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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 11/10/2011, at 1:40 p.m., it is observed:

-- 1. Smoke barrier wall near Maintenance Room has gaps around wires, pipes and conduit which have not been sealed with approved materials.

Maintenance Staff A was present and acknowledged that the gaps were not properly sealed.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based upon a review of records and staff interview, the facility fails to assure generators are inspected and exercised in accordance with NFPA 99. The deficient practice does not ensure that the generator will perform as expected in the event of an emergency, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 11/10/2011, a review of records performed between 11:30 a.m. and 1:00 p.m. revealed the following:

-- 1. The monthly load testing of the generator is not with sufficient load to reach 30% of the 519 Amps listed on the data plate on the generator and no annual load bank test been performed within the last 12 months.

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

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 observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 11/10/2011, at 1:40 p.m., it is observed:

-- 1. Smoke barrier wall near Maintenance Room has gaps around wires, pipes and conduit which have not been sealed with approved materials.

Maintenance Staff A was present and acknowledged that the gaps were not properly sealed.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based upon a review of records and staff interview, the facility fails to assure generators are inspected and exercised in accordance with NFPA 99. The deficient practice does not ensure that the generator will perform as expected in the event of an emergency, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of the survey.

Findings Include:

During the tour conducted on 11/10/2011, a review of records performed between 11:30 a.m. and 1:00 p.m. revealed the following:

-- 1. The monthly load testing of the generator is not with sufficient load to reach 30% of the 519 Amps listed on the data plate on the generator and no annual load bank test been performed within the last 12 months.

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

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