HospitalInspections.org

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

06/15/2016 between approximately 0800 and 1600 hours in the Eastlake building:

-In room #106 there was an unsealed penetration in the wall caused by heat detector hanging out of the ceiling.
There was an unsealed penetration in storage room #113 caused by fire sealant having fallen off.
-There was a large unsealed opening/penetration in the wall of the men ' s restroom by the Admin office area.



The above was discussed and acknowledged by the Safety Officer who said that multiple unsealed penetrations were observed on a previous JCHO inspection and that the facility was still in the process of sealing them all.

Based upon observations and staff interviews on 6/14/16 to 6/16/16 during the physical tour of the facility, the facility has failed to maintain doors capable of resisting fire for at least 20 minutes. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1430 hours:
-The G271 Men's room door to the corridor in the Westlake building did not have enough self-closer force to fully close and latch.
-The Westlake dish room door to the corridor was blocked open with a wooden door wedge and prevented from fully closing and latching.
-The Westlake Housekeeping closet near the kitchen suite was blocked open with a door wedge and prevented from fully closing and latching.
On 06/15/16 between 0800 and 1400 hours:
-The door to Room 134 was observed to have a hole in the door just below door hardware.
-The door to Room 167 was observed to have hole in the door.
-The cross-corridor fire door between the 1st floor Eastlake Hospital building and the Administration was blocked open with an extension cord and prevented from closing.
-There was an unsealed penetration in the room E221 room door to the corridor due to missing door hardware.
-There was an unsealed penetration in the room S1-006 door to the corridor due to missing door hardware near the door latch.
On 06/16/16 between 0800 and 1400 hours:
-The 2nd floor elevator lobby doors in Kitchen building had an inoperative door-closing coordinator
-The exam room S-1322 door to the corridor in the Eastlake building did not latch when closed.



The above was discussed with the Maintenance Director who said they conduct a monthly door audit, but had not previously observed the lobby doors to not close and latch.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain vertical openings between floors with a construction having a fire resistive rating of at least one hour. This could result in the passage of toxic products of combustion from one floor to another which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between approx. 0800 and 1600 hours in the Westlake building:
-The B Stairwell exit 2-hour rated fire door was missing door hardware, exposing the inner construction material of the door.

On 6/15/16 between approx. 1100 and 1400 hours in the Eastlake building:
-There was an unsealed penetration in the intervening wall of the fire barrier between the exit stairwell AS-S001 and the interior exit corridor above the drop ceiling.
-There was an unsealed penetration in the ON1 Stairwell wall above the door into the exit corridor

The Safety Officer stated that they were in the process of sealing existing penetrations observed during a previous JCHO inspection and that the Carpenter shop had previously observed the issues with some 2 hour fire doors and missing hardware, and had already created a work order to repair the doors with Fire Door caulk.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain the ability of fire/smoke doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:


On 6/16/16 between approx. 0830 ad 1300 hours in the Eastlake building:
-There was a Cornell rolling fire door within room #048 and enclosing the kitchen prep area that had been disable to prevent automatic door closing via fusible links.

The above was discussed and acknowledged by the Safety Officer who said all of the Cornell rolling fire doors had been disable some time ago, and was unaware where the authorization to do so had come from.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain doors in hazardous areas as being self closing and in maintaining hazardous areas as being smoke resistant. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

On 6/14/16 between approximately 0800 and 1600 hours in the Westlake building:
-Room F278 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
-B100 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
Room B09 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
-Room F213, F 212, F211, F210, F208, F207 are now being used as a storage rooms over 50 square feet and automatic/ self-closing door closures have not been installed.

On 6/15/16 between approximately 0845 and 1400 hours in the Eastlake building:
-The Steam room/boiler room in the basement is enclosed within a 1 hour barrier and has an unsealed opening into the corridor's supply / return air plenum.

06/16/16 between approximately 0900 and 1400 hours in the Eastlake building:

-Room 354 and Room 350 were former seclusion rooms that were converted to storage rooms over 50 square feet and automatic door closures have not been installed.

-There were unsealed penetrations in the North wall of electrical room 003 under the new Generator Annunciator panel.


The above was discussed and acknowledged by the Safety Officer and Maintenance Manager who said they were unaware the self-closer's were required on rooms over 50 square feet used for storage and were in the process of sealing penetrations observed from a previous JCHO inspection.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1600 hours in the Westlake building:
-room #F220 had no sprinkler coverage.
-Electrical closet F223 had no sprinkler coverage.

On 6/15/16 between 0800 and 1400 hours in the Westlake building:
-There was an Acoustical booth approximately 8x8 in size in room F26 the did not have any sprinkler coverage within. In addition the booth was obstructing the spray pattern of the existing head in the room from covering the rest of the open room.
-There was no sprinkler coverage in the E245 electrical room.

06/15//2016 between 0800 and 1600 hours in the Eastlake building:

- Room 355 has an electrical room with no sprinkler coverage.
- Electrical Room #319 does not have sprinkler coverage.
-Electrical Room #119 does not have sprinkler coverage.
-The vestibule across from Central supply on the ground floor was remodeled post-initial construction and enclosed and is not equipped with sprinkler coverage.


06/16/2016 between 0800 and 1400 hours in the Eastlake building
-The janitor/cleaning supply closet in large kitchen storage room does not have sprinkler coverage.
-The Food Service Manager closet does not have sprinkler coverage.
-The Café dish room has the escutcheon plate missing from sprinkler head.
-The sprinkler head at the 2N1 entrance was obstructed by an Exit sign.
-The 2N1 electrical room has no sprinkler coverage.
-A sprinkler head was obstructed by an Exit sign near the main nurses station.


The above was discussed and acknowledged by the Maintenance Manager and Safety Officer who said they were unaware of the missing sprinkler coverage.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain fire sprinkler systems as required. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
On 6/14/16 between approx. 0800 and 1600 hours in the Westlake building:
-There were 3 of 4 dry barrell sprinkler heads at the exterior loading dock that were extremely corroded.
-1 of 4 guages on the Sprinkler riser were outdated and due for replacement (marked with an installation date of 2010, must be replaced every 5 years)
-There was a concealed sprinkler head cover that was glued to the ceiling with fire caulk in the F214 storage closet, preventing from the cover releasing at the required temperature.

On 6/15/16 between approximately 1100 and 1400 hours in the Eastlake building:
-3 of 8 heads in room E-021 were covered in spray-on insulation.
-1 of 2 heads in room 019 were covered in spray-on insulation.

On 6/16/16 between approximately 0830 and 1300 hours in the Eastlake building:
-3 of 12 heads in the Payroll office were heavily corroded or covered in a glue like substance.


The above was discussed and acknowledged by the Maintenance Manager and the Safety Officer who said they had not previously observed the corroded or covered sprinkler heads.

Based upon record review and staff interviews on 6/14/16 during the document review between approximately 0930 and 1530 hours the facility has failed to maintain a written smoking policy or regulation for residents and staff. This could result in a failure to monitor and prevent unauthorized smoking resulting in the possible ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility has not adopted a Smoking Policy for residents as required.

The above was discussed and acknowledged by the Safety Officer who said they were unaware they needed a policy for residents.

Based upon observation and staff interviews on 6/14/16 though 6/16/16 during the physical tour of the campus the facility has maintain the use of portable electric heaters in accordance with Listing requirements within the facility. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:

06/15/16 between approximately 0900 and 1100 hours in the Eastlake building:

-Office room #337 had an unapproved heater without tip-over protection.
-Room #335 to have an unapproved heater without tip-over protection.

06/16/16 between approximately 1000 and 1100 hours in the Eastlake building
-The kitchen Food Service office had an unapproved heater without tip-over protection.


The above was discussed and acknowledged by the Safety Officer who said they were unaware these heaters did not have tip-over protection in accordance with UL listings.

Based upon observations and staff interviews on 6/14/16 though 6/16/16 during the physical tour of the campus the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between approximately 0800 and 1600 hours in the Westlake building:
-There was a curtain covering the fire door window of the corridor door of Oxygen Storage room C107 that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
06/15/2016 between approximately 1200 and 1300 hours in the Eastlake building:

-Room 142 had a bed sheet covering the entire window. There was no documentation indicating the sheet had been treated or manufactured to be NFPA 701 approved.

06/16/2016 between approximately 0800 and 1200 hours in the Eastlake building:

- Exam room in 1 South was using a beige shower curtain as a privacy curtain. No documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-Room 243 on 2N1 had a home shower curtain used as a privacy curtain. No documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.

6/16/16 between approximately 0800 and 1400 hours in the Eastlake building:

-There was a curtain in the 2-South Visitor's room that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-There were pink curtains in the 2-South Nurses station that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-There were curtains in the PT suite 024 that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.




The above was discussed and acknowledged by the Maintenance Manager and Safety Officer who said they were unaware of the existence of the untreated curtains.

Based upon observations and staff interviews from 6/14/16 to 6/16/16 during the physical tour of the facility, the facility has failed to restrict the use of extension cords to providing power to permitted electrical equipment on a temporary basis and from ensuring all electrical wiring is in accordance with NFPA 70. This could result in a fire from overheating of the extension cord due to the prolonged power draw or result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1600 hours in the Westlake building:

-There was a powerstrip plugged into another powerstrip in room G290
-There was an open electrical junction box on the west wall of the Boiler room
-There was a powerstrip plugged into another powerstrip in room D249
-There was a powerstrip plugged into a multi-plug UPS box in the HH electrical closet of room A145

06/15/2016 between the hours of 0850 to 1500 in the Eastlake Building:

- In office #366 Financial Services Specialist there was a power strip plugged into a white extension cord.
-In room 367 there was a broken electrical cover and cover missing on computer wiring.
-In room 362 there was an unsecured/ hanging powerstrip, resulting in pulling and stress on the cords, potentially resulting in electrical arcing.
-In room 325 there was an extension cord used in place of permanent wiring for a coffee pot.
-In the Safety Program Coordinator office there was a refrigerator plugged into a power strip.
-In the Safety Program Coordinator's office there was an air conditioner plugged into a power strip then into an orange extension cord.
-In the IT office back area there was a refrigerator and microwave plugged into a power strip.
-In the IT Manager's office there was a power strip plugged into power strip.
-In ITS 1 there was a power strip plugged into an extension cord.
-In HR Consultant 1 there was an extension cord used in place of permanent wiring for a speaker/radio.
-There was an open electrical junction box above the clock in room S2018.
-There was a powerstrip plugged into a multi-plug UPS at the Pharmacy desk area.


On 6/15/16 between the hours of 0845 and 1400 in the Westlake building:

--There was a multi-plug UPS box plugged into a powerstrip in room E245
- There was a powerstrip plugged into another powerstrip at the East desk in room E247.
-There was an extension cord in use with a toaster in room J206.

On 6/16/16 between 0830 and 1230 hours in the Westlake and Kitchen buildings:

- In the FSU Administrative Manager office there was a power strip plugged into another power strip.
-There was an unapproved multi-plug adaptor in the S1-116 CRN Office.
-In the Staff Education/Conference room there was a powerstrip plugged into an extension cord.
-In Room 105 there was a microwave plugged into a power strip.
- The 218A Kitchen Office there was a power strip plugged into another power strip.
-In the Food Services Manager-East Lake Office there was power strip plugged into another power strip.



The above was discussed and acknowledged by the Safety Officer and Maintenance Manager who said their staff conducts periodic audits for extension cords, but that they were unaware of the observed extension cords in use and other electrical violations.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

06/15/2016 between approximately 0800 and 1600 hours in the Eastlake building:

-In room #106 there was an unsealed penetration in the wall caused by heat detector hanging out of the ceiling.
There was an unsealed penetration in storage room #113 caused by fire sealant having fallen off.
-There was a large unsealed opening/penetration in the wall of the men ' s restroom by the Admin office area.



The above was discussed and acknowledged by the Safety Officer who said that multiple unsealed penetrations were observed on a previous JCHO inspection and that the facility was still in the process of sealing them all.

Based upon observations and staff interviews on 6/14/16 to 6/16/16 during the physical tour of the facility, the facility has failed to maintain doors capable of resisting fire for at least 20 minutes. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1430 hours:
-The G271 Men's room door to the corridor in the Westlake building did not have enough self-closer force to fully close and latch.
-The Westlake dish room door to the corridor was blocked open with a wooden door wedge and prevented from fully closing and latching.
-The Westlake Housekeeping closet near the kitchen suite was blocked open with a door wedge and prevented from fully closing and latching.
On 06/15/16 between 0800 and 1400 hours:
-The door to Room 134 was observed to have a hole in the door just below door hardware.
-The door to Room 167 was observed to have hole in the door.
-The cross-corridor fire door between the 1st floor Eastlake Hospital building and the Administration was blocked open with an extension cord and prevented from closing.
-There was an unsealed penetration in the room E221 room door to the corridor due to missing door hardware.
-There was an unsealed penetration in the room S1-006 door to the corridor due to missing door hardware near the door latch.
On 06/16/16 between 0800 and 1400 hours:
-The 2nd floor elevator lobby doors in Kitchen building had an inoperative door-closing coordinator
-The exam room S-1322 door to the corridor in the Eastlake building did not latch when closed.



The above was discussed with the Maintenance Director who said they conduct a monthly door audit, but had not previously observed the lobby doors to not close and latch.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain vertical openings between floors with a construction having a fire resistive rating of at least one hour. This could result in the passage of toxic products of combustion from one floor to another which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between approx. 0800 and 1600 hours in the Westlake building:
-The B Stairwell exit 2-hour rated fire door was missing door hardware, exposing the inner construction material of the door.

On 6/15/16 between approx. 1100 and 1400 hours in the Eastlake building:
-There was an unsealed penetration in the intervening wall of the fire barrier between the exit stairwell AS-S001 and the interior exit corridor above the drop ceiling.
-There was an unsealed penetration in the ON1 Stairwell wall above the door into the exit corridor

The Safety Officer stated that they were in the process of sealing existing penetrations observed during a previous JCHO inspection and that the Carpenter shop had previously observed the issues with some 2 hour fire doors and missing hardware, and had already created a work order to repair the doors with Fire Door caulk.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain the ability of fire/smoke doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:


On 6/16/16 between approx. 0830 ad 1300 hours in the Eastlake building:
-There was a Cornell rolling fire door within room #048 and enclosing the kitchen prep area that had been disable to prevent automatic door closing via fusible links.

The above was discussed and acknowledged by the Safety Officer who said all of the Cornell rolling fire doors had been disable some time ago, and was unaware where the authorization to do so had come from.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain doors in hazardous areas as being self closing and in maintaining hazardous areas as being smoke resistant. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

On 6/14/16 between approximately 0800 and 1600 hours in the Westlake building:
-Room F278 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
-B100 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
Room B09 is now being used as a storage room over 50 square feet and automatic/ self-closing door closures have not been installed.
-Room F213, F 212, F211, F210, F208, F207 are now being used as a storage rooms over 50 square feet and automatic/ self-closing door closures have not been installed.

On 6/15/16 between approximately 0845 and 1400 hours in the Eastlake building:
-The Steam room/boiler room in the basement is enclosed within a 1 hour barrier and has an unsealed opening into the corridor's supply / return air plenum.

06/16/16 between approximately 0900 and 1400 hours in the Eastlake building:

-Room 354 and Room 350 were former seclusion rooms that were converted to storage rooms over 50 square feet and automatic door closures have not been installed.

-There were unsealed penetrations in the North wall of electrical room 003 under the new Generator Annunciator panel.


The above was discussed and acknowledged by the Safety Officer and Maintenance Manager who said they were unaware the self-closer's were required on rooms over 50 square feet used for storage and were in the process of sealing penetrations observed from a previous JCHO inspection.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1600 hours in the Westlake building:
-room #F220 had no sprinkler coverage.
-Electrical closet F223 had no sprinkler coverage.

On 6/15/16 between 0800 and 1400 hours in the Westlake building:
-There was an Acoustical booth approximately 8x8 in size in room F26 the did not have any sprinkler coverage within. In addition the booth was obstructing the spray pattern of the existing head in the room from covering the rest of the open room.
-There was no sprinkler coverage in the E245 electrical room.

06/15//2016 between 0800 and 1600 hours in the Eastlake building:

- Room 355 has an electrical room with no sprinkler coverage.
- Electrical Room #319 does not have sprinkler coverage.
-Electrical Room #119 does not have sprinkler coverage.
-The vestibule across from Central supply on the ground floor was remodeled post-initial construction and enclosed and is not equipped with sprinkler coverage.


06/16/2016 between 0800 and 1400 hours in the Eastlake building
-The janitor/cleaning supply closet in large kitchen storage room does not have sprinkler coverage.
-The Food Service Manager closet does not have sprinkler coverage.
-The Café dish room has the escutcheon plate missing from sprinkler head.
-The sprinkler head at the 2N1 entrance was obstructed by an Exit sign.
-The 2N1 electrical room has no sprinkler coverage.
-A sprinkler head was obstructed by an Exit sign near the main nurses station.


The above was discussed and acknowledged by the Maintenance Manager and Safety Officer who said they were unaware of the missing sprinkler coverage.

Based upon observations and staff interviews on 6/14/16 through 6/16/16 during the physical tour of the campus, the facility has failed to maintain fire sprinkler systems as required. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
On 6/14/16 between approx. 0800 and 1600 hours in the Westlake building:
-There were 3 of 4 dry barrell sprinkler heads at the exterior loading dock that were extremely corroded.
-1 of 4 guages on the Sprinkler riser were outdated and due for replacement (marked with an installation date of 2010, must be replaced every 5 years)
-There was a concealed sprinkler head cover that was glued to the ceiling with fire caulk in the F214 storage closet, preventing from the cover releasing at the required temperature.

On 6/15/16 between approximately 1100 and 1400 hours in the Eastlake building:
-3 of 8 heads in room E-021 were covered in spray-on insulation.
-1 of 2 heads in room 019 were covered in spray-on insulation.

On 6/16/16 between approximately 0830 and 1300 hours in the Eastlake building:
-3 of 12 heads in the Payroll office were heavily corroded or covered in a glue like substance.


The above was discussed and acknowledged by the Maintenance Manager and the Safety Officer who said they had not previously observed the corroded or covered sprinkler heads.

Based upon record review and staff interviews on 6/14/16 during the document review between approximately 0930 and 1530 hours the facility has failed to maintain a written smoking policy or regulation for residents and staff. This could result in a failure to monitor and prevent unauthorized smoking resulting in the possible ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility has not adopted a Smoking Policy for residents as required.

The above was discussed and acknowledged by the Safety Officer who said they were unaware they needed a policy for residents.

Based upon observation and staff interviews on 6/14/16 though 6/16/16 during the physical tour of the campus the facility has maintain the use of portable electric heaters in accordance with Listing requirements within the facility. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:

06/15/16 between approximately 0900 and 1100 hours in the Eastlake building:

-Office room #337 had an unapproved heater without tip-over protection.
-Room #335 to have an unapproved heater without tip-over protection.

06/16/16 between approximately 1000 and 1100 hours in the Eastlake building
-The kitchen Food Service office had an unapproved heater without tip-over protection.


The above was discussed and acknowledged by the Safety Officer who said they were unaware these heaters did not have tip-over protection in accordance with UL listings.

Based upon observations and staff interviews on 6/14/16 though 6/16/16 during the physical tour of the campus the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between approximately 0800 and 1600 hours in the Westlake building:
-There was a curtain covering the fire door window of the corridor door of Oxygen Storage room C107 that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
06/15/2016 between approximately 1200 and 1300 hours in the Eastlake building:

-Room 142 had a bed sheet covering the entire window. There was no documentation indicating the sheet had been treated or manufactured to be NFPA 701 approved.

06/16/2016 between approximately 0800 and 1200 hours in the Eastlake building:

- Exam room in 1 South was using a beige shower curtain as a privacy curtain. No documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-Room 243 on 2N1 had a home shower curtain used as a privacy curtain. No documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.

6/16/16 between approximately 0800 and 1400 hours in the Eastlake building:

-There was a curtain in the 2-South Visitor's room that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-There were pink curtains in the 2-South Nurses station that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.
-There were curtains in the PT suite 024 that had no documentation indicating the curtain was treated or manufactured to be NFPA 701 approved.




The above was discussed and acknowledged by the Maintenance Manager and Safety Officer who said they were unaware of the existence of the untreated curtains.

Based upon observations and staff interviews from 6/14/16 to 6/16/16 during the physical tour of the facility, the facility has failed to restrict the use of extension cords to providing power to permitted electrical equipment on a temporary basis and from ensuring all electrical wiring is in accordance with NFPA 70. This could result in a fire from overheating of the extension cord due to the prolonged power draw or result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
On 6/14/16 between 0800 and 1600 hours in the Westlake building:

-There was a powerstrip plugged into another powerstrip in room G290
-There was an open electrical junction box on the west wall of the Boiler room
-There was a powerstrip plugged into another powerstrip in room D249
-There was a powerstrip plugged into a multi-plug UPS box in the HH electrical closet of room A145

06/15/2016 between the hours of 0850 to 1500 in the Eastlake Building:

- In office #366 Financial Services Specialist there was a power strip plugged into a white extension cord.
-In room 367 there was a broken electrical cover and cover missing on computer wiring.
-In room 362 there was an unsecured/ hanging powerstrip, resulting in pulling and stress on the cords, potentially resulting in electrical arcing.
-In room 325 there was an extension cord used in place of permanent wiring for a coffee pot.
-In the Safety Program Coordinator office there was a refrigerator plugged into a power strip.
-In the Safety Program Coordinator's office there was an air conditioner plugged into a power strip then into an orange extension cord.
-In the IT office back area there was a refrigerator and microwave plugged into a power strip.
-In the IT Manager's office there was a power strip plugged into power strip.
-In ITS 1 there was a power strip plugged into an extension cord.
-In HR Consultant 1 there was an extension cord used in place of permanent wiring for a speaker/radio.
-There was an open electrical junction box above the clock in room S2018.
-There was a powerstrip plugged into a multi-plug UPS at the Pharmacy desk area.


On 6/15/16 between the hours of 0845 and 1400 in the Westlake building:

--There was a multi-plug UPS box plugged into a powerstrip in room E245
- There was a powerstrip plugged into another powerstrip at the East desk in room E247.
-There was an extension cord in use with a toaster in room J206.

On 6/16/16 between 0830 and 1230 hours in the Westlake and Kitchen buildings:

- In the FSU Administrative Manager office there was a power strip plugged into another power strip.
-There was an unapproved multi-plug adaptor in the S1-116 CRN Office.
-In the Staff Education/Conference room there was a powerstrip plugged into an extension cord.
-In Room 105 there was a microwave plugged into a power strip.
- The 218A Kitchen Office there was a power strip plugged into another power strip.
-In the Food Services Manager-East Lake Office there was power strip plugged into another power strip.



The above was discussed and acknowledged by the Safety Officer and Maintenance Manager who said their staff conducts periodic audits for extension cords, but that they were unaware of the observed extension cords in use and other electrical violations.