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Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants of the building. The facility census was 60.

Findings included:

Observation during a tour of the facility conducted on the afternoon of 11/29/11 at 2:16 PM, showed the area where the emergency generators are located was not provided a battery emergency light of at least 1 and ? hour duration to provide task illumination in the event of mechanical failure of the generator.

Staff C Director of Plant Operations confirmed at that time a battery emergency light was not provided for the generators.

Chapter 3-4.2.2.2 of the 1999 Edition of National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants. The facility census was 60.

Findings included:

During an interview, conducted at 2:54 PM on 11/29/11, Staff C Director of Plant Operations stated the facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Chapter 9.7.6.2 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-
Based Fire Protection Systems.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants. The facility census was 60.

Findings included:

During an interview, conducted at 2:54 PM on 11/29/11, Staff C Director of Plant Operations stated the facility did not have a procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Chapter 9.6.1.8 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants of the building. The facility census was 60.

Findings included:

Observation during a tour of the facility conducted on the afternoon of 11/29/11 at 2:16 PM, showed the area where the emergency generators are located was not provided a battery emergency light of at least 1 and ? hour duration to provide task illumination in the event of mechanical failure of the generator.

Staff C Director of Plant Operations confirmed at that time a battery emergency light was not provided for the generators.

Chapter 3-4.2.2.2 of the 1999 Edition of National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants. The facility census was 60.

Findings included:

During an interview, conducted at 2:54 PM on 11/29/11, Staff C Director of Plant Operations stated the facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Chapter 9.7.6.2 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-
Based Fire Protection Systems.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants. The facility census was 60.

Findings included:

During an interview, conducted at 2:54 PM on 11/29/11, Staff C Director of Plant Operations stated the facility did not have a procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Chapter 9.6.1.8 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.