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Based on observation and interview, the facility failed to ensure that all corridor doors were maintained to prevent the passage of smoke and/or fire into the corridor. This was evidenced by corridor doors that failed to close and latch when tested, and affected 1 of 4 floors in Building K, West Wing.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During a tour of the facility with Engineering Staff on 1/27/15, the corridor doors were observed.

FOURTH FLOOR

1. At 10:33 a.m., the door to Room 4KJ02 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch. When interviewed, Staff 1 stated that the hinges and the self-closing device need adjustment.

2. At 10:37 a.m., the door to Room 4K137 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch. When interviewed, Staff 1 stated that the self-closing device needs adjustment.

Based on document review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels in 12 of 14 operating rooms between 20% and 60%. This affected all patients and staff in the operating room, and could result in a fire emergency due to electrostatic charges in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review with the Engineering Staff on 1/27/15, the facility's humidity logs were reviewed.

At 12:45 p.m., the humidity logs were reviewed. The "Temperature and Humidity Log" noted the shifts (Day shift is 7 am - 3 pm; PM shift is 3 pm - 11 pm; and Night shift is 11 pm - 7 am) and humidity levels. The relative humidity levels in January 2015 and December 2014 were below 20%, and the relative humidity levels in October 2014, August 2014, July 2014 and February 2014 were above 60%. The Policy and Procedure indicated that the humidity would be maintained between 20% to 60%.

Operating Room 1:
1. On 1/1/15, the humidity levels were 19.2%, 16.2% and 17.3% on the night shift. The "Corrective actions/Room Occupies" on the Temperature/and Humidity Log " indicated that the temp was increased 1-2 degrees.
2. On 1/2/15, the "Corrective Actions/Room Occupied" column stated "OR#1 misted @ 2:30 boiler room and nursing Supervisor notified. Asked to monitor OR#1 on the weekend and not use the room."
3. On 8/6/14, the humidity level was 62.2% on the day shift. "Corrective Actions" stated Rm temp increased "Rm temp increased (up arrow), zero patient"
4. On 8/1/14, the humidity level was 61.2% on the day shift.
5. On 7/1/14, the humidity level was 64.7% on the day shift.

Operating Room 2:
6. On 1/1/15, the humidity levels were 14.9% on the night shift; 15.2%, 15%, 16.1% and 15.2% on the day shift, and 16.1% and 16.2% on the PM shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
7. On 1/2/15, the humidity level was 19.8% on the night shift. The "Corrective actions/Rooms Occupied" on the Temperature/and Humidity Log indicated that the nursing supervisor was notified of the low humidity, call to the boiler room and the temperature in the room was adjusted.
8. On 12/31/14, the humidity level was 7.7% on the day shift.
9. On 7/20/14, the humidity level was 63.6% on the day shift. Facilities were notified.
10. On 7/1/14, the humidity level was 63.8% on the day shift.

Operating Room 3:
11. On 1/1/15, the humidity levels were 18.3%, 18.4% and 19.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
12. On 7/1/14, the humidity level was 65.8% on the day shift.
13. On 2/8/14, the the night shift stated in the "Corrective Actions" column "OR #3 UNDER CONSTRUCTION!" The day shift stated "OR #3 under construction." The PM shift stated "Room 3 closed for repair."

Operating Room 4:
14. On 1/1/15, the humidity levels were 17.8% on the night shift; 17.1% and 15.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
15. On 8/6/14, the humidity level was 60.4% on the day shift. A staff at the "Boiler Plant called & aware of the situation."
16. On 8/1/14, the humidity level was 67.5% on the day shift. Facilities were notified and a service work request was completed.

Operating Room 5:
17. On 1/1/15, the humidity levels were 18.9% on the night shift; 18.6% and 18% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
18. On 8/6/14, the humidity level was 65.6% on the PM shift. A staff at the "Boiler Plant called & aware of the situation."
19. On 8/1/14, the humidity level was 62.2% on the day shift. Facilities were notified and a service work request was completed.
20. On 7/20/14, the humidity level was 62.5% on the PM shift. Facilities were notified
21. On 2/8/14, the humidity levels were 61.4% on the day shift and 60.7% on the PM shift. The OR was not in use.

Operating Room 6:
22. On 1/1/15, the humidity levels were 16.7% on the night shift; 16.1% and 15.9% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
23. On 12/31/14, the humidity levels were 10.5% and 17% on the day shift.
24. On 8/1/14, the humidity level was 61.4% on the day shift. Facilities were notified and a service work request was completed.
25. On 7/1/14, the humidity level was 65.5% on the day shift.
26. On 2/8/14, the humidity levels were 61.3% on the day shift and 61.8% on the PM shift. The OR was not in use.

Operating Room 7:
27. On 1/1/15, the humidity levels were 16.8% on the night shift; 16.3% and 18% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
28. On 12/31/14, the humidity levels were 12%, 14% and 18%. No shift was specified on the log.
29. On 7/1/14, the humidity level was 64% on the day shift.

Operating Room 8
30. On 1/1/15, the humidity levels were 15.2% on the night shift; and 15% and 16.4% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
31. On 8/7/14, the humidity level was 61.3% on the day shift. Facilities were notified. A patient was in the room.
32. On 8/6/14, the humidity level was 61.5% on the day shift. "Corrective Actions" stated ". Rm temp increased (up arrow)"
33. On 8/1/14, the humidity level was 64.8% on the day shift. Facilities were notified and a service work request was completed. The OR was not in use.
34. On 7/1/14, the humidity level was 65.7% on the day shift.

Operating Room 9:
35. On 1/1/15, the humidity level was 18.8% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
36. On 8/1/14, the humidity level was 63% on the day shift. Corrective Action - Facilities were notified and a service work request was done. There was an ongoing case in the operating room.
37. On 7/28/14, the humidity level was 64.3% on the day shift.
38. On 7/1/14, the humidity level was 66.4% on the day shift.
39. On 2/8/14, the humidity level was 60.7% on the PM shift. The OR was not in use.

Operating Room 10:
40. On 1/1/15, the humidity levels were 14.6% on the night shift; 19.9% on the PM shift; and 17.5%, 14.2% and 19.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
41. On 1/2/15, the humidity level was 18% on the night shift. The " Corrective actions/Room Occupied " on the Temperature/and Humidity Log " indicated that the nursing supervisor was notified of the low humidity, call to the boiler room and the temperature in the room was adjusted.
42. On 1/2/15, the humidity level was 18.6% on the day shift. The case was moved to OR 7.
43. On 10/17/14, the humidity level was 69.5% on the night shift. Facilities and nurse supervisor were notified.

Operating Room 11:
44. On 1/1/15, the humidity level was 14.7% on the night shift; 14.9% and 18.9% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
45. On 1/2/15, the humidity level was 19.2% on the night shift. The "Corrective actions/Room Occupied" on the Temperature/and Humidity Log indicated that the nursing supervisor was notified of the low humidity call to the boiler room and the temperature in the room was adjusted.
46. On 1/2/15, the humidity level was 19.5% on the day shift. The case was moved to OR 12.
47. On 7/1/14, the humidity level was 62.6% on the day shift.

Operating Room 12:
48. On 1/1/15, the humidity levels were 16.7% on the night shift; and 15.8% and 16.4% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.

At 3 p.m., the Director of Facilities was interviewed. He confirmed the findings and stated that the staff in the operating rooms had complete control of the temperature. When the room is warm, the gauge on the temperature is lowered, and this affects the humidity in the room. The Director of Facilities stated that they have a set point in place for the humidity to 25 percent and set the temperatures in the operating room to 68 degrees and locked the control for the temperature.

Based on document review and interview, the facility failed to provide complete documentation of generator monthly load tests. This was evidenced by incomplete documentation of the transfer times for the emergency back-up generator. This affected all staff and patients in six of seven buildings at the Main Campus, and could result in the generator failing to function during a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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.
(b) Inspection and Testing.
1.* Test Criteria. 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,
2. Test Conditions. 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.
3. Test Personnel. 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.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for 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.

Findings:

During document review with Director of Facilities on 1/26/15, the generator maintenance records were reviewed.

At 3:06 p.m., the generator log failed to document the transfer times during the monthly load tests. When interviewed, the Director of Facilities confirmed the findings and stated that they will start documenting the transfer times during the monthly load.

Based on observation and interview, the facility failed to ensure that all corridor doors were maintained to prevent the passage of smoke and/or fire into the corridor. This was evidenced by corridor doors that failed to close and latch when tested, and affected 1 of 4 floors in Building K, West Wing.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During a tour of the facility with Engineering Staff on 1/27/15, the corridor doors were observed.

FOURTH FLOOR

1. At 10:33 a.m., the door to Room 4KJ02 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch. When interviewed, Staff 1 stated that the hinges and the self-closing device need adjustment.

2. At 10:37 a.m., the door to Room 4K137 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch. When interviewed, Staff 1 stated that the self-closing device needs adjustment.

Based on document review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels in 12 of 14 operating rooms between 20% and 60%. This affected all patients and staff in the operating room, and could result in a fire emergency due to electrostatic charges in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review with the Engineering Staff on 1/27/15, the facility's humidity logs were reviewed.

At 12:45 p.m., the humidity logs were reviewed. The "Temperature and Humidity Log" noted the shifts (Day shift is 7 am - 3 pm; PM shift is 3 pm - 11 pm; and Night shift is 11 pm - 7 am) and humidity levels. The relative humidity levels in January 2015 and December 2014 were below 20%, and the relative humidity levels in October 2014, August 2014, July 2014 and February 2014 were above 60%. The Policy and Procedure indicated that the humidity would be maintained between 20% to 60%.

Operating Room 1:
1. On 1/1/15, the humidity levels were 19.2%, 16.2% and 17.3% on the night shift. The "Corrective actions/Room Occupies" on the Temperature/and Humidity Log " indicated that the temp was increased 1-2 degrees.
2. On 1/2/15, the "Corrective Actions/Room Occupied" column stated "OR#1 misted @ 2:30 boiler room and nursing Supervisor notified. Asked to monitor OR#1 on the weekend and not use the room."
3. On 8/6/14, the humidity level was 62.2% on the day shift. "Corrective Actions" stated Rm temp increased "Rm temp increased (up arrow), zero patient"
4. On 8/1/14, the humidity level was 61.2% on the day shift.
5. On 7/1/14, the humidity level was 64.7% on the day shift.

Operating Room 2:
6. On 1/1/15, the humidity levels were 14.9% on the night shift; 15.2%, 15%, 16.1% and 15.2% on the day shift, and 16.1% and 16.2% on the PM shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
7. On 1/2/15, the humidity level was 19.8% on the night shift. The "Corrective actions/Rooms Occupied" on the Temperature/and Humidity Log indicated that the nursing supervisor was notified of the low humidity, call to the boiler room and the temperature in the room was adjusted.
8. On 12/31/14, the humidity level was 7.7% on the day shift.
9. On 7/20/14, the humidity level was 63.6% on the day shift. Facilities were notified.
10. On 7/1/14, the humidity level was 63.8% on the day shift.

Operating Room 3:
11. On 1/1/15, the humidity levels were 18.3%, 18.4% and 19.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
12. On 7/1/14, the humidity level was 65.8% on the day shift.
13. On 2/8/14, the the night shift stated in the "Corrective Actions" column "OR #3 UNDER CONSTRUCTION!" The day shift stated "OR #3 under construction." The PM shift stated "Room 3 closed for repair."

Operating Room 4:
14. On 1/1/15, the humidity levels were 17.8% on the night shift; 17.1% and 15.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
15. On 8/6/14, the humidity level was 60.4% on the day shift. A staff at the "Boiler Plant called & aware of the situation."
16. On 8/1/14, the humidity level was 67.5% on the day shift. Facilities were notified and a service work request was completed.

Operating Room 5:
17. On 1/1/15, the humidity levels were 18.9% on the night shift; 18.6% and 18% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
18. On 8/6/14, the humidity level was 65.6% on the PM shift. A staff at the "Boiler Plant called & aware of the situation."
19. On 8/1/14, the humidity level was 62.2% on the day shift. Facilities were notified and a service work request was completed.
20. On 7/20/14, the humidity level was 62.5% on the PM shift. Facilities were notified
21. On 2/8/14, the humidity levels were 61.4% on the day shift and 60.7% on the PM shift. The OR was not in use.

Operating Room 6:
22. On 1/1/15, the humidity levels were 16.7% on the night shift; 16.1% and 15.9% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
23. On 12/31/14, the humidity levels were 10.5% and 17% on the day shift.
24. On 8/1/14, the humidity level was 61.4% on the day shift. Facilities were notified and a service work request was completed.
25. On 7/1/14, the humidity level was 65.5% on the day shift.
26. On 2/8/14, the humidity levels were 61.3% on the day shift and 61.8% on the PM shift. The OR was not in use.

Operating Room 7:
27. On 1/1/15, the humidity levels were 16.8% on the night shift; 16.3% and 18% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
28. On 12/31/14, the humidity levels were 12%, 14% and 18%. No shift was specified on the log.
29. On 7/1/14, the humidity level was 64% on the day shift.

Operating Room 8
30. On 1/1/15, the humidity levels were 15.2% on the night shift; and 15% and 16.4% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
31. On 8/7/14, the humidity level was 61.3% on the day shift. Facilities were notified. A patient was in the room.
32. On 8/6/14, the humidity level was 61.5% on the day shift. "Corrective Actions" stated ". Rm temp increased (up arrow)"
33. On 8/1/14, the humidity level was 64.8% on the day shift. Facilities were notified and a service work request was completed. The OR was not in use.
34. On 7/1/14, the humidity level was 65.7% on the day shift.

Operating Room 9:
35. On 1/1/15, the humidity level was 18.8% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
36. On 8/1/14, the humidity level was 63% on the day shift. Corrective Action - Facilities were notified and a service work request was done. There was an ongoing case in the operating room.
37. On 7/28/14, the humidity level was 64.3% on the day shift.
38. On 7/1/14, the humidity level was 66.4% on the day shift.
39. On 2/8/14, the humidity level was 60.7% on the PM shift. The OR was not in use.

Operating Room 10:
40. On 1/1/15, the humidity levels were 14.6% on the night shift; 19.9% on the PM shift; and 17.5%, 14.2% and 19.2% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room was notified.
41. On 1/2/15, the humidity level was 18% on the night shift. The " Corrective actions/Room Occupied " on the Temperature/and Humidity Log " indicated that the nursing supervisor was notified of the low humidity, call to the boiler room and the temperature in the room was adjusted.
42. On 1/2/15, the humidity level was 18.6% on the day shift. The case was moved to OR 7.
43. On 10/17/14, the humidity level was 69.5% on the night shift. Facilities and nurse supervisor were notified.

Operating Room 11:
44. On 1/1/15, the humidity level was 14.7% on the night shift; 14.9% and 18.9% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.
45. On 1/2/15, the humidity level was 19.2% on the night shift. The "Corrective actions/Room Occupied" on the Temperature/and Humidity Log indicated that the nursing supervisor was notified of the low humidity call to the boiler room and the temperature in the room was adjusted.
46. On 1/2/15, the humidity level was 19.5% on the day shift. The case was moved to OR 12.
47. On 7/1/14, the humidity level was 62.6% on the day shift.

Operating Room 12:
48. On 1/1/15, the humidity levels were 16.7% on the night shift; and 15.8% and 16.4% on the day shift. The Nursing Supervisor staff and staff at the Boiler Room were notified.

At 3 p.m., the Director of Facilities was interviewed. He confirmed the findings and stated that the staff in the operating rooms had complete control of the temperature. When the room is warm, the gauge on the temperature is lowered, and this affects the humidity in the room. The Director of Facilities stated that they have a set point in place for the humidity to 25 percent and set the temperatures in the operating room to 68 degrees and locked the control for the temperature.

Based on document review and interview, the facility failed to provide complete documentation of generator monthly load tests. This was evidenced by incomplete documentation of the transfer times for the emergency back-up generator. This affected all staff and patients in six of seven buildings at the Main Campus, and could result in the generator failing to function during a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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.
(b) Inspection and Testing.
1.* Test Criteria. 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,
2. Test Conditions. 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.
3. Test Personnel. 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.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for 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.

Findings:

During document review with Director of Facilities on 1/26/15, the generator maintenance records were reviewed.

At 3:06 p.m., the generator log failed to document the transfer times during the monthly load tests. When interviewed, the Director of Facilities confirmed the findings and stated that they will start documenting the transfer times during the monthly load.