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Based on observation and interview with facility staff, the facility failed to maintain smoke resistance in a hazard area. Failure to maintain this hazard area smoke tight puts all the patients of the facility in one of two smoke zones at risk should a fire develop in the hazard area because of the spread of smoke. Patient census was 3 .

Findings are:

During the survey on 10-15-15 at 11:05 AM, it was observed that the Central Supply was open and the arm on the closure was disconnected.

Interview with Maintenance " A " at 11:05 AM confirmed the door closure was disconnected and there was a lack of smoke tightness.

Based on record review and interview, this facility was not maintaining the emergency generator by monthly testing to at least 30% of the nameplate rating or conducting an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair affecting all occupants in the facility. Census was 3.
Findings Are:
Record review conducted on 10-15-15, at 10:13 a.m., of the facility ' s generator inspection testing and maintenance records revealed the documentation does not indicate the generator was tested monthly at 30% of the nameplate rating for at least 30 minutes with an additional cool-down period. The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.
The deficient practice was confirmed by Maintenance Staff " A " at 10:13 a.m. on 10-15-15.

Record review of the following NFPA Standard revealed: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2

Record review of the following NFPA Standard revealed: Diesel powered EPS installations that do not meet 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads. 1999 NFPA 110, 6-4.2.2

Based on observation and interview with facility staff, the facility failed to maintain smoke resistance in a hazard area. Failure to maintain this hazard area smoke tight puts all the patients of the facility in one of two smoke zones at risk should a fire develop in the hazard area because of the spread of smoke. Patient census was 3 .

Findings are:

During the survey on 10-15-15 at 11:05 AM, it was observed that the Central Supply was open and the arm on the closure was disconnected.

Interview with Maintenance " A " at 11:05 AM confirmed the door closure was disconnected and there was a lack of smoke tightness.

Based on record review and interview, this facility was not maintaining the emergency generator by monthly testing to at least 30% of the nameplate rating or conducting an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair affecting all occupants in the facility. Census was 3.
Findings Are:
Record review conducted on 10-15-15, at 10:13 a.m., of the facility ' s generator inspection testing and maintenance records revealed the documentation does not indicate the generator was tested monthly at 30% of the nameplate rating for at least 30 minutes with an additional cool-down period. The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.
The deficient practice was confirmed by Maintenance Staff " A " at 10:13 a.m. on 10-15-15.

Record review of the following NFPA Standard revealed: Level 1 and level 2 Emergency Power Supply Sources (EPSS)s, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes using one of the following methods: Under operating temperature conditions or at not less than 30% of the EPS nameplate rating or loading that maintains the minimum exhaust temperatures as recommended by the manufacturer. 1999 NFPA 110, 6-4.1 and 6-4.2

Record review of the following NFPA Standard revealed: Diesel powered EPS installations that do not meet 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads. 1999 NFPA 110, 6-4.2.2