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.
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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