HospitalInspections.org

Based on observation and staff interview, the facility failed to remain in compliance with requirements for means of egress per NFPA 101 (2012).

On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. During the tour of the facility with the Plant Operations Staff in the Dental area door #64, 65 revealed that main entrance door and the interior entrance door measured 28" which does not allow a non-ambulatory patient access to services or the ability to egress while sitting in a wheelchair. The Director of Maintenance observed the finding along with the Director of Nursing which agreed that patients cannot pass through each door for care.

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the egress capacity were not compliance and he had no comment.

per: NFPA 101 (2012 Edition) 7.2, 7.2.1.1.1

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to provide exit sign with proper directional indication to show the proper means to egress from the facility in accordance with NFPA 101 (2012).

The findings include:

On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12, Floor 3 while on tour with facility staff, it was observed near door 30, an EXIT sign on the wall over door 30 without directional indication of which way to EXIT. This EXIT sign gives the impression that door 30 might be an EXIT due to the appearance of the EXIT sign above the door. Egress shall be provided with directional signs which are continuously illuminated by the emergency lighting system in accordance with

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the exit sign directional indication was not visible and he stated that "the facility would correct it."

per: NFPA 101 (2012) 4.5.8, 4.6.13, 7.10.1, 7.10.2, 19.2.10, 19.7.6.

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review, observation and staff interview, the facility failed to maintain the kitchen hood fire suppression system as required by NFPA 17A (2009).

The findings include:

Dietary Bldg. #11
1) During record review with the Plant Operations Staff on 3/10/25 at 1:00 PM, the facility failed to produce documentation for the fire suppression hood semi-annual inspection, inspection for 3/24 was not produced.

per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12.
per: NFPA 17A (2009 Edition) 7.5.1.

2) During the facility tour with the Plant Operations Staff on 3/11/24 from 9:30 PM to 3:30 PM, in the kitchen, observed fire extinguishing system manual pull station was not secured, pin were broken.

per: NFPA 101 (2012 Edition) 19.3.2.5., 9.2.3.
per: NFPA 96 (2011 Edition) 10.5.2.

3) During the record review with the Plant Operations Staff on 3/10/25 at 1:10 PM, evidence of the 8 point monthly quick check inspection of the dietary kitchen could not be produced.

per NFPA 101 (2012 Edition) 19.3.2.5.1., 9.2.3.
per NFPA 96 (2011 Edition) 10.2.6.(4)
per NFPA 17A (2009 Edition) 7.2.1, 7.2.2.

4) During the facility tour with the Plant Operations Staff on 3/11/24 from 9:30 PM to 3:30 PM, in the kitchen, observed the deep fryer were located less than 16" from the gas stove.

per: NFPA 101 (2012 Edition) 19.3.2.5.1., 9.2.3.
per: NFPA 96 (2011 Edition) 10.2.6.(4)
per: NFPA 17A (2009 Edition) 7.2.1, 7.2.2.


During an interview with the Plant Operations Staff on 3/11/25 at 10:05 AM, and he acknowledged the semi-annual inspection were not conducted and he stated, "I was not aware that the inspection were not completed."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to maintain the interior finishes (ceiling tiles) in the facility per NFPA 101 (2012 Edition).

On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12 During the tour of the facility along with the Plant Operations Staff it was observed that the resident hall floor 3 had been painted which contributes for excessive fire load and changes the rating of the installed ceiling tiles. Ceiling finishes, including surfaces of the tiles have a flame spread rating of Class B. The addition of spray paint increases the flammability and could cause the sprinkler system to not function properly.

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the ceiling tiles were painted and he stated that "the facility were not aware of the painted tiles."

NFPA 101 (2012 Edition) 10.2., 19.3.3.1, 19.3.3.2., 4.6.12.1.

These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to install fire alarm system components in accordance with NFPA 101 (2012).

The findings include:

On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed:
1) No heat / smoke detector was installed in the mechanical room in buildings 36-D, and 36-A.

During an interview with the Plant Operations Staff on 3/10/25 at 3:30 PM, he acknowledged the smoke detector was not installed and he stated that "the facility would install it."

per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6, 9.6.1.8
per: NFPA 72 (2010 Edition) 17.5.3.1, 17.6.1.1, 17.6.2.1.

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review, observation and staff interview, the facility failed to maintain the fire alarm system in accordance with NFPA 101 (2012).

The findings include:

1) During record review with the Plant Operations Staff on 3/10/25 at 10:30 AM, the facility failed to produce documentation for the fire alarm system smoke and duct detectors sensitivity testing.

per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1.
per: NFPA 72 (2010 Edition) Table 14.4.2.2.(14)(g)(1)


2) During record review with the Plant Operations Staff on 3/10/25 at 10:35 AM, the facility failed to produce documentation for the fire alarm system duct detectors differential pressure testing.

per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1.
per: NFPA 72 (2010 Edition) Table 14.4.2.2.(14)(g)(6)


3) During record review with the Plant Operations Staff on 3/10/25 at 10:40 AM, the facility failed to produce documentation of the semi-annual (visual) inspection of the fire alarm system.

per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1.
per: NFPA 72 (2010 Edition) Table 14.3.1.

4) On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed:
A) Fire Alarm breakers, located in equipment rooms in buildings 36-A, 36-B, 36-D, 7, and 8 failed to have a red marking.
B) Fire Alarm breakers in buildings 36-A, 36-B, 36-D, 7, and 8 failed to have a locking device installed to prevent breaker from being turned off.

per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6
per: NFPA 72 (2010 Edition) 10.6.5.2.3, 10.6.5.4

During an interview with the Plant Operations Staff on 3/11/25 at 3:00 PM, he acknowledged the fire alarm system inspection and testing was not completed and he stated that "the facility would schedule the inspections."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review, observation and staff interview, the facility failed to maintain required inspections of the automatic fire sprinkler system (AFSS) in accordance with NFPA 101 (2012). Failure to maintain or have inspected, the system could lead to an AFSS failure.

The findings include:

BLDG. #13
1) During record review with the Plant Operations Staff on 3/10/25 at 12:40 PM, the facility provided documentation that revealed the fire sprinkler system inspections were overdue, the last reports were dated 2023.

per: NFPA 101 (2012 Edition) 19.3.5.1., 9.7.1.1.
per: NFPA 25 (2011 Edition) 7.3.1.


2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12 between the hours of 1:00 p.m. and 4:00 p.m. during the facility tour with the Maintenance Director, it was found that the spare sprinkler cabinet located on the exterior of facility in fire riser room on the South East corner, failed to have an inventory list of the installed sprinklers and sprinkler wrench within the facility.

per: NFPA 101 (2012 Edition) 19.3.5.1, 9.7, 9.7.1.1
per: NFPA 13 (2010 Edition) 6.2.9.7, 6.2.9.7.1.(1-4)

During an interview with the Plant Operations Staff on 3/10/25 at 3:30 PM, he acknowledged the fire sprinkler system inspections were overdue and he stated that "the facility would schedule the inspections."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to maintain the fire extinguishers in the facility in accordance with NFPA 101 (2012). Failure to provide a clean agent fire extinguisher in the data and communication room could delay the extinguishment of a fire.

The findings include:

1) On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed:
A) Fire Extinguisher, 1 of 1, located in equipment room 25 of building 36-D, failed to have monthly inspections performed and documented on inspection tag. The annual inspection was completed in December 2024.
B) Fire Extinguisher, 1 of 1, located in equipment room 23 of building 7, failed to have the annual inspection completed. The last inspection was completed in June 2023.

per: NFPA 101 (2012 Edition) 19.3.5.12
per: NFPA 10 (2010 Edition) 7.2.1.1, 7.2.1.2, 7.2.4.1.2, 7.2.4.1.4


2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the tour of the building 12 it was discovered that the fire Extinguisher's located in maintenance room with generator has an expired portable fire extinguisher dated 2023 and not signed off monthly as required. Located in Building 12-3 room 120 fire extinguisher not signed off monthly as required and sitting on the floor. Located in room 123 CO2 fire extinguisher not signed off monthly as required. Located behind door 124 fire extinguisher expired 2023, not signed off monthly as required. Located in elevator roof maintenance area entry door fire extinguisher not signed off monthly as required. Located in elevator switch room fire extinguisher expired 2023, not signed off monthly as required. Located in beauty salon behind door 70 fire extinguisher expired 2023, not signed off monthly as required.

per: NFPA 99 ( 2012 Edition) 16.9.1.3.


During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the fire extinguishers annual and monthly inspection were not done and he stated that "the facility would do the inspections."

These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to properly maintain the required fire/smoke barriers penetrations, which have not been fire-stopped or smoke-sealed per the requirements of NFPA 101 (2012).

The findings include:

During the facility tour with the Plant Operations Staff on 3/10-12/25 from 9:00 AM to 3:30 PM, in Building 12-3, it was found that the smoke/fire walls were not properly protected with the required firestopping system in the following area(s):
1) Located on the first, second and third floors inside room 43 by hazardous room drywall has been removed from room
2) Located in room 46 open penetrations in the walls
3) Open wall behind washing machine machines has penetrations
4) Located in room 15 open hole penetrations in the ceiling

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the penetrations in the wall and he stated that "he would repair the penetration."

per: NFPA 101 (2012 Edition) 19.3.7.3., 8.5.6., 8.5.6.1. thru 8.5.6.6.

These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review and staff interview, the facility failed to maintain fire/smoke dampers in the facility in accordance with NFPA 90A (2011).

The findings include:

Bldg. #12 & 13
During the record review with the Plant Operations Staff on 3/10/25 at 12:30 PM, the facility failed to produce documentation for fire/smoke dampers inspection. All dampers shall be operated to verify that they fully close, fusible links shall be removed at least every four years.

During an interview with the Plant Operations Staff on 3/10/25 at 12:35 PM, he acknowledged the fire/smoke dampers inspection was not completed and he stated that "the facility would schedule the inspections."

per: NFPA 101 (2012 Edition) 19.5.2.1., 9.2.1.
per: NFPA 90A (2011 Edition) 5.4.8.1.
per: NFPA 80 (2010 Edition) 19.4.1.1., 19.4.9., 19.4.10.

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review and staff interview, the facility failed to maintain and inspect fire doors in accordance with NFPA 80 (2010).

The findings include:

Bldg. #13
1) During the record review with the Plant Operations Staff on 3/10/25 at 11:20 AM, it was found that the facility failed to produce documentation for fire doors inspection, the last inspection report was dated 2/17/22.

per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12.
per: NFPA 80 (2010 Edition) 5.2.4.1.


2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12-3. During the tour of the facility with the Plant Operations Staff in the main hallway between building 12 and 12-3 it was observed that a listed fire door number 7 is missing the lower half of the releasing hardware and has open penetrations at the panic hardware on each side of the door.

per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12.
per: NFPA 80 (2010 Edition) 5.2.4.1.

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 AM, he acknowledged the fire doors inspection was not completed and he stated that "he would complete the fire doors inspection immediately."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on record review and staff interview, the facility failed to maintain the emergency generators in accordance with NFPA 101 (2012). This in the event of a power failure could result in the generator malfunctioning with a resulting loss of power to the facility.

The findings include:

BLDG. #12 & 13 / Entire Facility Generator
1) During record review with the Plant Operations Staff on 3/10/25 at 10:50 AM, it was found that the annual Fuel Quality Testing was not completed.

per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1.
per: NFPA 110 (2010 Edition) 8.3.8.


2) During record review with the Plant Operations Staff on 3/10/25 at 10:55 AM, no evidence of annual 1.5 hour load testing was found. There was also no record of exceptions to testing as allowed by NFPA 110.

per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1.
per: NFPA 110 (2010 Edition) 8.4.2.3.


3) During record review with the Plant Operations Staff on 3/10/25 at 11:00 AM, it was found that the annual major PM service was not completed.

per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1.
per: NFPA 110 (2010 Edition) 8.1.1.


4) During record review with the Plant Operations Staff on 3/10/25 at 11:05 AM, no records of main and feeder circuit breaker inspection and exercising was provided.

per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12.
per: NFPA 99 (2012 Edition) 6.4.4.1.2.1.


During an interview with the Plant Operations Staff on 3/10/25 at 11:10 AM, he acknowledged the emergency generator inspections was not completed and he stated that "he would call the vendor and complete the generator inspections immediately."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to prevent the improper use of power strips in accordance with NFPA 101 (2012). This failure could result in endangerment to the residents, staff and other building occupants.

The findings include:

On 10 - 12 March 2025 at Northeast Florida State Hospital, building 12 and 13 with the Plant Operations Staff it was found that the facility was improperly using extension cords, power strips and multi-port adapters.
1.) Main hallway room number 9 copier and microwave plugged into power strip
2.) Main hallway room number 6 refrigerator and microwave plugged into power strip
3.) Bldg. 12 room 100 office power strips being daisy chained.
4.) Bldg. 12 room 104 refrigerator and microwave plugged into power strip.
5.) Bldg. 12 multi-port adapter shows signs of being overheated.
6.) Bldg. 12 IT room has power strip used as permanent wiring for IT equipment in rack

per: NFPA 99 (2012 Edition) 10.2.3.6, 10.2.4
per: NFPA 70 (2011 Edition) 400.8, 590.3(D)

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the power strips were used improperly and he stated that "he would remove them."

These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.

Based on observation and staff interview, the facility failed to maintain medical gas storage rooms in accordance with NFPA 99 (2012). This failure could result in endangerment to the residents, staff and other building occupants
The findings include:

1) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the facility tour with the Plant Operations Staff, it was found on 3rd floor door 2, 74 & 98 oxygen storage room in the O2 storage room by the south nursing station that the facility failed to display the correct signage per NFPA 99 for storing oxidizing gases.

per: NFPA 99 (2012 Edition) 11.3.2.3, 11.3.4.1, 11.3.4.2.


2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the tour of the facility with the Plant Operations Staff in the Medical Triage area revealed that an E Oxygen cylinder was observed free standing without being secured in transport cart or secured to the wall as required.

NFPA 99 (2012 Edition) 11.6.5.2, 11.6.5.3.

During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the oxygen storage signage were not installed and he stated that "he would order the signs immediately."

These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.