HospitalInspections.org

Based on observations and interviews the facility failed to maintain essential life safety systems, building integrity, and environmental care of a portion of the building. All areas, systems and buildings in healthcare facilities have to be maintained according to the requirements of NFPA and all of its referenced publications as well as the Florida Administrative Code. Any area or life safety system not maintained can pose harm and danger to all occupants.

Findings include:

During the Life Safety Survey tour of the facility between 10:00 am and 1:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed on the second floor area known as wound healing care and outpatient surgery that (1) the entire area has been closed off; (2) the roof was leaking; and (3) there was water damage (4) All of the life safety systems and building components not being maintained, and they are the following:
1-Fire Sprinkler system
2-Fire Alarm
3-Fire Doors and Smoke Doors
4-Fire and Smoke Door Hardware
5-Fire Stopping
6-Stairwells
7-Ceiling Tiles
8-Interior smoke and fire walls and finish
9-Medical Gas
10-Electrical circuitry, electric breaker panels and electrical systems
11-Emergency lights and Exit lights
12-Roof
13- Evidence of bio growth in stairwells, wallpaper, walls and ceilings
A complete review, testing and maintenance of all of the above listed systems in the area noted is due immediately at this time. NFPA 101 (2012 Edition) sec 4.5.8 sec 4.6.1.2 sec 4.6.12 sec 4.6.12.1


During the Life Safety Survey tour of the facility between 10:00 am and 1:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed that the roof on the second floor on the south side of the building is the original roof from 1959 and has reached the end of its life span. A complete review and written assessment is required and due at this time for the portion of the second floor roof noted from an Engineer, Architect or Master Roofer. . NFPA 101 (2012 Edition) sec 4.5.8 sec 4.6.1.2 sec 4.6.12 sec 4.6.12.1

During the staff interview between 10:00 am and 1:00 pm on 05/20/2024, the Interim Plant Operations Director acknowledged these findings. These findings were also discussed and acknowledged by the Chief Executive Officer during the exit conference.

Based on observations and staff interview, the facility failed to maintain the elevators in accordance with the National Fire Protection Association (NFPA) 101.

Findings include:

During the Life Safety Survey tour of the facility between 11:00 am and 3:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed that: (1) all elevators have expired certificates and inspections; (2) there were 3 out of 7 elevators operational; and (3) there were no repairs completed to inspection reports listed failures and deficiencies. NFPA 101 (2012 Edition) sec 19.5.3 sec 9.4, 9.4.6 sec 9.4.6.1

During the staff interview between 10:00 am and 1:00 pm on 05/20/2024, the Interim Plant Operations Director acknowledged these findings. These findings were also discussed and acknowledged by the Chief Executive Officer during the exit conference.

Based on observations and interview, the facility failed to protect and store flammable liquids as required by the National Fire Protection Association (NFPA) 99.

Findings include:

Observation and interview with the interim facilities director on May 20, 2024 between the hours of 10:00 AM to 1:00 PM at the main driveway in front of the main entrance revealed the facility set up a temporary portable diesel water pump for the down lift station for sewage with four 55 gallon drums of diesel fuel that was not protected. The four 55-gallon drums of diesel fuel were directly on the side of the main driveway unprotected with the potential of a vehicle to hit the drums endanger all occupants, patients and staff using the main entrance to enter or exit the facility.

The facilities interim facilities director acknowledged the findings. Photographic evidence provided.

NFPA 99 (2012 Edition) 15.3, 15.3.1(1)
NFPA 30 (2012 Edition) 22.15
NFPA 30 (2012) Edition Sec 22.15