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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.

On 02/03/10 at 10:20 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that the conduit that went between the 1st floor, Fan/Ventilator Room and the exit-access corridor; was nor protected with materials having a 1-hour fire resistance rating; i.e. open conduit-no fire stopping on fan room side.

The facility did not ensure that fire/smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and the LSC.
On 02/03/10 and 02/04/10 at 11:30 AM and at times throughout the day, The surveyor along with the Director of Operations observed that the smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls on the ground, 1st, 2nd and 3rd floors had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

The Blue Hills Facility (Off Site) @ Capital Region Complex 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 02/04/10 at 11:30 AM the surveyor was not provided with documentation from the Facility Plant Engineer II (PFE II) to indicate that the fire alarm deficiencies ' from the Simplex/Grinnell Fire Alarm Test Report of 09/10/09 had been addressed; i.e. 3 audio/visuals tested NG & door release mechanisms on smoke barriers did not work.

The Cedarcrest and Blue Hills Facility (Off Site) @ Capital Region 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.

1. On 02/03/10 at 10:00 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that the (supply) pressure gauge for the sprinkler system riser was not listed or approved for such use; i.e. gauge not sprinkler type.

2. On 02/03/10 at 10:00 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that the risers that supply the building with fire protection were not labeled, placarded nor identified as to what portions of the building they supplied as required by NFPA 13, 14 or 25-as required by the referenced LSC; i.e. control valves with no identification.

3. On 02/03/10 at 10:00 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that the automatic sprinkler systems ' control valves were not supervised, as required by NFPA 13, 14 or 25-as required by the referenced LSC; i.e. control valves for water supply installed-built in tamper switches-NOT WIRED TO FIRE ALARM.

4. On 02/03/10 at 10:00 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that the automatic sprinkler system was not active throughout the facility (kitchen only and auditorium in the ground/basement floor ) but, sprinkler heads were installed; i.e. Life Safety systems must be maintained or removed-as required by the Life Safety Code.

The Blue Hills Facility (Off Site) @ Capital Region Complex did not ensure that heating, ventilating, and air conditioning did comply with 9.2 and was installed in accordance with the manufacturer ' s specifications.

1. On 02/03/10 at 10:22 AM, the surveyor while accompanied by the Facility Plant Engineer II (PFE II) observed that a fuel-oil, supply line/piping that was routed through the mechanical room/space where the sprinkler risers are located was leaking; i.e. active fuel-oil leak inside of building, absorbent materials left on floor-2nd floor stair enclosure smells like fuel oil.

2. On 02/03/10 at 10:10 AM the surveyor was not provided with documentation from the Facility Plant Engineer II (PFE II) to indicate that the smoke dampers that were installed in the 1st floor, Fan/Ventilator Room had been installed, tested, maintained or approved-in accordance with the referenced, Life Safety Code.

K 130
1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and
maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

a. On 02/04/10 at 10:30AM, The surveyor was not provided with documentation by the Facility Plant Engineer II that the facilities two (2) emergency generators were being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " i.e. during documentation review it was found that the facilities contractor (Northeast Generator) for the facilities two (2) emergency generators indicated on 03/03/09 and 12/16/09 that deficiencies were present for the fuel system, cooling system and belts and that they needed to be replaced and or repaired. The documentation and operational logs for the generator sets maintained by the plant facilities maintenance personnel that load test the generator on a monthly basis revealed the same findings as the contractor for the generators and subsequent observation of the generator at the steam plant on the day of survey showed evidence of previous fuel leaks and an active fuel leak being contained in a catch pan with absorbent pads and seedy dry absorbent;

2. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

a. On 02/04/10 at 10:30AM, the surveyor was not provided with documentation by the Facility Plant Engineer II 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.