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Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain three (3) of 40 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke/heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.


Findings are:

During the general life safety tour of the facility on April 20, 2011 with the manager of plant operations and the maintenance assistant, observed that the following doors had impediments to self closing and/or latching:

1. Direct observation / testing of the self closing corridor door (3G23) to the soiled utility room on the 3rd floor's medical surgical wing at 9:50 a.m., revealed that it would not self close and latch. Testing revealed that this door's latching mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching this door so it works as intended / required (maintains positive latching). Interview of manager of plant operations revealed that this condition would be corrected.

2. Direct observation/testing of the corridor door (2F21) to patient care room A221 on the 2nd floor at 10:05 a.m., revealed that it would not close and latch. Testing revealed that this door's latching mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching this door so it works as intended/required (maintains positive latching). Interview of manager of plant operations revealed that this condition would be corrected.

3. Direct observation/testing at 11:16 a.m. revealed that the corridor door to the patient care room 3241 (TMA-2C12) on the 2nd floor did not operate as required. It would not close and seal/latch to limit the transfer of smoke / heated gases should a fire occur. This door was equipped with an isolation station that was hung over the top of this door. The hanger flanges interfered with the door closure devices and would not allow this door to close and latch per requirements. A follow-up interview with the manager of plant engineering at 12:15 a.m., re-confirmed that this condition/issue would be evaluated and a suitable solution developed and implemented.

These findings were verified / acknowledged by the chief executive officer, the vice president of security & safety, the security manager and the manager of plant operations at the exit interview at 4:15 p.m. on April 20, 2011.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A & NFPA 80
Class III
Correction Date: 05/20/2011

Based on observations and interviews, the facility did not maintain a kitchen hood's fire protection system per the requirements of NFPA 96 and per NFPA 101-2000, 4.6.12.1, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition." The facility failed to ensure that the kitchen's fire suppression nozzles/system are properly positioned which could affect the proper functioning of this system.

Findings are:

During a life safety tour of the kitchen on April 20, 2011 with the manager of plant operations and the kitchen manager, observed the following:

At 11:45 a.m., observed that the ansul fire protection system nozzle within the kitchen's number 5 exhaust hood (located near the serving line) was not positioned directly/centered over deep fat fryer. One nozzle was positioned/directed to the left of this unit and not directed at the vegetable oil inside the unit. Therefore, this nozzle layout did not protect this appliance when in use.

Upon interview of the manager of plant operations and the kitchen manager, it was stated that this fryer was repositioned for cleaning and not returned to its original location. This nozzle was out of alignment and therefore would not provide the maximum spray pattern efficiency/coverage. A further interview of the manager of plant operations and the corporate dietary director, revealed that they would evaluate this situation and insure that this fryer would have proper coverage.

These findings were verified/acknowledged by the chief executive officer, the vice president of security & safety, the security manager and the manager of plant operations at the exit interview at 4:15 p.m. on April 20, 2011.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 4.6.12.1-.4 & 9.6; NFPA 96(98), 8-2, & 13-3.2.4; NFPA 17, 9-2 & NFPA 17A, 5-2
Class III
Correction Date: 05/20/2011

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain three (3) of 40 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke/heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.


Findings are:

During the general life safety tour of the facility on April 20, 2011 with the manager of plant operations and the maintenance assistant, observed that the following doors had impediments to self closing and/or latching:

1. Direct observation / testing of the self closing corridor door (3G23) to the soiled utility room on the 3rd floor's medical surgical wing at 9:50 a.m., revealed that it would not self close and latch. Testing revealed that this door's latching mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching this door so it works as intended / required (maintains positive latching). Interview of manager of plant operations revealed that this condition would be corrected.

2. Direct observation/testing of the corridor door (2F21) to patient care room A221 on the 2nd floor at 10:05 a.m., revealed that it would not close and latch. Testing revealed that this door's latching mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching this door so it works as intended/required (maintains positive latching). Interview of manager of plant operations revealed that this condition would be corrected.

3. Direct observation/testing at 11:16 a.m. revealed that the corridor door to the patient care room 3241 (TMA-2C12) on the 2nd floor did not operate as required. It would not close and seal/latch to limit the transfer of smoke / heated gases should a fire occur. This door was equipped with an isolation station that was hung over the top of this door. The hanger flanges interfered with the door closure devices and would not allow this door to close and latch per requirements. A follow-up interview with the manager of plant engineering at 12:15 a.m., re-confirmed that this condition/issue would be evaluated and a suitable solution developed and implemented.

These findings were verified / acknowledged by the chief executive officer, the vice president of security & safety, the security manager and the manager of plant operations at the exit interview at 4:15 p.m. on April 20, 2011.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A & NFPA 80
Class III
Correction Date: 05/20/2011

Based on observations and interviews, the facility did not maintain a kitchen hood's fire protection system per the requirements of NFPA 96 and per NFPA 101-2000, 4.6.12.1, "every...item of equipment required by this Code shall be continuously maintained in proper operating condition." The facility failed to ensure that the kitchen's fire suppression nozzles/system are properly positioned which could affect the proper functioning of this system.

Findings are:

During a life safety tour of the kitchen on April 20, 2011 with the manager of plant operations and the kitchen manager, observed the following:

At 11:45 a.m., observed that the ansul fire protection system nozzle within the kitchen's number 5 exhaust hood (located near the serving line) was not positioned directly/centered over deep fat fryer. One nozzle was positioned/directed to the left of this unit and not directed at the vegetable oil inside the unit. Therefore, this nozzle layout did not protect this appliance when in use.

Upon interview of the manager of plant operations and the kitchen manager, it was stated that this fryer was repositioned for cleaning and not returned to its original location. This nozzle was out of alignment and therefore would not provide the maximum spray pattern efficiency/coverage. A further interview of the manager of plant operations and the corporate dietary director, revealed that they would evaluate this situation and insure that this fryer would have proper coverage.

These findings were verified/acknowledged by the chief executive officer, the vice president of security & safety, the security manager and the manager of plant operations at the exit interview at 4:15 p.m. on April 20, 2011.

59A-3.077/.078/.079, F.A.C.
NFPA 101-2000, 4.6.12.1-.4 & 9.6; NFPA 96(98), 8-2, & 13-3.2.4; NFPA 17, 9-2 & NFPA 17A, 5-2
Class III
Correction Date: 05/20/2011