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STANDARD is not met as evidenced by: During the tour of the facility with the staff, it was determined that the facility failed to provide proper operation of the Kitchen Hood System as required by NFPA 96, (Chapter 8, and Section 8.3.2). This deficient practice could affect all residents, and staff should a fire occur.

Annual Kitchen Hood inspection indicated the replacement air does not shut down when system is activated.

NFPA 96 -8.3.2. When the fire-extinguishing system activates, makeup air supplied internally to a hood shall be shut off.

The Maintenance Director acknowledge deficiency of the dry chemical system during a tour of the facility.

STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the survey, the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 18.5.1. Failure to maintain the fire alarm system has the potential to harm all occupants, staff and visitor in the ground floor activity/dining room area if the fire alarm system failed to operate as designed if a fire was to occur.

Located in the north storage room the visible notification appliance obstructed by shelving not allowing field of view throughout the room.

NFPA 72, section 18.5.1* Visible Signaling. Public mode visible signaling shall meet the requirements of Section 18.5 using visible notification appliances.

The Director of Maintenance acknowledge the deficient condition of the visible notification appliance during the tour of the facility.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by 2012 NFPA 101 Section 19.3.5.12, 9.7.4.1; 2010 NFPA 10 Section 5.5.5.3 This deficient practice could affect all residents, staff and visitors should the facility fail to provide fire extinguishers.

A placard was not conspicuously place near the K Class fire extinguisher in the kitchen that states (The fire protection system shall be actuated prior to using the fire extinguisher).

2010 NFPA 10 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

The Maintenance Director acknowledged the lack of signage near the fire extinguisher during record review of the facility.

STANDARD not met as evidenced by: Based on observation and staff interview during the tour of the facility, it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems in accordance with Section 9.2, 19.5.2.1.9.2, NFPA 90A and 19.5.2.2. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur.
Sheet metal screws being used to connect the pipe joints on the exhaust vents on both Type 2 clothes dryers in the laundry.

NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.

The dryer vent deficiencies were discussed with the Maintenance Director during the survey.

This STANDARD is not met as evidenced by: Through observation during the walkthrough of the survey it was determined that the facility failed to meet the Utilities- gas and electric requirements in accordance with NFPA 101 and NFPA 54. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one (1) smoke compartment.

Orifice for dryer not sized correctly currently set for 0-2000 feet according to dryer data plate.

NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:
(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

The deficient items were discussed with the Maintenance Staff during the exit conference.

STANDARD not met as evidenced by: Based on record review and staff interview during the course of the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.

1) At the time of the survey, no records were available to verify testing and recording of the EPSS Loads L1, L2 and L3 after transfer.
2) Diesel annual fuel quality test not conducted as annually using applicable ASTM Standards.
3) At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (Emergency Generator) monthly.
4) No records to indicate the generator transfer time during monthly load bank testing.

NFPA 110, Section 6-4.1 Level I and Level EPSSs, including all appurtenant components, shall be inspected and shall be exercised under load at least monthly.

NFPA 110, Section 8.3.7. A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer's recommendations.

The emergency power supply deficiency was discussed with the Director of Maintenance during the survey.