintenance Director at the time of the record review. The absence of the current annual preventative maintenance report means the facility could not demonstrate compliance with required generator maintenance protocols, which are essential for ensuring the emergency power system's reliability in the event of a main utility power loss.
Plan Of Correction
K918 1. No residents were harmed as a result of this deficient practice. 2. The annual generator preventative maintenance and testing has been completed on 4/3/2025. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly generator load tests as scheduled and submit the results of those tests to QAPI. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.