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Based on observation and interview, the facility failed to ensure the interior finish for 1 of 1 patient/staff conference on the third floor has a flame spread rating of Class A, Class B or Class C finish. This deficient practice could affect 1 or 2 patients in the third floor patient/staff conference room.

Findings include:

Based on observation and interview with the Director of Environmental Services on 10/01/14 at 1:30 p.m., documentation to demonstrate the paneling on the bottom third of the wall in the patient/staff conference room provided Class A, Class B or Class C finish was not available.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls in the 2001 addition was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect one of one smoke compartments in the 2001 addition.

Findings include:

Based on observations with Director of Environmental Services on 10/01/14 from 2:52 p.m. to 2:57 p.m., above the ceiling tile of the third floor smoke barrier wall along the PACU unit there were unfinished drywall joints and unsealed penetrations measuring in size from three quarters inch to one half inch around sprinkler lines and conduct. Additionally there was an unsealed gap along the top of the same smoke barrier wall where it meets the roof deck above. In the same smoke barrier wall above the ceiling tile at the south entrance to the PACU unit there were unsealed penetration measuring from two inches to one inch around water lines and conduit. After referring to the building construction plans the Director of Environmental Services confirmed this was a smoke barrier wall at 2:57 p.m.

3.1-19(b)

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 2 smoke barrier walls was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect one of two smoke compartments.

Findings include:

Based on observations with Director of Environmental Services on 10/02/14 at 11:10 a.m., on the first floor above the ceiling tile at the smoke barrier wall between the 2001 addition and the 2008 addition there were unsealed penetrations measuring one and one half inch around conduit and four inches by five inches around a bundle of wires and conduit. Measurement were provided by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 3 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect three of four smoke compartments.

Findings include:

Based on observations with Director of Environmental Services on 10/02/14 from 11:00 a.m. to 11:10 a.m., on the first floor above the ceiling tile at the following was noted:
a) at the smoke barrier wall between the original building and the 2001 addition there was an unsealed penetration measuring from 12 inches by three and one half inches around water lines and two inches by three inches around a bundle of wires and conduit.
b) at the smoke barrier wall between the 2001 addition and the 2008 addition there were unsealed penetrations measuring one and one half inch around conduit and four inches by five inches around a bundle of wires and conduit.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Environmental Services on 09/30/14 at 2:00 p.m., acknowledged the elevator equipment room in Patient access room A111 lacked sprinkler coverage or protection from an automatic extinguishing system.


2. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 endoscopy area electrical rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. Exception: Sprinklers shall not be required where all of the following conditions are met: (a) the room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room. This deficient practice could affect any patients near or in the elevators near the endoscopy area.

Findings include:

Based on an observation and interview, the Director of Environmental Services on 09/30/14 at 3:15 p.m., acknowledged electrical room A397 lacked sprinkler coverage and was unable to determine the enclosure was rated for two hours. Additionally, the door entering the electrical room was an unrated door that lacked a self closing device.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on an observation and interview, the Director of Environmental Services on 10/02/14 at 10:45 a.m., acknowledged the elevator equipment room near the physician's offices lacked sprinkler coverage or protection from an automatic extinguishing system.

Based on observation and interview, the facility failed to ensure 2 of 4 fire extinguishers on the third floor was readily accessible at all times. NFPA 10, Standard for Portable Fire Extinguishers, Section 1-6.3 requires that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect 1 of 3 smoke compartments.

Findings include:

Based on an observation with the Director of Environmental Services on 10/01/14 at 12:20 p.m., access to the two fire extinguishers located in a wall cabinet in the west end of the third floor was obstructed by a portable computer workstation and a chair. This was acknowledged by the Director of Environmental Services at the time of observation.

1. Based on observation and interview, the facility failed to ensure 1 of 2 manual hood fire extinguishing activation devices was located in the path of egress. Section 9.2.3 requires commercial cooking equipment to be in compliance with NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 at Section 7-5.1 states a readily accessible means for manual activation shall be located between 42 inches and 60 inches above the floor, located in a path of exit or egress, and clearly identify the hazard protected. This deficient practice affects patients, staff and visitors in and near the main kitchen.

Findings include:

Based on an observation with the Director of Environmental Services on 10/01/14 at 1:55 p.m., the activation device for the main kitchen hood fire protection system was mounted on the wall behind kitchen stove cooking bank of equipment. At the time of observation the Director of Environmental Services acknowledged the only activation device for the hood suppression system was behind the cooking banking which was not in the path of egress.


2. Based on observation and interview, the facility failed to ensure 1 of 1 Class K portable fire extinguishers was provided in the snack bar. NFPA 96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, at 7-10.2 requires portable fire extinguishers to be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10, at 2-3.2 requires portable fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. This deficient practice affects patients, staff and visitors in and near the snack bar.

Findings include:

Based on observation and interview with the Director of Environmental Services on 10/01/14 at 1:30 p.m., he acknowledged there was no Class K type portable fire extinguisher to accompany the hood suppression system in the snack bar grill area.

3. Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system was protected in accordance with NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 5-1.1 states, approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, and listed for this use. NFPA 96, 8-1.6 states, cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or otherwise impaired. This deficient practice could affect patients, staff and visitors near and/or in the main kitchen.

Findings include:

Based on record review with the Director of Environmental Services on 10/01/14 at 11:00 a.m., the untitled Hood main kitchen hood cleaning report dated 06/19/14 stated "Fan not hinge, Parts of ductwork not accessible". Based on an interview with the Director of Environmental Services at the time of record review, he stated he was aware of the issue but had not made the correction.

Based on observation and interview, the facility failed to enforce the policy for the use of 1 of 1 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect patients in the PPG Cardiology clinic.

Findings include:

Based on an observation with the Director of Environmental Services on 09/30/14 at 1:50 p.m., there was a space heater in the doctors office of the PPG Cardiology clinic. Based on interview with the Director of Environmental Services on at the time of observation, the facility does allow space heaters but he was not aware of this space heater and could not confirm the heating element didn't exceed 212 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers was maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Director of Environmental Services on 10/02/14 at 11:50 a.m., there were sixteen unsealed ceiling penetrations in the furnace room measuring one fourth inch. This was confirmed by the Director of Environmental Services at the time of observation.

Based on record review and interview, the facility failed to ensure the load testing for the past 12 months indicated a load test was conducted under operating temperature conditions, minimum exhaust gas temperatures or not less than 30 percent of the nameplate rating for 1 of 3 diesel powered emergency generator sets. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating temperature conditions, maintains the minimum exhaust gas temperatures or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients in the original building.

Findings include:

Based on record review of the "Generator weekly/monthly check" with the Director of Environmental Services on 10/01/14 at 11:40 a.m., diesel generator "A" test log showed a monthly load test for the past twelve months but the log did not indicate if the diesel generator was exercised under operating conditions, maintains the minimum exhaust gas temperatures or not less than thirty percent of the EPS nameplate rating at least monthly, for a minimum of thirty minutes. Based on an interview with the Director of Environmental Services at the time of record review, the generator did reach 30 percent of the EPS nameplate rating during some monthly load tests but not all. He stated an annual load bank was not performed on diesel generator "A".

3.1-19(b)

Based on observation and interview, the facility failed to ensure the interior finish for 1 of 1 patient/staff conference on the third floor has a flame spread rating of Class A, Class B or Class C finish. This deficient practice could affect 1 or 2 patients in the third floor patient/staff conference room.

Findings include:

Based on observation and interview with the Director of Environmental Services on 10/01/14 at 1:30 p.m., documentation to demonstrate the paneling on the bottom third of the wall in the patient/staff conference room provided Class A, Class B or Class C finish was not available.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls in the 2001 addition was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect one of one smoke compartments in the 2001 addition.

Findings include:

Based on observations with Director of Environmental Services on 10/01/14 from 2:52 p.m. to 2:57 p.m., above the ceiling tile of the third floor smoke barrier wall along the PACU unit there were unfinished drywall joints and unsealed penetrations measuring in size from three quarters inch to one half inch around sprinkler lines and conduct. Additionally there was an unsealed gap along the top of the same smoke barrier wall where it meets the roof deck above. In the same smoke barrier wall above the ceiling tile at the south entrance to the PACU unit there were unsealed penetration measuring from two inches to one inch around water lines and conduit. After referring to the building construction plans the Director of Environmental Services confirmed this was a smoke barrier wall at 2:57 p.m.

3.1-19(b)

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 2 smoke barrier walls was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect one of two smoke compartments.

Findings include:

Based on observations with Director of Environmental Services on 10/02/14 at 11:10 a.m., on the first floor above the ceiling tile at the smoke barrier wall between the 2001 addition and the 2008 addition there were unsealed penetrations measuring one and one half inch around conduit and four inches by five inches around a bundle of wires and conduit. Measurement were provided by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 3 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect three of four smoke compartments.

Findings include:

Based on observations with Director of Environmental Services on 10/02/14 from 11:00 a.m. to 11:10 a.m., on the first floor above the ceiling tile at the following was noted:
a) at the smoke barrier wall between the original building and the 2001 addition there was an unsealed penetration measuring from 12 inches by three and one half inches around water lines and two inches by three inches around a bundle of wires and conduit.
b) at the smoke barrier wall between the 2001 addition and the 2008 addition there were unsealed penetrations measuring one and one half inch around conduit and four inches by five inches around a bundle of wires and conduit.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Environmental Services on 09/30/14 at 2:00 p.m., acknowledged the elevator equipment room in Patient access room A111 lacked sprinkler coverage or protection from an automatic extinguishing system.


2. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 endoscopy area electrical rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. Exception: Sprinklers shall not be required where all of the following conditions are met: (a) the room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room. This deficient practice could affect any patients near or in the elevators near the endoscopy area.

Findings include:

Based on an observation and interview, the Director of Environmental Services on 09/30/14 at 3:15 p.m., acknowledged electrical room A397 lacked sprinkler coverage and was unable to determine the enclosure was rated for two hours. Additionally, the door entering the electrical room was an unrated door that lacked a self closing device.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on an observation and interview, the Director of Environmental Services on 10/02/14 at 10:45 a.m., acknowledged the elevator equipment room near the physician's offices lacked sprinkler coverage or protection from an automatic extinguishing system.

Based on observation and interview, the facility failed to ensure 2 of 4 fire extinguishers on the third floor was readily accessible at all times. NFPA 10, Standard for Portable Fire Extinguishers, Section 1-6.3 requires that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect 1 of 3 smoke compartments.

Findings include:

Based on an observation with the Director of Environmental Services on 10/01/14 at 12:20 p.m., access to the two fire extinguishers located in a wall cabinet in the west end of the third floor was obstructed by a portable computer workstation and a chair. This was acknowledged by the Director of Environmental Services at the time of observation.

1. Based on observation and interview, the facility failed to ensure 1 of 2 manual hood fire extinguishing activation devices was located in the path of egress. Section 9.2.3 requires commercial cooking equipment to be in compliance with NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 at Section 7-5.1 states a readily accessible means for manual activation shall be located between 42 inches and 60 inches above the floor, located in a path of exit or egress, and clearly identify the hazard protected. This deficient practice affects patients, staff and visitors in and near the main kitchen.

Findings include:

Based on an observation with the Director of Environmental Services on 10/01/14 at 1:55 p.m., the activation device for the main kitchen hood fire protection system was mounted on the wall behind kitchen stove cooking bank of equipment. At the time of observation the Director of Environmental Services acknowledged the only activation device for the hood suppression system was behind the cooking banking which was not in the path of egress.


2. Based on observation and interview, the facility failed to ensure 1 of 1 Class K portable fire extinguishers was provided in the snack bar. NFPA 96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, at 7-10.2 requires portable fire extinguishers to be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10, at 2-3.2 requires portable fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. This deficient practice affects patients, staff and visitors in and near the snack bar.

Findings include:

Based on observation and interview with the Director of Environmental Services on 10/01/14 at 1:30 p.m., he acknowledged there was no Class K type portable fire extinguisher to accompany the hood suppression system in the snack bar grill area.

3. Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system was protected in accordance with NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 5-1.1 states, approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, and listed for this use. NFPA 96, 8-1.6 states, cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or otherwise impaired. This deficient practice could affect patients, staff and visitors near and/or in the main kitchen.

Findings include:

Based on record review with the Director of Environmental Services on 10/01/14 at 11:00 a.m., the untitled Hood main kitchen hood cleaning report dated 06/19/14 stated "Fan not hinge, Parts of ductwork not accessible". Based on an interview with the Director of Environmental Services at the time of record review, he stated he was aware of the issue but had not made the correction.

Based on observation and interview, the facility failed to enforce the policy for the use of 1 of 1 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect patients in the PPG Cardiology clinic.

Findings include:

Based on an observation with the Director of Environmental Services on 09/30/14 at 1:50 p.m., there was a space heater in the doctors office of the PPG Cardiology clinic. Based on interview with the Director of Environmental Services on at the time of observation, the facility does allow space heaters but he was not aware of this space heater and could not confirm the heating element didn't exceed 212 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers was maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Director of Environmental Services on 10/02/14 at 11:50 a.m., there were sixteen unsealed ceiling penetrations in the furnace room measuring one fourth inch. This was confirmed by the Director of Environmental Services at the time of observation.

Based on record review and interview, the facility failed to ensure the load testing for the past 12 months indicated a load test was conducted under operating temperature conditions, minimum exhaust gas temperatures or not less than 30 percent of the nameplate rating for 1 of 3 diesel powered emergency generator sets. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating temperature conditions, maintains the minimum exhaust gas temperatures or not less than 30 percent of the EPS nameplate rating at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients in the original building.

Findings include:

Based on record review of the "Generator weekly/monthly check" with the Director of Environmental Services on 10/01/14 at 11:40 a.m., diesel generator "A" test log showed a monthly load test for the past twelve months but the log did not indicate if the diesel generator was exercised under operating conditions, maintains the minimum exhaust gas temperatures or not less than thirty percent of the EPS nameplate rating at least monthly, for a minimum of thirty minutes. Based on an interview with the Director of Environmental Services at the time of record review, the generator did reach 30 percent of the EPS nameplate rating during some monthly load tests but not all. He stated an annual load bank was not performed on diesel generator "A".

3.1-19(b)