Emergency Generator Alarm Annunciator Not Readily Observed by Staff
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.
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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