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SANFORD CANBY MEDICAL CENTER
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and staff interview, the facility failed to maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.2.1.4(2) and 5.4.1.6 This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 08/13/2025 at 10:48 AM, it was revealed by observation that there was not a sprinkler wrench located in the sprinkler storage cabinet.
An interview with the Maintenance Supervisor verified this deficient finding at the time of discovery.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and staff interview, the facility failed to maintain smoke barriers per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.2. This deficient finding could have a patterned impact on the residents within the facility.
Findings include:
On 08/13/2025 at 10:28 AM, it was revealed by observation that above the ceiling at the 1 hour smoke barrier and 2 hour fire barrier in between the Hospital and the Assisted Living there were multiple holes that were not properly fire stopped.
An interview with the Maintenance Supervisor verified this deficient finding at the time of discovery.
Utilities - Gas and Electric
Tag No.: K0511
Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.1.2 and NFPA 70 (2011 edition), National Electric Code, section 408.20. This deficient finding could have a patterned impact on the residents within the facility.
Findings include:
On 08/13/2025, at 10:04 AM, it was revealed by observation that the 2 electrical panels located in the Soiled Utility Room near the Nurse's Station were not secured.
An interview with the Maintenance Supervisor verified this deficient finding at the time of discovery.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a patterned impact on the residents within the facility.
Findings include:
On 08/13/2025 at 9:55 AM, it was revealed by observation that the fire doors located at Radiology did not shut completely when tested.
An interview with the Maintenance Supervisor verified this deficient finding at the time of discovery.