Emergency Generator Annunciator Panel Deficiency
Summary
The facility failed to ensure compliance with NFPA 99 standards regarding the emergency generator's remote annunciator. During an observation, it was noted that the remote annunciator panel for the emergency generator was not functioning properly at the nurse's station on the second floor. Specifically, the panel lacked a means to indicate it was receiving power and did not have a lamp test switch to verify the operation of all alarm lamps. This deficiency was confirmed through an interview with the U.S. FOIA representative present during the survey. The issue was 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 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. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Penalty
Surveyors observed that generator annunciator panels at two nurses’ stations had no functional indicator lights and had their key switches in the off position, contrary to NFPA 99 requirements for essential electrical systems. An MD reported that he only becomes aware of generator problems by physically checking the generator displays, and testing showed the key controlled an audible signal when the generators were running, confirming the annunciators were not being used to indicate emergency power source alarm conditions.
A remote annunciator for the emergency generator was installed in the back building electrical room, rather than in a location readily observed by operating personnel. This placement could result in generator alarms and conditions going unnoticed by staff, as confirmed by observation and interview with the maintenance director.
Surveyors found that the emergency backup generator annunciation panel was installed in the maintenance office, making it not readily observable by operating personnel. This configuration could result in generator alarms going unnoticed, as confirmed by the maintenance director during the survey.
Surveyors found that the generator annunciator panel, located behind the central nurses station, was not powered and appeared disconnected or disabled. This issue was confirmed by the Maintenance Director and acknowledged by facility leadership.
The facility's emergency generator annunciator panel was found to be malfunctioning, as the test lamp button did not work and no alarm condition lights functioned, despite the generator running. This issue was identified during an observation and had the potential to affect all residents.
Nonfunctional Generator Alarm Annunciators at Nurses’ Stations
Penalty
Summary
Surveyors found that the facility failed to maintain required generator alarm annunciators in accordance with NFPA 99, Sections 6.4.1.1.17 through 6.4.1.1.17.5, potentially affecting all 69 residents in the building. During a tour, the generator annunciator panel at the East nurses’ station was observed with no functional indicator lights and the key switch on the side of the box in the off position. The generator annunciator at the front nurses’ station was observed in the same condition, with no lights illuminated and the key in the off position. In an interview, the Maintenance Director stated that the only way he knows if there is a problem with the generators is by going to the generators themselves and checking their displays. When the Maintenance Director started the generators, it was determined that the key controlled an audible signal that sounded when the generator was running, confirming that the annunciators were not being used as intended to indicate alarm conditions of the emergency power source.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to annunciator deficiencies. The generator annunciator panel at the East nurse's station had no lights functional and the provider key on the side of the box was in an off position. Additionally, the generator annunciator at the front nurse's station having no functional lights and the provider key on the side of the box was in an off position. 2.The Medical Director was notified of non-functional annunciator panels. 3.Annunciator repairs will be completed by contracted vendor on or before 04/30/2026. 4.Monthly monitoring will be conducted and reviewed in QAPI. 5. LNHA educated Maintenance Director regarding having a generator annunciator that is functioning appropriately, and maintenance of the same.
Emergency Generator Annunciator Not Readily Observable
Penalty
Summary
The facility failed to ensure that the remote annunciator for the emergency generator was installed in a location that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the new emergency generator annunciator was placed in the back building electrical room, rather than in a more visible area. This placement could result in alarms and generator conditions going unnoticed by facility staff. The deficiency was confirmed through an interview with the maintenance director at the time of observation. No specific residents or patient medical histories were mentioned in the report, and the deficiency was identified through direct observation and staff interview.
Emergency Generator Alarm Annunciator Not Readily Observed by Staff
Penalty
Summary
The facility failed to ensure that the emergency backup generator annunciation panel was located in a place that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the annunciation panel was installed in the maintenance office, which is not a location that allows for easy monitoring by staff responsible for facility operations. This setup could result in generator alarms not being noticed promptly. The maintenance director confirmed these findings during the surveyor's interview at the time of observation. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. Annunciator panel was moved to an area readily observed by staff. 2. Audit completed of emergency notification systems to ensure location is easily accessible by staff. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Department on requirement that remote annunciation must be located outside of any locked rooms and easily accessible for staff to be notified of generator alarms. 4. Maintenance Director/Designee will complete random audits of emergency equipment and alarm devices are easily accessible to general staff with findings submitted to QAPI for review and recommendations. 5. Maintenance Director is responsible for maintaining compliance.
Generator Annunciator Panel Found Disconnected
Penalty
Summary
During a facility tour, surveyors observed that the generator annunciator panel, which is required to be powered and located in a place readily observed by operating personnel, was found to have no power. The panel was located on the wall behind the central nurses station near the central hallway. Testing of the annunciator revealed it was disconnected or disabled, and this was confirmed by the Maintenance Director during the tour. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information regarding residents or their medical conditions was included in the report.
Emergency Generator Annunciator Panel Malfunction
Penalty
Summary
The facility failed to ensure that the emergency generator annunciator was fully functional and operating in normal mode, as required by NFPA 99: 2012 Edition, Section 6.4.1.1.17 and 6.4.1.1.17.5. During an observation at 11:32 AM, it was noted that the generator annunciator panel's test lamp button did not work when activated. Although the generator produced a green light on the annunciator panel indicating it was running, no other alarm condition lights functioned at the time of observation. This deficiency was identified for the only generator annunciator panel in the facility and had the potential to affect all residents. The findings were communicated to the relevant personnel at the Life Safety Code exit conference.
Plan Of Correction
K0916 Level F Completion Date: 1/15/2025 Corrective Action: The generator was inspected and found to be functioning as designed and a new annunciator control board ordered for Generator Annunciator Panel. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Annunciator Panel Monitoring and Resident Safety to the Maintenance Department by the Maintenance Director completed by 12/20/2024. Monitoring: Audit - Annunciator Panel will be completed on the following schedule: every quarter x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
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