Failure to Maintain and Document Required Generator Testing and Maintenance
Penalty
Summary
The facility failed to maintain compliance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements for essential electrical systems, specifically regarding the generator and its associated equipment. During a record review, surveyors found that the facility did not provide documentation of a current monthly generator load test, with the last available record dating back to August 2024. Additionally, there was no documentation available for a current annual load bank test, annual service of the generator, or annual fuel analysis test for the generator fuel. These deficiencies were identified during a survey on 05/07/2025, and no current records for the required maintenance and testing were provided by the time the survey concluded. The lack of these records indicates that the facility did not ensure the generator and its components were properly maintained and tested as required, which could affect all occupants in the event of a power failure. No specific residents or patient conditions were mentioned in the report.
Plan Of Correction
The Maintenance Director and/or designee will schedule monthly generator load testing, annual load bank, service, and fuel analysis testing to be completed by the compliance date. The Administrator will review regulation K918 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will ensure the Preventative Maintenance system has all required generator testing scheduled to ensure regulatory compliance based upon education for tag 0918. Results of the required testing will be brought to the Quality Assurance Performance Improvement meetings for review. The Committee will determine whether modifications to the plan are necessary. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.