Emergency Generator Annunciator Panel Malfunction
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.
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.
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.
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