Lack of Remote Manual Stop Station for Generator
Penalty
Summary
The facility failed to ensure the Essential Electrical System (EES) was equipped with a remote manual stop station for the generator set, as required by NFPA 99: 2012 Edition and NFPA 110: 2010 Edition. During an observation on December 12, 2024, it was noted that the facility's generator, located outside the building, lacked a remote manual stop station. This deficiency was identified as having the potential to affect all residents. In an interview conducted on December 13, 2024, a staff member acknowledged awareness of the requirement for a remote manual stop station but was unable to locate one at the time. The absence of this critical safety feature was confirmed during the Life Safety Code Exit conference, highlighting a significant oversight in the facility's compliance with safety regulations.
Plan Of Correction
1/21/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: Powerhouse Generators will be installing the remote manual stop on 1/21/25, due to the recent cold weather and freezing of the ground. Appointment confirmation attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated to maintain remote manual stop and electrical systems. The Maintenance Director/Designee will test remote manual stop during weekly generator testing. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audits on a Quarterly basis x 12 months to ensure compliance.