Health inspection·December 27, 2024

Title 22 Article 6 Physical Plant California Code Regulations, Section 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter I, Division 17. Part 6. Title 24, California Administrative Code [Reference: 2022 California Building Code Section 1225.2 - New buildings and additions, alterations, or repairs to existing buildings subject to licensure shall comply with applicable provisions of the California Electrical Code, California Mechanical Code, California Plumbing Code and California Fire Code (Parts 3,4, 5 and 9 of Title 24)] and requirements of the State Fire Marshal. California Code Regulations, Section 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling, or alterations to such facility. The following reflects the findings of California Department of Public Health during the investigation of Complaint # CA00934820 survey. Event ID: WSQ411 Representing the Department, HFE I # 50180 State Citation (A) was written. On 12/10/24 at 9:51 AM, an unannounced visit to the facility to conduct the Life Safety Code survey, and to investigate a complaint regarding the physical environment. The facility did not have the written authorization, building permits or construction approval for the alterations to the emergency generator and the installation of a new natural gas fueled emergency generator from HCAI, and the facility lacked an alternate fuel source to power the emergency generator in the event of a power outage coinciding with a simultaneous gas shut-off. The facility failed to comply with California Code Regulations, Title 22, Article 6, Sections 72601(a) and 72605, including but not limited to: 1. Obtaining required written authorization, building permits, or attain construction approval for the alterations to the facility's emergency and standby power systems (emergency generator) and installation of a new natural gas fueled emergency generator from the Department of Healthcare Access and Information (HCAI, the State Agency); 2. Securing an alternate fuel source to power the emergency generator in the event of a power outage coinciding with a simultaneous gas shut-off; and 3. Notifying the Department (CDPH), within five days of the commencement of any construction/alterations to the skilled nursing facility. As a result, the facility did not have the written authorization, building permits or construction approval for the alterations to the emergency generator and the installation of a new natural gas fueled emergency generator from HCAI, and the facility lacked an alternate fuel source to power the emergency generator in the event of a power outage coinciding with a simultaneous gas shut-off. These failures jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result of the patients or residents. A) During a concurrent observation and interview on 12/10/24 at 10:06 AM with the Maintenance Supervisor (MS), there was an emergency generator outside of the building next to the laundry room entrance. The MS stated that the emergency generator was a natural gas generator. During an interview on 12/10/24 at 4:00 PM with the Administrator (ADM), the ADM stated that the emergency generator was new and was installed in September 2024 without a permit from HCAI. During an interview on 12/10/24 at 4:11 PM with the ADM, the ADM stated that the facility's old diesel fueled emergency generator was giving them problems, and had a temporary generator installed for approximately one to two months (August to September 2024). During an interview on 12/11/24 at 10:31 AM with the ADM, the ADM stated that the MS was conducting a routine test on the facility's previous diesel fueled emergency generator when the MS found that the emergency generator was running but not giving power. The ADM stated that the emergency generator stopped working, and the facility contacted the vendor (Vendor 1, Generator Services Company 1) that provided the annual service to come and assess and repair the emergency generator. The ADM stated that Vendor 1 was unable to repair the emergency generator. The ADM called a rental company (Vendor 2, Generator Rental Company) to rent a temporary generator the day they found out the diesel generator was not repairable. The ADM also stated that the temporary generator did not have an automatic transfer switch (ATS [a device that automatically switches a power supply from the primary power source to a backup generator when the primary power fails]), so someone had to turn on the generator on when the power went out. During a review of the facility's Generator Service Report, dated 3/30/23, a technician indicated the following on the report: 1. "Tested with load and when the generator is loaded the engine would not maintain speed (frequency). The fuel stream in the carburetor was very liquid and not a fine mist as expected. The engine throttle was wide open and manipulating the choke did not improve the situation." 2. "The engine electric choke was powered but did not seem to be heating up or opening when the engine was hot." 3. "The load measured (in normal position) was 5A, 5A, 18A, and 10A on the neutral. This is about 3.4 KW which is about 45% of the rated load." 4. "The exhaust has a split and a replacement was requested." 5. The technician recommended to "rebuild the carburetor with a kit and test the generator with a heat gun load", "check and/or replace the electric choke mechanism", and "replace the muffler". During a review of the facility's "Daily Reports", dated 1/2/24 to 12/10/24, authored by the MS, the reports indicated issues with the emergency generator on 7/2/24, 7/22/24, 7/28/24, 7/31/24, and 8/2/24. During an interview on 12/11/24 at 10:34 AM with the ADM, the ADM stated that the facility started the process to rent a temporary emergency generator on 8/1/24 and the temporary emergency generator was removed from the facility on 11/4/24. During a review of the facility's "Customer Copy Progress Billing" from Vendor 2 (Generator Rental Company), dated 8/30/24, the report indicated, "Rental Days: 28 Invoice From Date: 8/02/24 Invoice Thru Date: 8/30/24". During a review of the facility's "Customer Copy Progress Billing" from Vendor 2 (Generator Rental Company), dated 9/27/24, the report indicated, "Rental Days: 28 Invoice From Date: 8/30/24 Invoice Thru Date: 9/27/24". During a review of the facility's "Customer Copy Progress Billing" from Vendor 2 (Generator Rental Company), dated 10/25/24, the report indicated, "Rental Days: 28 Invoice From Date: 9/27/24 Invoice Thru Date: 10/25/24". During a review of the facility's "Customer Copy Progress Billing" from Vendor 2 (Generator Rental Company), dated 11/07/24, the report indicated, "Rental Days: 5 Invoice From Date: 10/25/24 Invoice Thru Date: 10/30/24". During an interview on 12/11/24 at 10:36 AM with the ADM, the ADM stated that the new (natural gas) emergency generator was installed on 10/24/24 by Vendor 3 (Generator Services Company 2) and the temporary (rental) generator was removed four days after the new (natural gas) emergency generator was installed. During an interview on 12/11/24 at 10:38 AM with the ADM, the ADM stated that the new natural gas fueled emergency generator was installed in the same exact spot as the old diesel fueled emergency generator. The ADM stated that Vendor 3 took the old diesel emergency generator off-site. The ADM also stated that the gas company was not involved in the installation of the new natural gas fueled emergency generator. During an interview on 12/11/24 at 10:41 AM with the ADM, the ADM stated that Vendor 3 tested the new (natural gas) generator but was unable to provide documentation of the test conducted. During an interview on 12/11/24 at 10:43 AM with the ADM, the ADM stated that the new (natural gas) generator provides power to emergency lighting, red plugs, oxygen concentrators (a medical device that gives a person extra oxygen), tube feedings (a medical device that is used to deliver nutrients directly into the gastrointestinal tract of a patient who is unable to take food or liquids orally), call lights, patient reading lights, and the fire alarm system. The ADM stated that equipment that can be plugged into the emergency generator are low air mattresses (a mattress designed to prevent and treat pressure wounds), oxygen machines (also known as oxygen concentrator), CPAP machines (a device that delivers a steady stream of air through a mask to help keep your airways open while you sleep), and tube feeding machines (devices that deliver nutrition to patients who are unable to swallow or obtain nutrition orally). During an interview on 12/11/24 at 11:00 AM with the ADM, the ADM stated that the facility would need to get 96 hours' worth of propane on site to maintain back up fuel source for the emergency generator, "but they don't have it at the moment". The ADM stated that if the power and the electricity went out, they would call the generator rental company or the generator service vendor to come out and assess the situation to see what can be done. The ADM also stated that there is no active back-up plan if the natural gas is unusable because they do not have an alternate fuel source at the moment until they get propane tanks on site. During an interview on 12/12/24 at 11:33 AM with the Director of Nursing (DON) and MS, the DON stated that he does not know how long it would take the company that services the emergency generator to service or provide an alternate fuel source in the case the gas line gets shut off and their emergency generator is not useable. The MS stated it would take the company a few hours. During an interview on 12/12/24 at 12:02 PM with the DON, the MS, and the ADM (via telephone), the ADM stated that there is no back up plan if the generator become unusable because they would need to make changes to the piping and plumbing to connect a spare natural gas tank. The ADM was unable to provide the turnaround time for the emergency generator service company to provide an alternate source of fuel or what they would do in the meantime. During a review of the facility's Policies and Procedures (P&P) titled, "Section V: Emergency Response", from the facility's Emergency Preparedness Planning and Resource Manual, last reviewed 4/11/24, the P&P indicated planning considerations for utility outages such as: 1. "Identifying all critical operations, including: a. Life safety system, security and alarm systems, elevators, lighting, life support systems, heating ventilation and air conditioning systems, and electrical distribution systems. b. Emergency generators, medical gas delivery systems, and other critical systems. c. Communication systems and both data and voice computer networks." 2. "Establish procedures for restoring systems." 3. "Determine the need for back-up systems." During a review of the facility's Policies and Procedures (P&P) titled, "Section V: Emergency Response", from the facility's Emergency Preparedness Planning and Resource Manual, last reviewed 4/11/24, the P&P indicated emergency procedure for utility outage including, to ensure back-up systems (emergency generators) are available and operating as designed in accordance with requirements. During a review of the facility's P&P titled, "Emergency Power", last reviewed 4/11/24, the P&P indicated the following: 1. Generator provides automatic restoration of power for Emergency circuits within TEN SECONDS after normal power failure. 2. The following services shall be powered by the Emergency Generator: a. Exit Lights b. Emergency "Call" System c. Fire Alarm System d. Hallway Lights (every third light fixture) e. Electrical Outlets (usually colored red) f. Refrigerator for Medicine g. Electric Doors (locked facilities)". During an interview on 12/11/24 at 11:20 AM with the ADM, the ADM stated that the facility did not notify anybody when the diesel emergency generator went out, when the temporary generator was installed, or when the new (natural gas) emergency generator was installed. The ADM stated it was his responsibility to notify the appropriate department regarding the new generator being installed and or contacting HCAI to get permits. During an interview on 12/11/24 at 11:29 AM with the ADM, the ADM stated that he understands the importance of obtaining permits and approval prior to the installation of the new emergency generator but it was an emergency and that it was not on the top of his to-do list to contact HCAI. During a concurrent observation and interview on 12/12/24 at 10:51 AM with HCAI Fire Life Safety Officer (FLSO) and MS, the FLSO observed the current emergency generator and stated that the location of the generator was not approved because it was supposed to be located at least five feet from combustible materials and it was located approximately one foot from a wooden shed. During a review of HCAI's Field Operations Report, dated 12/13/24, the report indicated the following: "1. A new Natural gas generator has been installed without the benefit OSHPD plan approval or construction over site in violation of California Administrative Code. Section 7-113 2. It is unlikely this generator would be approved in its current condition due to 2 main reasons. firstly, For level 1 generator installations in locations where the probability of interruption of off site fuel supply is high "earthquake" ON site storage of an alternate energy source sufficient to allow full output of the emergency power system to be delivered for the Class specified shall be required. NFPA 110 section 3-1.1 Secondly, Generators shall not be installed within 5' of combustible construction. NFPA 37 Section 4.1.2.2.1". During a review of the facility's invoice from Generator Services Company (Vendor 3), dated 10/30/24, the report indicated the following description of work: 1. "We will remove the existing gasoline generator and the automatic transfer switch from the premises." 2. "We will install a 20 kw - 120/208 volt - 3ph air-cooled standby generator on the backside of the building, between the storage shed and the transformer." 3. "We will install a surface-mounted 100 amp automatic transfer switch in the same location as the existing transfer switch." 4. "We will install surface-mounted electrical conduit and wiring along the side of the building from the automatic transfer switch to the generator." 5. "We will install a gas pipeline from the existing gas pipeline int the water heater closet to the generator." 6. "We will install a concrete pad for the generator to be installed and secured on. *This generator will be fueled by your natural gas and will supply power to the existing circuits automatically during utility outages." 7. Exclusions to the description of work included: OSHPD Approval, any and all additional requirements from OSHPD, City Permitting, and Generator relocation (If required by the city). B) During an interview on 12/11/24 at 11:20 AM with the ADM, the ADM stated that the facility did not notify anybody when the diesel emergency generator went out, when the temporary generator was installed, or when the new (natural gas) emergency generator was installed. The ADM stated it was his responsibility to notify the appropriate department regarding the new generator being installed and or contacting HCAI to get permits. The facility unable to provide documentation notifying the Department within five days of the commencement of alterations made to the emergency generator or installation of a natural gas fueled emergency generator. The facility failed to obtain required written authorization, building permits, or attain construction approval for the alterations to the facility's emergency and standby power systems (emergency generator) and installation of a natura