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Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining self closing doors as required in hazardous areas.

The findings include:

1) During the initial survey on April 24, 2013 at approximately 1030 hours it was observed and confirmed through interview with the General Foreman that the storage room between Accounting and the Day "Activity" Room on the Terrace Level of Meisel is greater than 50 square feet in area and contains approximately 50 cardboard boxes of paper files, racks of Styrofoam cups, etc. This meets the definition of a hazardous area and the doors to this room are required to be equipped with self-closing devices.

All doors to hazardous areas must be self-closing and/or automatic closing in the event of an emergency, smoke resistive when closed, and must not be held open unless by an approved device that is released by the fire alarm systems. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to ensure that all exit stairways are maintained as required by this Code.

The findings include:

During the initial survey on April 24, 2013 between approximately 0930 hours and 1200 hours it was observed and confirmed through interview with the General Foreman that the East EXIT stairway which spans five levels lacks the required stairway identification signs. The facility shall perform an audit of all exit stairs to insure compliance with the requirements of this section of the Code. (NFPA 101- 7.2.2.5.4, 2000 edition)

Failure to maintain the exit stairways in this manner has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to ensure that all exits and exit signs are identified and maintained as required by this Code.

The findings include:

During the initial survey on April 24, 2013 between approximately 1100 hours it was observed and confirmed through interview with the General Foreman that the Terrace Level lobby area of the Meisel building lacks the required "EXIT" signs. This area of Meisel was observed to display only one " EXIT " sign to direct building occupants to a means of egress. A minimum of two are required.

Failure to maintain the exit signs in this manner has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interview with facility staff, 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 for all portions of the building.

The findings include:

During the initial survey on April 24, 2013 at approximately 1045 hours it was determined through observation of the physical environment and confirmed through interview with the General Foreman that the exit enclosure between the two powered doors at Meisel Terrace level lobby exit to Belvedere Ave lacks automatic sprinkler coverage as required. This is a main means of egress/access for the building.

Per CMS the facility shall be fully automatic sprinkler protected by August 2013.

Failure to provide proper automatic sprinkler coverage to all parts of the building has the potential to promote harm to occupants of the facility in the event of a fire.

Based observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25.

The findings include:

During the initial survey on April 24, 2013 between 0900 hours and 1030 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the General Foreman that the standpipe system in the facility is not documented as having been inspected, serviced, tested and maintained in accordance with NFPA 25 as required. No reference to regular quarterly and annual inspection, testing, service, and maintenance of these systems as required was located. The facility shall furnish documentation of quarterly and annual required inspection, testing, service, and maintenance of the standpipe hose outlets and system throughout Meisel.

These systems shall be included in the testing, service, and maintenance program for the facility.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment and staff interviews, it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant electric portable space heater use in the facility.

The findings include:

At approximately 1125 hours on April 24, 2013 during this survey it was observed and confirmed through an interview with the General Foreman that several portable electric space heaters was observed in the Meisel Terrace level Accounting Office.. These space heaters was plugged into a 15 amp strip outlets instead of the wall outlets. The space heaters were also observed to be within 12" of combustibles.

The use of portable electric space heaters in this manner has the potential to promote harm to occupants of the facility.

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

The findings include:

1) During the survey at approximately 1125 hours on April 24, 2013 it was observed and confirmed through interview with the General Foreman that in the Ground Floor Employee Break Room there was a 1200 watt microwave oven and 2-slice toaster plugged into a 15 amp rated multi outlet extension cord plugged into a 120 VAC wall outlet. Separately, there was also a crock pot, coffee maker, and refrigerator plugged into a 15 amp rated multi outlet extension cord plugged into a 120 VAC wall outlet. These devices when used simultaneously would exceed the rated capacity of the circuit. Appliances are required to be plugged directly into a wall outlet of a proper amperage rated circuit. Strip outlets are to be secured to a wall or immovable item.

2) During the survey at approximately 1145 hours on April 24, 2013 it was observed and confirmed through interview with the General Foreman that in the Respiratory Therapy office behind the 1st floor Nurses station there was a toaster oven, fan, coffee maker, microwave oven, and fluorescent light all plugged into a 15 amp rated multi outlet extension cord which was plugged into a 120 VAC wall outlet. These devices when used simultaneously would exceed the rated capacity of the circuit. Appliances are required to be plugged directly into a wall outlet of a proper amperage rated circuit. Strip outlets are to be secured to a wall or immovable item.

The use of these items in this manner will create hazards and can result in fire or electrical shock. NFPA 70, National Electrical Code states that extension cords shall not be used as a substitute for permanent wiring. NFPA 1, Uniform Fire Code states- 11.1.5; 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. 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.