Emergency Generator Maintenance Deficiency
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, which had the potential to affect all residents. During a documentation review, it was discovered that the generator had not been tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a maintenance report from August 6, 2024, indicated that the fuel system might need rebuilding, including the injection pump and injectors. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. The report recommended repairing or replacing the unit to ensure dependability. During an interview, it was confirmed that the necessary repairs had not been made, and there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one. Furthermore, an observation on December 20, 2024, revealed that the emergency generator's remote annunciator panel at the nurse's station on floor 2 was not functioning properly. The panel lacked a means to show it was receiving power and was not equipped with a lamp test switch to test the operation of all alarm lamps. These deficiencies were communicated to the facility's representative during the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, NJ Ex Order 26.4(b)(1) was contacted and came to assess the generator on 1/6/25 and will complete the following: - The Maintenance Director contacted NJ Ex Order 26.4(b)(10) and executed a new MOU for a portable rental generator on 1/6/25. Rental generator was installed and operational to begin generator repairs on 1/6/2025. - NJ Ex Order 26.4(b)(1) began work to rebuild the generator fuel pump on 1/6/2025. Work was completed on 2/10/2025. Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will perform a four-hour generator load test. Load test was completed on 2/11/2025. - Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will repair/replace the remote annunciator panel to include a means to show that it is receiving power and a lamp test switch(es) to test the operation of all alarm lamps. This work was completed by NJ Ex Order 26.4(b)(1) on 2/11/2025. 2. NJ Ex Order 26.4(b) has been contracted by the facility to provide the required 4 hour load test of the generator every 36 months. The Maintenance Director added the required 4 hour load test to the generator maintenance schedule and will ensure completion every 36 months. The Maintenance Director will be the designated individual responsible for ensuring a current MOU is in place for a rental generator and will provide evidence of this to the administrator annually. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule and ensure completion monthly. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly ongoing to ensure that the required testing was completed timely. The results of this will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Penalty
The facility did not include a plan in its emergency preparedness policy for maintaining generator power and fuel during emergencies. Staff confirmed there was no documented procedure for ensuring emergency power systems would remain operational or for supplying power if the generator failed, as required by federal regulations and referenced standards.
During a utility power outage, the facility's emergency generator failed, resulting in a loss of power. When repairs were needed, the generator was shut down for several hours, and the facility did not secure a temporary backup generator as required by policy, leaving the building without emergency power.
The facility was unable to produce a letter of reliability for its natural gas emergency generator during a record review, leaving its backup power supply vulnerable to fuel supply issues. This deficiency was confirmed by the maintenance director.
Surveyors found that the facility did not have a written agreement with a fuel vendor to supply propane for its emergency generator, as required by federal regulations. Staff confirmed that a contract had been proposed but was not yet in place, leaving the emergency power plan incomplete for all residents and smoke compartments.
Deficiency in Emergency Generator Fuel and Power Maintenance Planning
Penalty
Summary
The facility failed to ensure that its emergency preparedness policy included a plan for maintaining generator power and fuel during an emergency. During a record review, it was found that the Emergency Preparedness Policy did not reference any procedures or strategies for keeping the emergency power systems operational in the event of a power outage or other emergency situations. This omission was specifically noted in the documentation provided by the facility. At the time of the survey, an interview with facility staff confirmed that there was no plan in place to maintain fuel sources for the emergency generator during an emergency. Additionally, there was no documented plan for supplying power to the building if the generator failed to operate during such an event. This lack of planning was acknowledged by the staff member interviewed by the surveyor. The deficiency was communicated to the facility's leadership during the Life Safety Code exit conference. The absence of a comprehensive emergency power and fuel maintenance plan was identified as a failure to meet the requirements set forth by federal regulations and referenced standards, including NFPA 99 and NFPA 110.
Plan Of Correction
Element #1 On 6/6/2025 the Administrator and the Maintenance Director went to do an audit on the facility contract and reports with our vendor Powerhouse, which services our generator. In the binder of contracts, we found the contract dated 1/1/2025, stating clearly that Powerhouse will service our facility with fuel throughout the time the generator is on during an emergency and will replace it with a rental if the current generator malfunctions (see policy attached). Element #2 All residents have the potential to be affected by this deficient practice when life safety reports and contracts are not handy and not in the right binder. Element #3 The administrator in-serviced the US FOIA (b)(6) the same day 6/6/25 about the importance of having all reports and contracts related to lift safety, to be stored in the emergency preparedness binder and to check monthly contract and report from the Vendor Powerhouse who services the generator, that they are up to date with life safety compliance. In addition, the administrator in-serviced the maintenance director on the responsibility of having a contracted vendor service the generator throughout the emergency and having a backup generator in case it malfunctions. Element #4 The Administrator will monitor the Maintenance Director for three (3) months starting 6/9/2025-9/9/2025 weekly on having all life safety reports and contracts handy and placed in the Emergency preparedness binder for all life safety compliance. All findings will be reviewed and discussed in the next Quarterly QAPI committee meeting.
Failure to Provide Emergency Power During Generator Outage
Penalty
Summary
The facility experienced a failure of its emergency generator during a utility power outage, resulting in a loss of power to the building. The generator initially failed on March 30, 2025, at approximately 7:00 PM, leaving the building without power until staff were able to restart the generator at 8:24 PM. The facility identified the cause of the failure as an issue with the generator's computer board and placed an emergency order for repair parts with their generator contractor. On April 1, 2025, the generator contractor arrived onsite to perform repairs, which required the generator to be shut down. During this planned shutdown, the building was again left without power from approximately 10:50 AM until 1:00 PM, when the generator was fixed and power was restored. Despite being aware of the need for a planned shutdown, the facility did not secure a temporary backup generator to maintain emergency power during this period. Review of facility policies and interviews with the Administrator and Maintenance Director confirmed that the facility's procedures required securing a backup generator in the event of a primary generator failure. However, the facility failed to follow this policy during the planned repair shutdown, resulting in the building being without emergency power for over two hours.
Failure to Provide Letter of Reliability for Emergency Generator Fuel Supply
Penalty
Summary
The facility failed to implement emergency and standby power systems in accordance with regulatory requirements. Specifically, during a record review, it was found that the facility could not produce a letter of reliability for its natural gas generator. This documentation is necessary to demonstrate that the generator's fuel supply is dependable and that the emergency power system will function as required during an emergency. The absence of this letter means the facility cannot verify the reliability of its backup power supply. This deficiency was confirmed during an interview with the maintenance director at the time of the record review. The lack of a documented plan or evidence regarding the reliability of the onsite fuel source for the emergency generator leaves the facility's emergency power system potentially vulnerable in the event of a power loss. No information about specific residents or their conditions was provided in the report.
Lack of Emergency Generator Fuel Supply Agreement
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan as required by federal regulations. During a document review and staff interview, surveyors requested the emergency fuel plan and found that the facility could not provide a written vendor agreement for the delivery of fuel for their 10-kilowatt propane generator in the event of an emergency. Staff confirmed that while a fuel contract had been proposed to the vendor, no agreement had been finalized or received at the time of the survey. This deficiency affected all 123 residents and four smoke compartments within the facility. The absence of a documented fuel supply agreement meant that the facility did not have a formalized plan to ensure the continued operation of its emergency power system during an emergency, as required by the applicable federal regulations and referenced NFPA codes.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain the Emergency Preparedness Plan. On 04/02/25, the Administrator requested a written agreement with [R] to deliver propane fuel for the generator in the event of an emergency. On 04/18/25, [R] provided an amended service agreement that includes a 24-hour emergency service for our facility. (Attachment A - page 6) II. Identify Other Residents at Risk No residents were affected by this deficient practice. III. Systematic Changes On 04/03/25 in-service was conducted by the DSD to facility staff to be informed of agreement in place between propane fuel supplier and facility to deliver propane fuel for generator in the event of an emergency (Attachment 1). EOP Manual updated and reviewed by QA Committee. Next review of EOP Manual will be on 03/2026. IV. Monitoring Process Maintenance Director will review monthly EOP Manual including Propane Fuel Delivery Agreement. Findings will be reported to Administrator in the daily operations meeting. The Administrator will report findings to QA Committee monthly for 3 months or until compliance is met. V. Completion Date 04/18/2025 E 041 The facility is not in substantial compliance with 42 CFR §483.90 for Long Term Care Facilities.
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