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The facility did not ensure that corridors were separated from use areas by walls constructed with at least a 30 minutes rating as required by the referenced LSC.
A. On 07/10/12 at 1:10 PM the surveyor, accompanied by Maintenance Department employees, observed that the corridor wall near corridor door # 251 had holes and missing pieces of drywall.
B. On 07/13/12 at 11:05 AM and at other times throughout the survey, the surveyor while accompanied by the Facility Plant Engineer I (PFE I) and the " DNS " at the Blue Hills facility, observed that the corridor walls throughout the facility had voids around penetrations used for the passage of wires, conduits and piping that were not sealed using a UL approved system for fire stopping through a smoke barrier; i.e., either not sealed, non-rated backing materials used, caulk shrinking and/or sagging away from voids leaving gaps not maintaining at least ? hour fire resistance rating of the corridor from use areas.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors.

A. On 07/10/12 at 10:35 AM and at various times throughout the day the surveyor, accompanied by Maintenance Department employees, observed that the following corridor doors were not resistant to the passage of smoke and fire i.e. gaps around door and frame, and/or damaged to the core: 4 North West Dormitory corridor door, 4 South West Dormitory corridor door, and 2 West Dormitory corridor door.

B. On 07/09/12 at 0930 AM and at various times throughout the day the surveyor, accompanied by facility maintenance personnel, observed that numerous patient room corridor doors throughout the Woodward facility were not resistant to the passage of smoke and fire i.e. gaps along top of door and/or along frame.

The facility did not ensure that fire drills conducted between 9:00 PM (2100 hours) and 6:00 AM (0600 hours), utilized an audible alarm and/or a coded announcement as required by the referenced LSC 19.7.1.2.
On 07/13/12 at 9:15 AM the surveyor was not provided with documentation by the Facility Plant Engineer I (PFE I) and the " DNS " at the Blue Hills Facility that fire drills conducted on the third shift on 03/24/12 (first quarter) and 06/13/12 (second quarter) utilized an audible alarm and/or a coded announcement as required by the referenced LSC 19.7.1.2.; i.e., audible alarm and/or coded announcement not documented on fire drill form.

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 07/13/12 at 8:55 AM, the surveyor was not provided with documentation by the Facility Plant Engineer I (PFE I) and the " DNS " at the Blue Hills Facility to indicate the Control panel/Central processing Unit, Alarm Initiating Devices, Alarm Indicating Devices and Control/Auxiliary Devices were inspected (semiannual) and tested (semiannual and annual)as required:

1. Semiannual visual inspection and battery testing not conducted between 05/18/11 and 04/25/12.
2. Seventeen (17) Duct Smoke Detectors not tested.
3. One (1) fixed Temperature Heat Detector not tested.
4. Nine (9) Heat Detectors not tested.
5. Sixty-three (63) Photo Smoke Detectors not tested.

The facility did not ensure that there is an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 19.3.5
On 07/09/12 at 1000 AM and at various times throughout the day the surveyor, accompanied by Maintenance Department employees, observed that the 3E Mechanical Room and 2E Mechanical Room within the Merritt facility lacked adequate fire sprinkler coverage.

The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .
On 07/13/12 at 9:20 AM , the surveyor was not provided with documentation by the Facility Plant Engineer I (PFE I) and the " DNS " at the Blue Hills Facility to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program; i.e., documentation of testing not available during survey.