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Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.

The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that:
1. One set of smoke barrier doors on the 1st floor between the Weinberg Building and the ABCD wings failed to close due to rubbing at the top of the door and frame - corrected the same day;
2. One set of smoke barrier doors between the Weinberg Building and the power plant was broken and failed to close - replacement door had been ordered on May 16 - awaiting delivery and installation.
Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of the residents.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that one set of corridor smoke barrier doors in the Co-Occurring Wing failed to close tightly when operated - staff reported that new doors are set to be ordered after July 1 - the existing doors need to be repaired so they will operate properly.
Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of the residents.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that stairways and smokeproof towers used as exits are in accordance with 7.2.
The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that exit stairwells in several locations had self-closing gates at the lower level landings to prevent people from going past the exterior exit doors and down into areas of the building without egress - these gates must have a sign that states: "NO EXIT." 7.10.8.3.1
These could result in people passing the gate and proceeding down the stairs in an emergency, thus bypassing the exit door to the outside.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that three areas of the facility did not have sprinkler coverage - these were vestibules that lead into quiet rooms - two of them had doors between the corridor and the vestibule and one had the door removed.
A fire in any one of these areas could spread since there is no automatic sprinkler coverage and this could impact up to 25% of the residents and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that one ceiling mounted sprinkler head in Ms. Marchetti's office was missing its locking escutcheon plate.
These could have the possibility of affecting some occupants of the facility and could result in improper operation of the sprinkler head.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.
The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that:
1.) Two ceiling mounted, recessed sprinkler heads were missing their escutcheon cover plates - one in corridor of 1H near room #265 and one above a vending machine in the Terrace Level;
2.) Several sprinkler system tamper switch covers were not secured in place with their tamper proof screws - two of these were located in stairwells and one was on the main riser of the boiler room - sprinkler contractor staff members were on the scene in the afternoon of the survey in the process of correcting the deficient tamper covers.
These could have the possibility of affecting 25 % of the occupants of the facility and could result in improper operation of the sprinkler heads or tampering with the sprinkler system without proper notification of trouble.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are tested and maintained as required by NFPA 10.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that fire extinguisher cabinets throughout the facility had Plexiglas covers that did not appear to be easily breakable - one was " scored " so that it could break away but there was no tool present to do this; several were not scored for breakage but were marked - " Break Glass " - two cabinets in the kitchen were also equipped with Plexiglas fronts but also had a tool for breakage - these extinguishers do not need to be in protected cabinets.
Since tamper resistant fire extinguisher cabinets are necessary in all resident areas, keyed cabinets should be installed and all employees should have access with a master key. Training for all staff on access to and use of fire extinguishers must then be provided.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that one power strip in the nurse ' s station of ECT was powering a coffee maker and a microwave - a refrigerator was in the same outlet but not in the power strip. High wattage appliances need to be plugged into their own outlets.
This could result in short circuit or fire and could effect up to 25% of the residents on the floor.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that:
1. One heavy duty extension cord was wired-tied to pipe in the air handler room - this cord powered a condensate pump;
2. One set of wires from the ceiling was exposed in the corridor of the kitchen supply area near the walk-in boxes - it appeared to be wires from an emergency lamp that had been removed;
3. An uncovered electrical junction box in the mechanical/alarm room had exposed wiring - this was corrected during the survey;
4. The Unit 70 laundry room had unprotected electrical outlets - outlets that were near water sources and were not ground fault circuit interrupter (GFCI) protected.
These items could cause overheating or electrical short circuits resulting in personal injury or fire. Item #4 could increase the potential for electrical shock to staff members or residents. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.

The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that:
1. One set of smoke barrier doors on the 1st floor between the Weinberg Building and the ABCD wings failed to close due to rubbing at the top of the door and frame - corrected the same day;
2. One set of smoke barrier doors between the Weinberg Building and the power plant was broken and failed to close - replacement door had been ordered on May 16 - awaiting delivery and installation.
Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of the residents.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that one set of corridor smoke barrier doors in the Co-Occurring Wing failed to close tightly when operated - staff reported that new doors are set to be ordered after July 1 - the existing doors need to be repaired so they will operate properly.
Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of the residents.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that stairways and smokeproof towers used as exits are in accordance with 7.2.
The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that exit stairwells in several locations had self-closing gates at the lower level landings to prevent people from going past the exterior exit doors and down into areas of the building without egress - these gates must have a sign that states: "NO EXIT." 7.10.8.3.1
These could result in people passing the gate and proceeding down the stairs in an emergency, thus bypassing the exit door to the outside.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that three areas of the facility did not have sprinkler coverage - these were vestibules that lead into quiet rooms - two of them had doors between the corridor and the vestibule and one had the door removed.
A fire in any one of these areas could spread since there is no automatic sprinkler coverage and this could impact up to 25% of the residents and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that one ceiling mounted sprinkler head in Ms. Marchetti's office was missing its locking escutcheon plate.
These could have the possibility of affecting some occupants of the facility and could result in improper operation of the sprinkler head.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.
The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that:
1.) Two ceiling mounted, recessed sprinkler heads were missing their escutcheon cover plates - one in corridor of 1H near room #265 and one above a vending machine in the Terrace Level;
2.) Several sprinkler system tamper switch covers were not secured in place with their tamper proof screws - two of these were located in stairwells and one was on the main riser of the boiler room - sprinkler contractor staff members were on the scene in the afternoon of the survey in the process of correcting the deficient tamper covers.
These could have the possibility of affecting 25 % of the occupants of the facility and could result in improper operation of the sprinkler heads or tampering with the sprinkler system without proper notification of trouble.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are tested and maintained as required by NFPA 10.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that fire extinguisher cabinets throughout the facility had Plexiglas covers that did not appear to be easily breakable - one was " scored " so that it could break away but there was no tool present to do this; several were not scored for breakage but were marked - " Break Glass " - two cabinets in the kitchen were also equipped with Plexiglas fronts but also had a tool for breakage - these extinguishers do not need to be in protected cabinets.
Since tamper resistant fire extinguisher cabinets are necessary in all resident areas, keyed cabinets should be installed and all employees should have access with a master key. Training for all staff on access to and use of fire extinguishers must then be provided.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:
During the initial survey on June 21, 2011 with the Director of Plant Operations, Safety & Security and the Occupational Safety Officer, it was observed between 9:00 am and 1:30 pm that one power strip in the nurse ' s station of ECT was powering a coffee maker and a microwave - a refrigerator was in the same outlet but not in the power strip. High wattage appliances need to be plugged into their own outlets.
This could result in short circuit or fire and could effect up to 25% of the residents on the floor.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.
The findings include:
During the initial survey on June 22, 2011 with the Director of Plant Operations, Safety & Security, the Occupational Safety Officer, and the Operations Director, it was observed between 8:30 am and 10:30 pm that:
1. One heavy duty extension cord was wired-tied to pipe in the air handler room - this cord powered a condensate pump;
2. One set of wires from the ceiling was exposed in the corridor of the kitchen supply area near the walk-in boxes - it appeared to be wires from an emergency lamp that had been removed;
3. An uncovered electrical junction box in the mechanical/alarm room had exposed wiring - this was corrected during the survey;
4. The Unit 70 laundry room had unprotected electrical outlets - outlets that were near water sources and were not ground fault circuit interrupter (GFCI) protected.
These items could cause overheating or electrical short circuits resulting in personal injury or fire. Item #4 could increase the potential for electrical shock to staff members or residents. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.