Emergency Generator Maintenance Deficiency
Penalty
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.