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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 all residents, staff and visitors in 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m. reveals documentation indicating that 30 second monthly testing of the emergency lighting units overall has been completed but does not indentify specific units, location, or the status of each.

Director of Facilities and Maintenance Staff A were 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 upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m., for the last 5 quarters, revealed the following:

-- 1. No documented drill conducted for the 1st Shift, 2nd Qtr. of 2013.

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

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

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 all residents, staff and visitors in 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings Include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m. revealed the following:

-- 1. Documentation of the inspection and testing of the diesel generator for 07/11/2013, 07/18/2013, and 07/25/2013 reflect an amperage reading of "0" for each of the 3 phases, indicating that no load was transferred to the generator.

-- 2. Invoice from the service vendor dated 04/30/2013 indicates that a load bank test was completed on 04/29/2013. No documentation available reflecting the details of the load bank test.

-- 3. Facility maintenance and testing records reflect results of only a single phase of the generator testing from October 2012 through the date of this survey.

Director of Facilities and Maintenance Staff A were present and acknowledged the results of the records review. Director of Facilities stated that Staff members were unaware of some of the requirements for testing and maintenance and that additional training by the generator service vendor has be requested.

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 all residents, staff and visitors in 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m. reveals documentation indicating that 30 second monthly testing of the emergency lighting units overall has been completed but does not indentify specific units, location, or the status of each.

Director of Facilities and Maintenance Staff A were 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 upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m., for the last 5 quarters, revealed the following:

-- 1. No documented drill conducted for the 1st Shift, 2nd Qtr. of 2013.

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

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

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 all residents, staff and visitors in 3 of 3 smoke zones. The facility has a capacity in the LTC of 21 with a census of 10, and a capacity in the ISB of 12 with a census of 12 at the time of this survey.

Findings Include:

During the portion of the tour conducted on 07/31/2013, a review of records between 1:30 p.m. and 3:30 p.m. revealed the following:

-- 1. Documentation of the inspection and testing of the diesel generator for 07/11/2013, 07/18/2013, and 07/25/2013 reflect an amperage reading of "0" for each of the 3 phases, indicating that no load was transferred to the generator.

-- 2. Invoice from the service vendor dated 04/30/2013 indicates that a load bank test was completed on 04/29/2013. No documentation available reflecting the details of the load bank test.

-- 3. Facility maintenance and testing records reflect results of only a single phase of the generator testing from October 2012 through the date of this survey.

Director of Facilities and Maintenance Staff A were present and acknowledged the results of the records review. Director of Facilities stated that Staff members were unaware of some of the requirements for testing and maintenance and that additional training by the generator service vendor has be requested.

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