Failure to Maintain and Document Emergency Generator Testing
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system as required by NFPA standards. During a document review, surveyors found that the facility could not provide documentation for several critical tests and inspections, including the monthly 30-minute load test, monthly operation of transfer switches, annual 90-minute load bank test (if the generator could not meet 30% of its nameplate rating), generator preventative maintenance records indicating no evidence of wet stacking, and the required 3-year 4-hour load test. An exit interview with the Maintenance Director confirmed the absence of these records. The lack of documentation affected the entire facility, as it could not be demonstrated that the emergency power system was being properly maintained and tested according to regulatory requirements.
Plan Of Correction
Documentation verifying maintenance and inspection of emergency generator not provided at survey has been obtained. a. Monthly 30-minute load tests have been completed and will continue on July 22, 2025. b. Monthly operation of transfer switch occurs during monthly load tests. A column will be added to the log to confirm completion. c. Annual 90-minute load bank had been completed. It will be completed next in April 2026. d. Preventative maintenance had been completed in March 2025 by a contractor with no signs of wet stacking. e. The 3-year 4-hour load test was completed. It will be completed next in March 2028. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by Director of Maintenance or designee.