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Based on observation, the facility failed to ensure the integrity of the building construction as evidenced by an unsealed penetrations in the wall and ceiling. This affected one of two smoke compartments, which could result in the passage of smoke or fire to other locations in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception:* Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
8.2.1* Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.


Findings:

During a facility tour with the Assistant Director of Plant Operations on 8/31/16, the walls and ceilings were observed.

1. At 9:37 a.m., there was an approximately 1/2 inch in diameter unsealed penetration in the wall behind the door knob in Room 635. The Assistant Director of Plant Operations confirmed the finding.

2. At 9:42 a.m., there was an approximately 1 inch long by 1/8 inch wide unsealed penetration on the side of the escutcheon ring in the ceiling in the restroom located in Room 638. This finding was acknowledged by the Assistant Director of Plant Operations.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by a self-closing device to a door that was inoperable. This affected one of two smoke compartments and could result in the passage smoke and flames in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition

19.2.3.6.3 Doors shall be provided with latches or other mechanisms suitable for keeping the doors closed. No doors shall be arranged to prevent the occupant from closing the door.
19.2.3.6.4 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Exception: Door-closing devices shall not be required in buildings protected throughout by an approved automatic sprinkler system in accordance with 19.2.3.5.2.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.


7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.


Findings:

During a tour of the facility with the Assistant Director of Plant Operations on 8/31/16, the corridor doors were observed.

At 9:34 a.m., the door to the Laundry room near Room 635 was equipped with a self-closing device that had the arm hinge disconnected from the door. This made the self-closing device not operable and the finding was confirmed by the Assistant Director of Plant Operations.

Based on observation and document review, the facility failed to maintain the emergency battery backup lighting system. This was evidenced by failure to conduct the 30-day intervals for not less than 30 seconds functional test and the annual functional test of the emergency battery backup lighting system. This could result in a failure to provide backup lighting in the event of evacuation and affected the generator location.


NFPA 101, Life Safety Code, 2000 Edition

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


Findings:

During a tour of the facility and document review with the Assistant Director of Plant Operations on 8/31/16, the emergency battery backup lighting system was observed and document reviewed.

At 1:30 p.m., the facility failed to conduct 8 of 12 monthly testing of not less than 30 seconds functional test and an annual test for not less than 1 1/2 hours for the emergency battery backup lighting system. The last annual test was conducted on 7/22/15. There were three emergency battery backup lighting system units observed in the Generator enclosure. This finding was confirmed by the Assistant Director of Plant Operations.

Based on observation and document review, the facility failed to maintain the battery-powered emergency exit signs. This was evidenced by failure to conduct the 30-day intervals for not less than 30 seconds functional test and the annual functional test of the battery-powered emergency exit signs. This could result in a failure to provide backup lighting in the event of evacuation and affected two of two smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours annually. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


Findings:

During a tour of the facility and document review with the Assistant Director of Plant Operations on 8/31/16, the battery-powered emergency exit signs were observed and documentation was reviewed.

At 1:25 p.m., the facility failed to conduct 8 of 12 monthly tests of not less than 30 seconds functional test and an annual test for not less than 1 1/2 hours for the battery-powered emergency exit signs. The last annual test was conducted on 7/22/15. There were three battery-powered emergency exit signs observed in the facility. This finding was confirmed by the Assistant Director of Plant Operations.

Based on document review and interview, the facility failed to ensure that smoke detectors were maintained. This was evidenced by no documented sensitivity test for four smoke detectors. The smoke detector could fail in the event of a fire and affected two of two smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.
(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section_____ ."
(8) Functional Test of Detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem, corrected/success-fully retested, device abandoned in place)


Findings:

During a tour of the facility and document review with Assistant Director of Plant Operations on 8/31/16, the smoke detector maintenance records were reviewed and staff was interviewed.

At 11:45 a.m., the smoke detector sensitivity test conducted on 12/28/15 failed to indicate the four smoke detectors along the west wing corridor were tested. The Assistant Director of Plant Operations contacted the vendor to inquire as to the reason for not including the smoke detectors in the corridor. The vendor stated that the smoke detectors in the corridor are self-testing and a print out will be provided to show the results. This finding was acknowledge by the Assistant Director of Plant Operations who stated that the print out out will be provided when they receive it from the vendor.

Based on document review, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to conduct three of four quarterly waterflow test for the automatic sprinkler system. This could affect the effectiveness of the automatic sprinkler system in the event of a fire and affected two of two smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT
9.7.1 Automatic Sprinklers.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

) 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions.

9-3.5 Maintenance. The operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.

9-4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

9-4.4.1.5 Strainers, filters, and restricted orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


Findings:

During document review with the Assistant Director of Plant Operations on 8/31/16, the documents for the automatic sprinkler system were reviewed.

At 12:27 p.m., the facility failed to conduct three of four quarterly sprinkler tests. The facility provided waterflow test conducted by the sprinkler system vendor for the first quarter (3/2/16). There were no waterflow test conducted during the second quarter (6/6/16) 2016, third quarter (9/11/15), and fourth quarter (12/11/15). This finding was confirmed by the Assistant Director of Plant Operations.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by failure to conduct monthly inspections for one fire extinguisher. This could result in a delayed notification of malfunctioning portable fire extinguisher and affected the room that housed the fire alarm control panel (FACP).


NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.


Chapter 4 Inspection, Maintenance, and Recharging
4-1 General.
4-1.1 This chapter is concerned with the rules governing inspection, maintenance, and recharging of fire extinguishers. These factors are of prime importance in ensuring operation at the time of a fire.
4-1.2 The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly "quick check" or inspection in order to follow the inspection procedure as outlined in Section.
4-3. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer's service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.

4-4.4* Maintenance Recordkeeping.
Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that
identifies the person performing the service.




Findings:

During a tour of the facility with the Assistant Director of Plant Operations on 8/31/16, the fire extinguishers were observed.

At 10:04 a.m., the fire extinguisher in the FACP/Airhandler room was not inspected during the months of June and July of 2016. The annual service was conducted on 5/4/16. This finding was confirmed by the Assistant Director of Plant Operations.

Based on document review and interview, the facility failed to maintain the emergency generator. This was evidenced by failure to conduct weekly visual inspections and by failure to exercised at least once monthly, for a minimum of 30 minutes for the diesel powered emergency generator. This two of two smoke compartments and could result in a malfunctioning emergency generator in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.1 UTILITIES

7.9.2 Performance of System.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-4.1.1.8 Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
3-4.4.1.1(a) Maintenance of Alternate Power Source. The generator set 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.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
6-3 Maintenance and Operational Testing.
6-3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising,operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5* Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.
6-3.6* Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.

Findings:
During document review and interview with the Assistant Director of Plant Operations on 8/31/16, the documents for the emergency generator were reviewed and staff was interviewed.
At 1:10 p.m., the documents for the diesel powered emergency generator were reviewed. The facility failed to conduct 28 of 52 weekly visual inspections, and 6 of 12 monthly tests under load. The facility failed to conduct monthly load tests during the months of September, October, November, and December of 2015, January and February of 2016. The last annual load bank test performed was dated 7/27/15. The Assistant Director of Plant Operations acknowledged the finding and stated that there were no monthly tests conducted under load during those months.