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Based on observation, and interview, the facility failed to maintain their smoke barrier doors. This was evidenced by a door that was impeded from closing. This could allow smoke and fire to travel in the event of a fire. This affected 2 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During a tour of the facility with the Director of Plant Operations, and the Director of Support Services on 5/2/17, the doors connected to the fire alarm system were inspected, and a staff person was interviewed.

1. At 9:37 a.m., the west smoke barrier door near the entrance to Adult II, was impeded from closing with a chair in front of the door.

2. At 9:38 a.m., the Director of Plant Operations said during an interview, that the chair should never be in front of any door.

Based on document review, and interview, the facility failed to visually inspect the fire alarm battery monthly, and test the battery semi-annually. This was evidenced by no monthly documented inspections and semi-annual testing. The fire alarm system could fail to transmit a signal in the event of a fire. This affected 5 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
9.6.1.3 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 and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

Table 14.3.1 Visual Inspection Frequencies
3. Batteries
(a) Lead-acid X (Initial) X (Monthly)
(b) Nickel-cadmium X (Initial) X (Monthly) X (Semi-Annual)
(c) Primary (dry cell) X (Initial) X (Monthly)
(d) Sealed lead-acid X (Initial) X (Monthly) X (Semi-Annual)

5. Fire alarm control unit trouble signals X (weekly)

Table 14.4.2.2
6. Battery tests (specific types)
(a) Primary battery load voltage test The maximum load for a No. 6 primary battery shall not be more than 2 amperes per cell. An individual (1.5 volt) cell shall be replaced when a load of 1 ohm reduces the voltage below 1 volt. A 6. volt assembly shall be replaced when a test load of 4 ohms reduces the voltage below 4 volts.
(b) Lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall not fall below 2.05 volts per cell.
(3) Specific gravity The specific gravity of the liquid in the pilot cell or all of the cells shall be measured as required. The specific gravity shall be within the range specified by the manufacturer. Although the specified specific gravity varies from manufacturer to manufacturer, a range of 1.205.1.220 is typical for regular lead-acid batteries, while 1.240.1.260 is typical for high-performance batteries. A hydrometer that shows only a pass or fail condition of the battery and does not indicate the specific gravity shall not be used, because such a reading does not give a true indication of the battery condition.
(c) Nickel-cadmium type
(1) Charger test With the batteries fully charged and connected to the charger, an ampere meter shall be placed in series with the battery under charge. The charging current shall be in accordance with the manufacturer recommendations for the type of battery used. In the absence of specific information, 1.30 to 1/25 of the battery rating shall be used.
(2) Load voltage test Under load, the float voltage for the entire battery shall be 1.42 volts per cell, nominal. If possible, cells shall be measured individually.
(d) Sealed lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall perform in accordance with the battery manufacturer specifications.
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Findings:

During document review with the Director of Support Services, and the Director of Plant Operations on 5/2/17, the fire alarm system inspection and testing records were requested, and a staff person was interviewed.

1. At 10:56 a.m., there was no documented evidence of visual monthly inspections and semi-annual testing of the fire alarm control panel batteries . No documented evidence was provided during the survey.

2. At 10:57 a.m., the Director of Plant Operations said during an interview, that the fire alarm control panel battery was only inspected and test annually by a vendor.

Based on document review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by no current sensitivity smoke detector test. The smoke detectors could fail in the event of a fire. This affected 5 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.3.6.1 Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following:
(1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8, waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft 2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
(3)*This requirement shall not apply to spaces for nurses' stations.
(4) Gift shops not exceeding 500 ft 2 (46.4 m2) shall be permitted to be open to the corridor or lobby, provided that one of the following criteria is met:
(a) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
(b) The gift shop is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, and storage is separately protected.
(5) Limited care facilities in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have group meeting or multipurpose therapeutic spaces open to the corridor, provided that all of the following criteria are met:
(a) The space is not a hazardous area.
(b) The space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the space is arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.
(c) The space does not obstruct access to required exits.
(6) Cooking facilities in accordance with 19.3.2.5.3 shall be permitted to be open to the corridor.
(7) Spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b)*Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.
(8)*Waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) Each area does not exceed 600 ft 2 (55.7 m2).
(b) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(c) The area does not obstruct any access to required exits.
(9) Group meeting or multipurpose therapeutic spaces, other than hazardous areas, that are under continuous supervision by facility staff shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) Each area does not exceed 1500 ft 2 (139 m2).
(b) Not more than one such space is permitted per smoke compartment.
(c) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(d) The area does not obstruct access to required exits.

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

19.3.5.8* Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically references this paragraph, the sprinkler system shall meet all of the following criteria:
(1) It shall be installed throughout the building or smoke compartment in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
(6)*Standard-response sprinklers shall be permitted to be continued to be used in approved existing sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.

19.3.4.5.1 Corridors. An approved automatic smoke detection system in accordance with Section 9.6 shall be installed in all corridors of limited care facilities, unless otherwise permitted by one of the following:
(1) Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors.
(2) Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7 shall be permitted.

9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device 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.

Findings:

During document review with the Director of Plant Operations and Director of Support Services on 5/2/17, the smoke detector testing documents were requested and a staff person was interviewed.

1. At 1:00 p.m., there was no documented evidence of smoke detector sensitivity testing for the 88 smoke detectors within the facility. No documented evidence was provided during the survey.

2. At 1:02 p.m., the Director of Plant Operations said during an interview, that the facility did not have any sensitivity test. The previous testing was misplaced or not done. The Director of Plant Operations stated, that he would schedule a vendor to come out, and perform the test.

Based on document review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documented monthly inspections of the sprinkler components. This could result in a malfunction of the sprinkler components in the event of a fire. This affected 5 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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, 2011 Edition
5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

Findings:

During document review with the Director of Plant Operations, and the Director of Support Services on 5/2/17, the sprinkler inspection documents were requested, and a staff person was interviewed.

1. At 11:11 a.m., there was no documented evidence of monthly inspections of the sprinkler gauges and valves as required. No documented evidence was provided during the survey.

2. At 11:14 a.m., the Director of Plant Operations said that the gauges were inspected quarterly with the sprinkler flow test. The Director of Plant Operations stated, that there was no other documented evidence of any other inspection.

Based on observation, and interview, the facility failed to maintain their doors. This was evidenced by doors that were impeded from closing, and by a door that failed to latch. This could allow the spread of smoke and fire in the event of a fire. This affected 3 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Fire Windows, 2010 Edition
5.2.14.1 Self-closing devices shall be kept in working condition at all times.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Findings:

During a tour of the facility with the Director of Nursing, the Director of Plant Operations, and the Director of Support Services on 5/1/17 to 5/2/17, the doors in the facility were inspected, and a staff person was interviewed.

5/1/17

1. At 1:58 p.m., the door to the mailroom by the receptionist area, was impeded from closing with a rubber wedge under the door.

2. At 2:49 p.m., the Adult I Staffing Services Office self-closing corridor door, was impeded from closing with a rubber wedge under the door.

3. At 3:42 p.m., the west self-closing corridor door to the Group Room in Adult II, was not latching when tested. The coordinator was slower than the east door, and the west door would hit against the opposing door frame.

4. At 4:03 p.m., the self-closing corridor door to the Reason's Nurse Station, was impeded from closing with a rubber wedge under the door.

5/2/17

5. At 9:15 a.m., the self-closing corridor door to Adult I exam room, was impeded from closing with a rubber wedge under the door.

6. At 9:31 a.m., the self-closing corridor door to Adult I consult room, was impeded from closing with a trash can between the door and door frame.

7. At 1:27 p.m., the Reason's Dining Room self-closing door, was impeded from closing with a rubber wedge under the door.

8. At 2:29 p.m., the Director of Plant Operations said during an interview, that the doors should not be impeded from closing at any time.

Based on observation, and interview, the facility failed to maintain their utilities. This was evidenced by utilizing extension cords, by utilizing plug adapters, by power strips plugged into power strips,by a painted and broken outlet, by appliances plugged into power strips, and by an impeded electrical panel. This could result in an electrical fire. This affected 3 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
18.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. Informational Note: Accepted industry practices are described in ANSI/NECA 1-2006, Standard Practices for Good Workmanship in Electrical Contracting, and other ANSI-approved installation standards.
(A) Unused Openings. Unused openings, other than those intended for the operation of equipment, those intended for mounting purposes, or those permitted as part of the design for listed equipment, shall be closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (1/4 in.) from the outer surface of the enclosure.
(B) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

314.20 In Wall or Ceiling. In walls or ceilings with a surface of concrete, tile, gypsum, plaster, or other noncombustible material, boxes employing a flush-type cover or faceplate shall be installed so that the front edge of the box, plaster ring, extension ring, or listed extender will not be set back of the finished surface more than 6 mm (1/4 in.). In walls and ceilings constructed of wood or other combustible surface material, boxes, plaster rings, extension rings, or listed extenders shall be flush with the finished surface or project therefrom.

408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

408.58 Panelboard Marking. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring.

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

240.5 Protection of Flexible Cords, Flexible Cables, and Fixture Wires. Flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either 240.5(A) or (B).
(A) Ampacities. Flexible cord and flexible cable shall be protected by an overcurrent device in accordance with their ampacity as specified in Table 400.5(A)(1) and Table 400.5(A)(2). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402.5. Supplementary overcurrent protection, as covered in 240.10, shall be permitted to be an acceptable means for providing this protection.
(B) Branch-Circuit Overcurrent Device. Flexible cord shall be protected, where supplied by a branch circuit, in accordance with one of the methods described in 240.5(B)(1), (B)(3), or (B)(4). Fixture wire shall be protected, where supplied by a branch circuit, in accordance with 240.5(B)(2).

(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Finding:

During a tour of the facility with the Director of Support Services, and the Director of Nursing on 5/1/17, the electrical system was examined, and a staff person was interviewed.

1. At 2:05 p.m., there was a blue extension cord in use under the desk of the Receptionist in the office area.

2. At 2:06 p.m., the Director of Support services said during an interview, that there was no need for the extension cord. There were plenty of outlets.

3. At 2:20 p.m., electrical Panel B in the Administration Electrical Room, was impeded from access with a box, and two folded up floor mats stored in front of the panel.

4. At 2:21 p.m., the Director of Support Services said during an interview, that nothing should be stored in front of the electrical panel.

5. At 2:30 p.m., there was an orange extension plugged into an outlet near the ceiling in the dining room adjacent to the Kitchen.

6. At 2:36 p.m., the refrigerator in the Staffing Office, was plugged into a black extension cord.

7. At 2:42 p.m., there was an orange extension cord in use with a three plugged adapter plugged into it in the Dietary Supervisor Office.

8. At 3:09 p.m., the electrical outlet in the Adult I treatment Team Office, was approximately 50 percent covered with paint and the bottom ground port was broken off. The Director of Support Services acknowledged the finding.

9. At 3:26 p.m., there was a microwave oven plugged into a power strip in the Adult II Utility Room near the nursing station.

10. At 3:50 p.m., there was a power strip plugged into another power strip in the Youth Services Backroom/Video Room.

Based on document review, and interview, the facility failed to conduct disaster drills at a minimum of twice a year. This was evidenced by no current disaster drills provided. This could result in staff not being prepared to respond to a disaster. This affect 5 of 5 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. 19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

19.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

Finding:

During document review with the Director of Plant Operations, and the Director of Support Services on 5/2/17, the disaster drills were requested, and staff was interviewed.

1. At 8:43 a.m., the last disaster drill was conducted on 3/20/16. No other documented evidence of a disaster drill was provided.

2. At 8:45 a.m., the Director of Plant Operations said during an interview, that the facility had made some staff changes, and that he was now in the position of being in charge of scheduling the disaster drills.

Based on document review, and interview, the facility failed to maintain their generator battery. This was evidenced by no documented testing of their battery. This could result in generator failure in the event of a power loss. This affected 5 of 5 smoke compartments.

NFPA 99, Health Code Facilities Code, 2012 Edition
15.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects.

Finding:

During document review with the Director of Support Services and the Director of Plant Operations on 5/2/17, the generator inspection and testing documents were reviewed, and a staff person was interviewed.

1. At 10:42 a.m., there was no documented evidence of testing of the generator battery. No documented evidence was provided during the survey.

2. At 10:43 a.m., the Director of Plant Operations said during an interview, that the generator battery was visually inspected on a weekly basis, but the facility did not check the battery electrolyte levels or voltage.