Failure to Repair Generator Coolant Leak and Document Corrective Action
Penalty
Summary
The facility failed to ensure that its generator or alternative power source was maintained and tested in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements. During record review on two separate occasions, it was found that the facility did not document repairs for a coolant leak behind the generator's radiator, as cited in the preventative maintenance report dated 2/13/2025. The deficiency was not addressed, and no corrective action was taken to resolve the issue noted in the generator report. Interviews with the Maintenance Director and Facility Administrator confirmed that the leak was not considered significant by facility staff, and the plan of correction only included obtaining a proposal for repair rather than actually correcting the deficiency. Written records did not show that the generator was repaired or that any action was taken to address the coolant leak, as required by the cited NFPA standards.
Plan Of Correction
This plan of correction is submitted to meet state and federal requirements. Except with respect to statements finally determined to be indisputable, submission of this plan of correction is not an admission that the deficiency exists or that it is cited accurately. ELEMENT # 1 No residents were found to be adversely affected by the cited deficiency. ELEMENT # 2 The Maintenance Director has recorded and repaired the deficiency noted on the preventative maintenance report dated 2/13/2025. The documentation and repair is available for inspection. ELEMENT #3 The citation states the facility "failed to record the generator repairs cited in the deficiencies of the preventative maintenance report dated 2/13/2025." The facility has completed the following steps to address the coolant leak: 1) On June 5, 2025, a commercial grade radiator sealant was purchased; 2) The sealant was poured into the generator radiator during the regular weekly test; 3) The generator then ran for 30 minutes continuously (temp range of 168-172 degrees); 4) A visual inspection was conducted after this test and found no leaks anywhere in the radiator; 5) On 6/9/2025, another generator test and inspection were performed and found no leaks in the generator radiator; 6) All service work and inspections were recorded in the generator maintenance binder. ELEMENT #4 The Maintenance Director will ensure all proposed and actual generator service will be documented and recorded in the generator maintenance binder. The Maintenance Director will observe and monitor the generator radiator for leaks during the weekly generator test as well as the monthly load test. Any leaks in the generator radiator will be identified, recorded, and addressed as soon as practicable with follow-up report to the Administrator. The Maintenance Director is responsible for sustained compliance. ELEMENT #5 Corrective action compliance date: 6/10/2025