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Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 09/05/2012, a review of records between 8:45 a.m. and 10:00 a.m., for the last four quarters, revealed no documented 90-minute functional testing of the emergency lighting units within the last 12 months.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and staff interview, this facility is not providing a range hood suppression system that is in compliance with NFPA 96, NFPA 17 and with the standard UL-300. The deficient practice could result in the perpetuation of a kitchen range fire without proper fire suppression protection, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of the survey.

Findings include:

During the tour conducted on 09/04/2012, at 4:12 p.m., it is observed that suppression system nozzles designed to protect the kitchen range are obstructed by a plate shelf on the range.

Administrative Staff A was present and acknowledged that the spray pattern of the kitchen hood suppression system is obstructed by the plate shelf

NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2 and 1998 NFPA 17A, 3-1.1, and 1998 NFPA 96, 7-2.2

Based upon observation and staff interview, the facility fails to maintain the emergency generator as required by NFPA 99. The deficient practice reduces the reliability of the generator in the event of loss of power, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 09/05/2012, between 8:45 a.m. and 10:00 a.m. a review of records for the last 5 quarters revealed the following:

-- 1. Generator maintenance documentation is incomplete.
a.) Several weeks show no weekly visual inspection.
b.) Documentation for monthly load testing is missing for several months.
c.) Records do not indicate transfer times.
d.) No documented load bank testing within the last 12 months.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he is relatively new to his position and had not been trained in proper procedures for testing and maintaining generators.

NFPA Standard: Generator sets 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. 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. 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. 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. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 09/05/2012, a review of records between 8:45 a.m. and 10:00 a.m., for the last four quarters, revealed no documented 90-minute functional testing of the emergency lighting units within the last 12 months.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and staff interview, this facility is not providing a range hood suppression system that is in compliance with NFPA 96, NFPA 17 and with the standard UL-300. The deficient practice could result in the perpetuation of a kitchen range fire without proper fire suppression protection, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of the survey.

Findings include:

During the tour conducted on 09/04/2012, at 4:12 p.m., it is observed that suppression system nozzles designed to protect the kitchen range are obstructed by a plate shelf on the range.

Administrative Staff A was present and acknowledged that the spray pattern of the kitchen hood suppression system is obstructed by the plate shelf

NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2 and 1998 NFPA 17A, 3-1.1, and 1998 NFPA 96, 7-2.2

Based upon observation and staff interview, the facility fails to maintain the emergency generator as required by NFPA 99. The deficient practice reduces the reliability of the generator in the event of loss of power, affecting 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 09/05/2012, between 8:45 a.m. and 10:00 a.m. a review of records for the last 5 quarters revealed the following:

-- 1. Generator maintenance documentation is incomplete.
a.) Several weeks show no weekly visual inspection.
b.) Documentation for monthly load testing is missing for several months.
c.) Records do not indicate transfer times.
d.) No documented load bank testing within the last 12 months.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he is relatively new to his position and had not been trained in proper procedures for testing and maintaining generators.

NFPA Standard: Generator sets 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. 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. 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. 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. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1