Failure to Complete Annual Emergency Generator Fuel Quality Test
Penalty
Summary
The facility failed to perform required emergency generator maintenance testing, specifically the Annual Fuel Quality Test for the emergency generator. Documentation reviewed during the survey revealed that the facility did not pass the Annual Fuel Quality Test due to contaminants found in the fuel. At the time of inspection, the fuel had not been repaired or replaced, and this failure was confirmed in interviews with both the Facility Administrator and the Maintenance Director. This deficiency affected the entire facility, as the emergency generator is a critical component for maintaining essential electrical systems. The lack of compliance with the required maintenance and testing protocols, as outlined by NFPA 101 and related standards, was directly observed and documented by surveyors during the recertification survey.
Plan Of Correction
Emergency generator maintenance testing is now current for the facility. The Maintenance Director/designee has replaced the emergency generator fuel and completed the Annual Fuel Quality Test for the emergency generator maintenance testing and documented passing results. The Facility Administrator will ensure compliance by confirming results of Emergency Generator Fuel Quality test annually. Findings will be reviewed at monthly Quality Assurance Meetings.