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The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced, "Life Safety Code " .

On 11/04/13 at 1:00 PM, the surveyor, while accompanied by the General Trades Worker and the Assistant Fire Chief observed that nearly all of the patient rooms within the Blue Hills Nursing Unit on the 2nd floor were provided with a system that was intended to cover over abandoned, conduits and penetrations through the floor for heating pipes which were not sealed with materials having a fire resistance rating; i.e. when the makeshift caps are removed a gap can be seen between the conduit (sleeve),the fire calk, fiberglass pipe insulation and the metallic pipe.

K 029 Battell Hall
The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self closing doors as required by 19.3.2.1

On 11/05/13 at 2:30PM, the surveyor along with the Fire Chief and/or the Facilities Plant Engineer observed that the facility was utilizing an area ajacent to the basement elevator lobby and exit egress cooridor as a storage area and it was not seperated as required i.e. no sprinklers, no walls, no self closing positivley ltching door.

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72.
On 11/06/13 at 10:30 AM, the surveyor was not provided with documentation by the Assistant Fire Chief, Fire Chief and or the Facilities Plant Engineer to indicate that all the facilities fire alarms were tested semiannually as required by NFPA 72 i.e. visual inspections and battery load testing.

K 062 Merritt Building
The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC and NFPA 25.

On 11/06/13 at 10:30 AM, the surveyor was not provided with documentation by the Assistant Fire Chief, Fire Chief and or the Facilities Plant Engineer to indicate when the dry pipe valve had last been Full (total flooding) trip testing trip tested per NFPA 25

K 130 Facility Wide
1. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.
On 11/06/13 at 10:30 AM, The surveyor was not provided with documentation by the Assistant Fire Chief, Fire Chief and/or the Facilities Plant Engineer to indicate all employees are in serviced annually as to their duties during a fire emergency and or facility disaster i.e. completion ratios provided during documentation review indicated only 91.57% of employees completed the mandatory online emergency plans continuing education in service.

2. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facilities " .
On 11/04 and 11/05/13 at 10:30 AM and times throughout the survey, the surveyor along with the Fire Chief and/or the Facilities Plant Engineer observed that the facilities patient care equipment was being inspected by multiple contractors and medical equipment in the patient environment was marked with stickers that indicated that the equipment failed inspection. Subsequent to these observations on 11/06/13 during documentation review the facility was unable to produce documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2. and as part of the facilities preventive maintenance program, and equipment that had failed had been removed from the patient care environment and/or been repaired and retested.

K 130 Battell Hall
3. The facility did not assure that the sprinklers installed as protection for isolated hazardous area were installed in accordance with the NFPA 101 " Life Safety Code "19.3.5.4 & 9.7.1.2
On 11/05/13 at 2:00 PM and times throughout the survey, the surveyor along with the Fire Chief and/or the Facilities Plant Engineer observed that the sprinklers installed exceeded the allowance of six (6) sprinklers allowed by code, i.e. ten (10) were installed and connected to a domestic water supply and subsequent interview of the Fire Chief & Facilities Plant Engineer indicated they were unaware of the location of the control valves and if the control valves were supervised by the fire alarm panel, and if flow switches were provided to indicate activation of the system. Further interview indicated the Battell building had additional isolated hazard sprinklers in the soiled utility rooms and other areas within the building.

The facility did not ensure that generators are inspected weekly and exercised under load for 30 minutes per month as required by the referenced, "Life Safety Code " .

On 11/06/13 at 1:00 PM, the surveyor was not provided with documentation from the Facilities Plant Engineer to indicate that the generators at Blue Hills and Woodward Buildings were exercised at least once monthly, for a minimum of 30 minutes under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer, as required by section 6-4 of NFPA 110, " Standard for Emergency and Standby Power Systems "; i.e.no documentation that temporary, rental generator sets are exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours-annual load bank testing not done on Woodward temporary generator-100 KW load bank done on temporary, Blue Hills 200 KW unit (cannot get to 75% with smaller bank).

The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, " National Electrical Code " as required by section # 9.1.2 of the referenced, "Life Safety Code "

On 11/04/13 at 2:00 PM, the surveyor, while accompanied by the General Trades Worker and the Assistant Fire Chief observed that the electric, clothes dryer in the Laundry Room on the 2nd floor at the off-site, Blue Hills Nursing Unit was not provided with materials and methods to exhaust as required by the manufacturers requirements and the referenced, "Life Safety Code "; i.e. clothes dryer not exhausted to the building exterior, screws used to connect duct that penetrates duct and can trap lint and the vent hose is combustible.