HospitalInspections.org

The facility failed to maintain a two-hour fire resistance-rated occupancy separation between the hospital of Type II (000) construction and the attached non-sprinklered administration building of Type V (000) construction.

Observation determined there were numerous unsealed penetrations, open holes and exposed structural components in the two-hour fire resistance wall separating the hospital from the attached non-sprinklered administration building.

Failure to maintain the integrity of the two-hour-fire rated occupancy separation increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) two-hour fire resistance barriers in the facility.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

The facility failed to ensure exit access was readily available at all times.

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

1) The corridor door to Elevator A on the 1st Floor.
2) The corridor door to the center stair enclosure on the 1st Floor.
3) The corridor door to Elevator A on the 2nd Floor.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous corridor doors in the means of egress throughout the facility.

Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. on each side shall be permitted at 38 in. and below. 7.3.2.2

In addition to the requirements of the Life Safety Code, health care facilities must comply with the requirements of the ADA, including the requirements for protruding objects. The 2010 Standards for Accessible Design generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object's leading edge is located more than 27 inches, but not more than 80 inches, above the floor. This requirement protects persons who are blind or have low vision from being injured by bumping into a protruding object that they cannot detect with a cane. Although the Life Safety Code allows 6-inch projections, under the ADA, objects mounted above 27 inches and no more than 80 inches high can only protrude a maximum of 4 inches into the corridor beyond a detectable surface mounted less than 27 inches above the floor (except for certain handrails which may protrude up to 4 1/2 in.)

The facility failed to maintain the means of egress as required.

Observation determined:

1) Speakers that were located in the corridors on the 2nd Floor mounted at a height of seventy-eight (78) inches, extended approximately ten (10) inches from the corridor wall and protruded into the exit corridor.

2) Nurse charting stations that were located in the corridors on the 2nd Floor mounted at a height of thirty-three (33) inches, that were left in the open position extended approximately twenty (20) inches from the corridor wall and protruded into the exit corridor.

The corridor was eight (8) feet wide at all locations.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected egress from one (1) of two (2) floors in the facility.

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

1) Record review determined monthly and annual testing of the emergency battery-powered emergency lighting system was not documented.

2) Observation determined the battery powered emergency light in the Staff Sleeping Room failed to illuminate when tested.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.1.2.1.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit.

Observation determined:

1) No directional exit sign was provided on the west side of the northwest cross-corridor smoke barrier doors in the West Wing on the 2nd Floor to identify the direction of travel to the East Exit Stairway from the west.

2) The exit sign in the corridor by the Ultrasound Exam Room on the 1st Floor directed exit travel through the elevator lobby into the noncompliant administration building and not to the right down the southeast exit corridor.

Failure to provide exit signage as required increases the risk of death or injury due to fire.

The deficiency affected exiting from two (2) of two (2) floors in the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined:

1) The corridor door to the OB Mechanical Room had two (2) unsealed penetrations.

2) The corridor door to the West Mechanical Room had three (3) unsealed penetrations.

3) The south wall in the West Mechanical Room had two (2) unsealed pipe penetrations.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous hazardous areas in the facility.

Gas and vacuum system zone valves shall not be located in a room with station outlets/inlets that it controls. Zone valves shall be readily operable from a standing position in the corridor on the same floor they serve. A zone valve shall be located immediately outside each vital life-support area, critical care area, and anesthetizing location of moderate sedation, deep sedation, or general anesthesia, in each medical gas or vacuum line, or both, and located so as to be readily accessible in an emergency. NFPA 99 5.1.4.8

The facility failed to install gas and vacuum systems in accordance with NFPA 99, Health Care Facilities Code.

Observation determined the medical air zone valve for OR1 was located in OR1 and not immediately outside the room as required.

Failure to install gas and vacuum systems in accordance with NFPA 99 increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous gas and vacuum system zone valves in the facility.

1) Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. 19.3.2.5.1, 9.2.3, NFPA 96 11.2.1.

The facility failed to test and service the fire-extinguishing system serving the Kitchen exhaust hood in accordance with NFPA 96.

Record review determined the fire-extinguishing system serving the Kitchen exhaust hood was last inspected and serviced during February 2018 by an outside company, exceeding the required 6 months testing requirement.

Failure to inspect and service the fire-extinguishing system for the Kitchen exhaust hood at required intervals increases the risk of injury or death due to fire.

This deficiency affected two (2) of two (2) required inspections of the Kitchen exhaust hood fire-extinguishing system in the past year.

2) The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

At a minimum, this quick check or inspection shall include verification of the following:

(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

If any deficiencies are found, appropriate corrective action shall be taken immediately.
Where the corrective action involves maintenance, it shall be conducted by a trained service technician.
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.
The records shall be retained for the period between the semiannual maintenance inspections. 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed.

Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

The facility failed to ensure alcohol-based hand-rub dispensers were not installed over an ignition source.

Observation determined:

1) An alcohol-based hand-rub dispenser was installed on the wall directly above the push plate for the handicap door opener in OR1.

2) An alcohol-based hand-rub dispenser was installed on the wall directly above a light switch in OR2.

3) An alcohol-based hand-rub dispenser was installed on the wall directly above a light switch in the Dietician Office.

4) An alcohol-based hand-rub dispenser was installed on the wall directly above a light switch in the Ultrasound Room.

Failure to install alcohol-based hand rub dispensers as required increases the risk of death or injury due to fire.

The deficiency affected four (4) of numerous alcohol-based hand rub dispensers in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

System defects and malfunctions shall be corrected. NFPA 72 14.2.1.2.2

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) Review of fire alarm system test records determined the fire alarm system batteries failed when tested on 09/13/2019 and had not been replaced at the time of the survey.

2) Observation determined the heat detector in the storage room across from the Center Tub Room on the 2nd Floor was covered in dust and lint.

Failure to maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

The facility failed to ensure smoke detectors were installed, maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

1) In the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft. The distance between detectors shall not exceed their listed spacing, and there shall be detectors within a distance of one-half the listed spacing, measured at right angles from all walls or partitions. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72: 17.7.3.2.3.1

Observation determined the smoke detector in the Recovery Room was more than 15 ft from the east wall.

2) In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1

Observation determined numerous smoke detectors throughout the facility were installed within 36 in. of an air supply diffuser or return air opening.

3) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. 19.3.4.5, 9.6.2.10.1.1, NFPA 72 14.4.5.3

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

No records were available to indicate smoke detectors were sensitivity tested at the required two-year test interval.

Failure to install, maintain, inspect and test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected all smoke detectors in the facility.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1)

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

1) NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

Observation determined one (1) sprinkler in the Kitchen Stairway installed within 7 ft. of a horizontal discharge unit heater was not high-temperature-rated.

2) NFPA 13 requires intermediate-temperature-rated sprinklers within a 7 ft. to 20 ft. radius pie-shaped cylinder extending 7 ft. above and 2 ft. below horizontal discharge heaters on the discharge side; also a 7 ft. radius cylinder more than 7 ft. above horizontal discharge unit heaters.

Observation determined one (1) sprinkler in the Kitchen Stairway installed between 7 ft. and 20 ft. on the discharge side of horizontal discharge unit heater was not intermediate-temperature-rated.

3) The maximum distance permitted between sprinklers shall be based on the centerline distance between adjacent sprinklers. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the applicable section for each type or style of sprinkler. Standard pendent and upright spray sprinklers shall be spaced not less than 6 ft on center.

Sprinklers shall be permitted to be placed less than 6 ft on center where the following conditions are satisfied:
(1) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(2) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(3) Baffles shall be not less than 8 in. wide and 6 in. high.
(4) The tops of baffles shall extend between 2 in. and 3 in. above the deflectors of upright sprinklers.
(5) The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.
NFPA 13 8.5.3.1, 8.6.3.4, 8.6.3.4.1, 8.6.3.4.2

Observation determined two (2) sprinklers in the Medical Records Room were closer than the minimum of 6 ft apart.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury or death due to fire.

The deficiency affected two (2) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. 19.7.6, 4.6.12, NFPA 25 4.1.4.1, 13.2.7.1, 13.3.2.1.1, 13.6.2.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and observation determined:

1) The control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

2) No annual back flow preventer test was conducted in the past year.

3) There was a steam line tied to a sprinkler pipe behind the dryers in the Laundry Room.

4) Shower curtains suspended from ceiling mounted tracks obstructed coverage of the sprinkler in the Medical-Surgical Tub Room.

5) There were numerous missing ceiling tiles throughout the facility that could delay the activation of the sprinkler system.

6) There were numerous ceiling tiles with holes in them throughout the facility that could delay the activation of the sprinkler system.

7) There were numerous gaps around sprinklers with missing escutcheon plates throughout the facility that could delay the activation of the sprinkler system.

8) There were numerous sprinklers throughout the facility with heavy dust and lint on them that could delay the activation of the sprinkler system.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

The facility failed to install, inspect and maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

1) Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). NFPA 10 6.1.3.8.1, 6.1.3.8.2, 6.1.3.8.3

Observation determined:

a) The portable fire extinguisher in the Telephone Equipment Room was installed with the top of the extinguisher more than 5 ft. above the floor.

b) The portable fire extinguisher in the Laundry Room was installed with the top of the extinguisher more than 5 ft. above the floor.

2) Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 19.3.5.12, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2

Observation determined the inspection tag on the fire extinguisher located in the Recovery Room had not been initialed to indicate a monthly inspection during June, July and August 2019.

3) Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. NFPA 10 7.3.1.1.1

Observation determined the annual maintenance of the portable fire extinguisher located in the Recovery Room had not been conducted since June 2018.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous portable fire extinguishers in the facility.

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, they shall have a fire resistance rating of not less than ½ hour and they shall resist the transfer of smoke. 19.3.6.2.1, 19.3.6.2.2, 19.3.6.2.3

The facility failed to ensure corridors were separated from use areas by walls with at least ½-hour fire resistance rating and constructed to resist the transfer of smoke.

Observation determined the corridor wall in the corridor by the Scheduling Office had unsealed penetrations around an electrical panel.

Failure to separate corridors from other areas increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor walls in the facility.

Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 19.3.6.3.5

The facility failed to ensure corridor doors latched into their frames and resisted the passage of smoke.

Observation and interview with staff determined:

1) The corridor door to the storage room across from the Center Tub Room on the 2nd Floor failed to latch into the frame.

2) The corridor door to the Library failed to latch into the frame.

3) The corridor door to the Classroom failed to latch into the frame.

4) The southeast corridor door to the OB Suite failed to latch into the frame.

5) The northeast pair of corridor doors to the OB Suite failed to latch into the frame.

6) The south pair of corridor doors to the OB Suite failed to latch into the frame.

7) The corridor door to the Maintenance Office was equipped with a deadbolt-type latch which required the use of a key to latch into the frame from the corridor side of the door.

Failure to ensure corridor doors latch properly increases the risk of death or injury due to fire.

The deficiency affected seven (7) of numerous corridor doors in the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70 210.8, 210.8(B)(1), 210.8(B)(2), 210.8(B)(5)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined:

1) Numerous electrical receptacles throughout the facility within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

2) Numerous electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected numerous electrical receptacles in the facility.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5.2.1, 9.2.1, NFPA 90A 5.4.8.1, NFPA 80, 19.4

The facility failed to test and inspect fire dampers in accordance with NFPA 80.

Review of records and staff interview determined the tests and inspections of fire dampers were not performed as required. On 10/22/2019, no records of tests and inspections of fire dampers were available.

Failure to test and inspect fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected all fire dampers in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) No fire drills were conducted on the AM Shift during the fourth quarter of 2018.

2) No fire drills were conducted on the AM and PM Shift during the first quarter of 2019.

3) The 01/29/2019 Night Shift fire drill did not include activating the fire alarm system.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected four (4) of twelve (12) drills in the past year.

The facility failed to ensure the two (2) emergency generators were in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.1, 8.4.2, 8.4.2.3

Review of generator test records did not indicate:

1) The minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 500 kW diesel generator loaded the generator to at least 30% (150 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended temperature during the required monthly exercises.

2) The minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 125 kW diesel generator loaded the generator to at least 30% (38 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended temperature during the required monthly exercises.

3) The generators were exercised under load for a minimum of 30 minutes during the months of June, August and September 2019.

4) The emergency generators were exercised under load for 4 continuous hours in the past 36 months.

Failure to inspect and maintain emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) emergency generators which provide all emergency power to the facility.