Failure to Document Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to provide documentation verifying that weekly inspections, monthly testing, and annual testing of the emergency generator were conducted within the previous twelve months. During a document review, surveyors were unable to locate records confirming that these required maintenance and testing activities had taken place as specified by NFPA 101, NFPA 110, and related standards. An interview with the Administrator confirmed the absence of documentation for the emergency generator's weekly inspections, monthly testing, and annual testing for the past year. This lack of records affected the entire emergency electrical system component, as there was no evidence to demonstrate compliance with the required maintenance and testing protocols.
Plan Of Correction
1) The facility cannot retroactively complete an annual, monthly, and weekly generator check. 2) The weekly generator check was completed, the monthly generator check was completed, and the annual generator was completed by Penn Power on 8/8/2025. Records were placed in the life safety binder. 3) The maintenance director was re-educated on monthly, weekly, and annual generator inspections. 4) The NHA or designee will conduct a quarterly audit for 1 year monthly, then for 3 years, to ensure generator inspections are completed. The results will be submitted to the QAPI committee for review and analysis of the need for continued monitoring.