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Based on observation the entity failed to ensure doors are provided with latches or other mechanisms suitable for keeping doors in a closed position.

The findings include:

A. Surveyors observed at approximately 10:00am to 1:30pm that facility's doors did not close and latch in frame in the following areas:

Transitional Unit, Room 292, Stairwell #12 outside of the Penthouse, Room 1D03, Forensic Unit, Room 2C66 and Room 2D092.


B. Surveyors observed at approximately 10:00am to 1:30pm that the facility's doors were held open using improper hold open devices in the following areas:

Transitional Unit, Room 1B67 and Room 115.02
Forensic Unit, Room 2C67, Room170.03, Room 1G67 and Room 181.02

C. Surveyors observed at approximately 10:00am to 1:30pm that the facility's doors hardware were removed or in need of tightening in the following areas:

Transitional Unit, Room 1A, Room 1B, Room 2FEL1,Room 2GT1,Room 289, and, Room 2ET1
Forensic Unit, Room 1G14 and Room 1F13

D. Surveyors observed at approximately 10:00am to 1:30pm that the facility's doors were sticking in the following areas:

Transitional Unit: Room 2A06

E. Surveyors observed at approximately 10:00am to 1:30pm that the facility's doors were removed in the following areas:

Transitional Unit: Room 283

F. Surveyors observed at approximately 10:00am to 1:30pm that the facility's doors were blocked in the following areas:

Transitional Unit: Room 108.09

All observations were made during the survey July 19, 2011 through July 21, 2011.

Observations during the survey were made with members of the security staff and the engineers.

Based on observation the entity failed to ensure that all exit signs are maintain in proper working order.

The findings include:

Surveyors observed at approximately 10:00am to 1:30pm that the facility has a exit sign base coming from ceiling in the following area:

Forensic: Room 1G30

The survey was conducted July 19, 2011 through July 21, 2011.

Observations during the survey were made with members of the security staff and the engineers.

Based on observation the entity failed to ensure that all staff have inservice training on evacuation in the event of an emergency.

The findings include:

A. Surveyors observed at approximately 10:00am to 1:30pm that the facility staff did not have access to keys for unit 1 D.

B. Surveyors observed at approximately 10:00am to 1:30pm that the facility staff's key was broken for the portable fire extinguisher cabinet.

C. Surveyors observed at approximately 10:00am to 1:30pm that the facility staff did not know which key went to the manual pull station.

The survey was conducted July 19, 2011 through July 21, 2011.

Observations during the survey were made with members of the security staff and the engineers.

Based on observation the entity failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition.

The findings include:

Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21,2011, that the facility's standpipe riser caps are not hand tighten ( no tool should be used) in the following areas:

Transitional Unit: Throughout the building.

Forensic Unit: Throughout the building.

A. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21,2011 that the facility's portable fire extinguishers need annual maintenance in the following areas:

Transitional Unit, throughout the 1st floor and Room 2A06
Forensic Unit, through the 2nd floor.

B. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011, that the facility portable fire extinguisher cabinets are not mounted in the following areas:

Forensic Unit, Room 1J67 and 1G57


2000 LIFE SAFETY CODE-LSC 4.5.1 Multiple Safeguards

The design of every building or structure intended for human occupancy shall be such that reliance for safety to life does not depend solely on any single safeguard. An additional safeguard (s) shall be provided for life safety in case any single safeguard is ineffective due to inappropriate human actions or system failure.

Based on observation the entity failed to ensure no fire or life safety hazards exist in the facility.

The findings include:

A. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011 that the facility storage is directly on the floor in the following areas:

Transitional Unit 118,122.04,114, 115.03,115.05, 1A11, 190.05, Forensic Unit
2D67.1, 2D14,176,178.02, 181 ,184.01 , 185.02, kitchen office, 156, and 150.02,

B. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011, that the facility's surge protectors are not mounted in
the following areas:

Transitional Unit:1A17, 1A12, 122.02, 114, 109.01 , 190.05, 120

Forensic Unit: 2C16, 2D11,2D12,172.01 , 176, 1F17, 1F11 ,
1F12, 1G17, 1G18, 156, 181

C. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21 , 2011, that the facility has extension cords used as permanent wiring in the following areas:

Transitional Unit: 1A16
Forensic Unit: 1F18 .

D. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011, that the facility need house cleaning in the following
areas:

Transitional Unit: 146.06,119.01 , 104, 109.03,190.06

E. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21 , 2011 , that the facility has a open junction box in the following area:

Transitional Unit: 2ET1

F. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011, that the facility has wall or ceiling penetrations in the following areas:

Transitional Unit: 2FEL1, 2GEL1(Damper)

G. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21,2011, that the facility has ceiling tiles missing in the following area:

Forensic Kitchen bay area


2000 Life Safety Code-LSC 4.6.12.1 Maintenance and Testing (Sprinkle System)

Whenever or wherever any device, equipment,system condition , arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device equipment system, condition arrangement, level of protection, or other feature I shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by authority having jurisdiction.

Based on observation the entity failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition.

The findings include:

A. Surveyors observed at approximately 10:00am to .1:30pm on July 19, 2011 to July 21 , 2011 , that the facility has an escutcheon plate missing in the
following area:

Transitional Unit: Room 107

B. Surveyors observed at approximately 10:00am to 1:30pm on July 19, 2011 to July 21, 2011, that the facility has labels missing (to identify an area) in the following area:

Transitional Unit: Room 118

Observations during the survey were conducted with members of the security staff and the engineers: