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Based on an interview and record review, the facility failed to maintain the emergency generator set in accordance with NFPA standards. This deficient practice affected all of the facility's smoke compartments, staff, and occupants of the building. The facility has the capacity for 240 beds with a census of 184 on the day of the survey.

The findings include:

During the Life Safety Code tour on 08/19/13, at 3:30 PM a record review of the facility's generator set revealed that during testing the generator's transfer of power exceeded the required time limit of 10 seconds.

An interview with the facility's Electrician on 08/19/13, at 3:35 PM revealed he started timing the test the instant he activated the transfer switch. The electrician stated he would contact the company that helped maintain the facility's generator in an effort to determine which transfer switches needed attention in order to reduce the amount of time it would take for the generator to transfer power.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 99 (1999 Edition).

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
a. Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
b. Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.