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Based on a review of the facility records, and interview with the staff on 9/13/11, it was determined that the facility failed to ensure that the emergency lighting was tested as required, and maintained in reliable operating condition. This could delay or deny safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show that the emergency lights were being tested for 90 minutes once a year. The staff stated that they were not performing these tests, and the task was not in the computer to be scheduled. One of the emergency lights failed when tested.

Based on observations made during tour of the facility on 9/14/11, it was determined that the facility failed to ensure the the fire alarm system was tested and installed in accordance with NFPA 101 9.7, NFPA 72 (the standard for the installation of fire alarm systems), and maintained in reliable operating condition. This denies the required warning that the sprinkler system is impaired or inoperable.

The findings include:

Sarasota Memorial Ambulatory Health Care Center at University Pkwy (0716) located at 5350 University Pkwy was observed to have both of the tamper switches removed from the backflow preventer located in the parking lot. Both tamper switches were found lying on the ground. The evidence that they were removed was the paint color change under where the switches were mounted when the valves were painted.

Based on observations made during tour of the facility and a review of the facility records, and interviews with the staff, it was determined that the automatic fire sprinkler system was tested as frequently as required by NFPA 25, installed in accordance with NFPA 13, and maintained in reliable operating condition.

The findings include:

1. There was no documentation on 9/14/11 to show that quarterly inspections were being performed. The plant operations director for offsite facilities stated that the facility leases space in this building and the owner refuses to have quarterly inspections performed.

2. There were a mix of standard response, and quick response sprinkler heads in the same compartment observed in the Critical Care Tower by the Microbiology Lab.

3. There was no documentation to show that the items required in the 5th year inspection were performed this was on 9/14/11 at the Sarasota Memorial Ambulatory Center at Blackburn (1016) located at 929 South Tamiami Trail Osprey, Florida.

Based on observations made during tour of the facility on 9/12/11 and 9/13/11, it was determined that the facility failed to maintain the commercial cooking equipment in reliable operating safe condition.

The findings include:

There was a build-up of grease dripping from exhaust hood of the main building, 4th floor cafeteria kitchen. This grease between the metal from the hood and the wall, and has to be from a leak in the exhaust system. The hood, cooking equipment, and the steam table were all observed to be grease laden. This was also observed in the main kitchen on 9/14/11 where the gas grille and the pan underneath the grille had excessive build-up. The dietary manager stated that the grille was thoroughly cleaned three weeks prior. The staff was advised by the surveyor that if this happens in three weeks then the a cleaning schedule is needed to assure that this equipment is safe in the future. There was no protocol or schedule for cleaning the grille.

Based on a review of the facility records, and interview with the staff during the Fire Life Safety survey on 9/13/11, it was determined that the facility failed to ensure that all Essential and standard Electrical Equipment was tested as frequently as required. Essential and standard Electrical Equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause the safety features of the equipment to fail.

The findings include:

The document review at Sarasota Memorial Hospital Health Care System Emergency Room (Free Standing) (1616) located at 2345 Bobcat Village Center Rd. North Port, Florida revealed that there was no documentation to show that the electrical receptacles were inspected and tested as required. The offsite facilities director acknowledged that they were not performing the inspections and tests of the receptacles, and further that they utilize a Computer System for preventative maintenance, and this test is not in there.