HospitalInspections.org

Based on observations made during tour of the facilities, and interviews with the staff, it was determined that the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction in accordance with NFPA 101-2000, 19.3.3.1, 19.3.3.2


The findings include:

1. On 1/24/11, at the Main Campus (0109)West Wing, 15th floor, at 2:04 pm in room 1532 wooden plywood on two (2) walls, floor to ceiling, with no fire rating.

2. On 1/26/11, Main Campus (0109)West Wing, 4th Floor, at 2:00 pm, room 406 had carpeted walls no flammable rating.

3. On 1/26/11, Main Campus (0109)West Wing, 2nd Floor, at 3:39 pm, room 203C had non-rated plywood on walls.

4. On 1/26/11, Main Campus (0109)West Wing, at 3:52 pm, in Suite 215, had wooden panel boards added to walls unknown if fire rated.

5. On 1/27/11 at the Main Campus (0109)West Wing, on the 1st floor, at 2:16 pm in room 119, plywood on all walls no fire rating.

6. On 1/27/11 at the Main Campus (0109) East Wing, on the 4th Floor, at 11:17am, in room 4119 there was a carpeted wall partition not fire rated.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the corridor doors were constructed properly, able to resist the passage of smoke, and have suitable means for keeping the door closed without impediments to closing, in accordance with NFPA 101-19.2.2.2

The findings include:

1. On 1/25/11, in the Main Campus (0109) Central Building room 423 a fire did not fully close when released from its magnetic hold open device.

2. On 1/26/11, in the Main Campus (0109) Central Building at the first floor elevator lobby (elevators 61-62) the smoke doors did not fully close when released from their magnetic hold open devices.

3. On 1/26/11, in the Main Campus (0109) Central Building the fire doors at 5 South to 5 Central did not fully close when released from their magnetic hold open devices. Gaps were observed exceeding 1/8 ".

4. On 1/24/11 at the Main Campus (0109) West Wing, at 10:31 am, the Elevator equipment room was missing the door closer and hardware.

5. On 1/24/11 at the Main Campus (0109) West Wing 15th floor, at 11:29 am, patient rooms 1501, 1505, 1511, 1521, 1529, 1531, 1533, and 1549 had an isolation cabinet placed over the doors in a manor that prevents door from closing.

6. On 1/24/11 at the Main Campus (0109) West Wing, 14th floor, at 2:54 pm, patient rooms 1415, 1419, 1427, 1429 had isolation cabinets placed over the door that prevent door from closing.

7. On 1/24/11 at the Main Campus (0109) West Wing, 12th floor, at 3:28 pm, the linen closet 1256, 1456 and 1556 had the door coordinator not working or installed.

8. On 1/24/11 at the Main Campus (0109) West Wing, 11th. floor, at 4:01 pm, the linen closet was missing the door coordinator.

9. On 1/25/11 at the Main Campus (0109) West Wing, 10th floor, at 9:32 am, room 1020 has a missing door coordinator.

10. On 1/24/11 at the Main Campus (0109) West Wing, at 9:35 am, room 1019, the door failed to close due to Isolation cabinet hanging from door.

11. On 1/24/11 at the Main Campus (0109) West Wing, at 9:37 am, all patient doors on floor have a metal kick plate installed 50% covered (48 inches x 48 inches).

12. On 1/24/11 at the Main Campus (0109) West Wing, at 10:11 am, linen closet 1046 was missing door coordinator.

13. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 10:44 am, room 929 and 919 had Isolation cabinet that denies the patient door to close.

14. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 10:46 am, all patient doors on floor had Metal kick plate installed (40 inches x 48 inches).

15. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 10:56 am, the room 912 door will not close due to needing adjustment.

16. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 11:01 am, room 901A is missing the door.

17. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 11:31 am, room 942 is a Linen closet missing the door coordinator.

18. On 1/24/11 at the Main Campus (0109) West Wing, 9th floor, at 11:37 am, room 930 is a Communication closet. The door failed to close and latch when tested.


19. On 1/24/11 at the Main Campus (0109) West Wing, 8th floor, at 1:54 pm, room 838, the door coordinator missing.


20. On 1/24/11 at the Main Campus (0109) West Wing, 7th floor, at 3:00 pm, all patient rooms have metal kick plates installed 48 inches x 48 inches.


21. On 1/24/11 at the Main Campus (0109) West Wing, 7th floor, at 3:18 pm, room 746 has a missing door coordinator.

22. On 1/26/11 at the Main Campus (0109) West Wing, 7th floor, at 9:58 am, room 720 has a door coordinator missing.

23. On 1/24/11 at the Main Campus (0109) West Wing, 6th floor, at 11:11 am, room 618 is missing the door coordinator.

24. On 1/24/11 at the Main Campus (0109) West Wing, 5th floor, at 11:47 am, room 554 is missing the door coordinator.

25. On 1/24/11 at the Main Campus (0109) West Wing, 6th floor, at 12:05 pm, room 503 has a missing door closer.

26. On 1/24/11 at the Main Campus (0109) West Wing, 6th floor, at 1:22 pm, room 526 has the door closer removed.

27. On 1/24/11 at the Main Campus (0109) West Wing, 6th floor, at 1:24 pm, room 530 and 542 have the door closer removed.

28. On 1/24/11 at the Main Campus (0109) West Wing, 3rd floor Operating room 4, at 3:09 pm, O.R. 4 Door will not close (surgery was in progress).

29. On 1/24/11 at the Main Campus (0109) West Wing, 2nd floor, at 3:35 pm, the door to room W203 will not close.

30. On 1/24/11 at the Main Campus (0109) West Wing, 2nd floor, at 3:39 pm, room 203C is missing the door closer.

31. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 9:42 am, room W201 had missing door closer.

32. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 9:50 am, Room 287 was missing the door closer.

33. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 9:55 am, room 289 was missing the door closer.

34. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:32 am, the Radiology Education door was missing the closer.

35. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 11:03 am, Room 203C is an electrical room with no door closer.

36. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 11:07 am, room 271B did not have a door.

37. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 11:08 am, room 4130 is missing the door closer.

38. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 11:10 am, room 4122 is missing the door closer.

39. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 11:20 am, room 4121 has no door closer.

40. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 1:13 pm, next to 4050 are double doors which have been removed.

41. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 1:42 pm, room 4046 is wedged in open position.

42. On 1/28/11, at the Main Campus (0109) East Building 10:45 am, Door # 2042 was wedged in open position.

43. On 1/24-25/11 at the South Campus (0109) , E.R. the cross-corridor fire door failed to close and latch.


44. On 1/24-25/11 at the South Campus (0109) Gift shop fire door auto-closure removed and door wedged in open position.


45. On 1/24-25/11 at the South Campus (0109) Lab fire exit door obstructed by equipment. PACU Soiled linen room obstructed by equipment.


46. On 1/24-25/11 at the South Campus (0109) CCU Nurses lounge corridor fire door obstructed by furnishings.


47. On 1/24-25/11 at the South Campus (0109) OB soiled holding fire door failed to latch.


48. On 1/24-25/11 at the South Campus (0109) Chapel fire corridor door failed to latch. copy room 2 North Nurses Station corridor fire door wedged open.


49. On 1/28/11, at the Main Campus (0109) Cystology Lab East Building #2155 failed to achieve positive latch when tested due to mechanism failure.


50. On 1/24-25/11 at the South Campus (0109) copy room at the 2 North Nurses Station, the corridor fire door wedged open.


51. On 1/24-25/11 at the South Campus (0109) dietary storage room fire door did not close/latch.


52. On 1/24-25/11 at the South Campus (0109) Conference room 2 North wedged open.


53. On 1/24-25/11 at the South Campus (0109) PACU Soiled linen room door obstructed by equipment.

Based on observations made during tour of the facility, and interviews with the staff, the facility failed to maintain the stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings in accordance with NFPA 101-2000 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life.
Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

The findings include:

1. Inspection of the Pediatric Unit in the Rehabilitation Center at the main campus (0109) on 1/26/11 revealed that there was an electrical closet labled 268A. There were vertical penetrations in the floor and ceiling by pipe and wire that were left unprotected.

2. On 1/25/11, in the Main Campus (0109) North wing, the shaft enclosure at the juncture of the north wing and east wings was observed to have multiple penetrations that were unprotected. These were observed from an access door on the fourth floor. Shafts shall maintain at least a one hour rating.

3. On 1/24/11 at the Main Campus (0109) West Wing, 12th Floor, at 3:24 pm, the room 1204 linen chute door would not close.

4. On 1/25/11 at the Main Campus (0109) West Wing, at 11:09 am, the room 904 linen chute door would not close.

5. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:50 am, the WW270 linen chute was not sealed to the wall.

Based on observation made during tour of Jackson Health System, it was determined that the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.

The findings include:

1. On 1/24/11 at the Main Campus (0109)West Wing, at 10:17 am, the smoke/fire doors numbered 07271 failed to close when tested.
2. On 1/24/11 at the Main Campus (0109)West Wing, 9th floor, at 11:07 am, the fire door 07287 will not close needs adjustment, missing closure hardware.

3. On 1/24/11 at the Main Campus (0109)West Wing, 9th floor, at 11:34 am, fire door 07281 fire door not closing correctly needs adjustment.

4. On 1/24/11 at the Main Campus (0109)West Wing, 3rd floor Operating room corridor, at 2:31 pm, fire door 00481 failed to latch when tested.

5. On 1/27/11 at the Main Campus (0109)West Wing, 2nd floor, at 9:12 am, the fire doors 03132 - Latching hardware removed.

6. On 1/27/11 at the Main Campus (0109)West Wing, 1st floor, at 11:25 am - Fire door 07370 - Latching device removed from fire doors.

7. On 1/27/11 at the Main Campus (0109)West Wing, 1st floor, at 11:47 am - Fire doors 07363 - Needs adjustment to close, Hinges were removed and accordion type hinge installed.

8. On 1/27/11 at the Main Campus (0109)West Wing, 1st floor, at 1:28 pm, the Fire door 07373 failed to latch when tested.

9. On 1/27/11 at the Main Campus (0109)West Wing, Basement, at 2:50 pm, the fire door 07382 is damaged and will not close.

10. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 11:17 am, room 4119 has no door closer on the fire door.

11. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 11:30 am, HC-406 or Fire door 0094 is missing latching hardware.

12. On 1/24/11 at the Main Campus (0109)West Wing, 15th floor, at 10:57 am, the Fire door 07234 had Penetration incorrectly protected with fire caulked (three different types) rating on the door is not recoverable.

13. On 1/27/11 at the Main Campus (0109)East Wing, 12th floor, at 3:22 pm, above fire door 07252 is an Electrical metallic tubing thru fire wall not sealed with fire caulk.

14. On 1/25/11 at the Main Campus (0109)West Wing, 10th floor, at 10:19 am, room 1036 had penetrations in the rated wall that were left unprotected.

15. On 1/25/11 at the Main Campus (0109)West Wing, 9th floor, at 11:07 am, the fire door 07287 had penetrations above door left unprotected.

16. On 1/25/11 at the Main Campus (0109)West Wing, 9th floor, at 1:46 pm, the Fire door 07292 had Penetration above ceiling left unprotected.

17. On 1/25/11 at the Main Campus (0109)West Wing, 9th floor, at 1:49 pm, the A side nursing station, had Pipe penetration above ceiling left unprotected.

18. On 1/25/11 at the Main Campus (0109)West Wing, 9th floor, at 2:17 pm, the room 805 air condition duct not sealed above rated wall.

19. On 1/26/11 at the Main Campus (0109)West Wing, 7th floor, at 9:32 am, room 736 is a rated room with penetrations left unprotected.

20. On 1/25/11 at the Main Campus (0109)West Wing, 6th floor, at 10:15 am, across from room 635 there were Penetrations at rated ceiling left unprotected.

21. On 1/25/11 at the Main Campus (0109)West Wing, 6th floor, at 11:03 am, fire doors 07317 had Penetrations above ceiling, left unprotected.

22. On 1/25/11 at the Main Campus (0109)West Wing, 5th floor, at 11:30 am, the hall communications room had penetrations above ceiling left unprotected.

23. On 1/25/11 at the Main Campus (0109)West Wing, 4th floor, at 1:35 pm, fire doors 07329 had penetrations above ceiling left unprotected.

24. On 1/25/11 at the Main Campus (0109)West Wing, 5th floor, at 2:03 pm, room 406B had penetrations left unprotected.

25. On 1/27/11 at the Main Campus (0109)West Wing, 2nd floor, at 10:05 am, fire door 03136 had penetration above the rated fire door 2 ' x 1 ' left unprotected.

26. On 1/25/11 at the Main Campus (0109)West Wing, Basement, at 3:05 pm, room WWB-41 houses Machine room 11 which had a Penetration in corridor wall left unprotected.

27. On 1/25/11 at the Main Campus (0109)West Wing, 5th floor, at 3:55 pm room WWB39 is a Linen chute room with unprotected 36" penetration.

28. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 10:09 am, room 4163 has a wall broken inside patient room.

29. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 10:54 am, room 4136 C has a penetration into hall corridor left unprotected.

30. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 11:30 am, room HC-406 or Fire door 0094 had a penetration above ceiling left unprotected.

31. On 1/27/11 at the Main Campus (0109)East Wing, 4th floor, at 11:41 am, room 4097C had Penetrations in hall corridor left unprotected.

32. On 01/26/11 at the Main Campus (0109)East Tower at 11:10 am, it was observed on the sixth floor in the telephone room a 4 ' inch conduit passing thru the floor/ceiling assembly not properly protected.

33. On 01/27/11 at the Main Campus (0109)Ryder Trauma Center, it was observed at 2:25 pm, in room T-238 three different size conduits passing thru the floor /ceiling assembly not properly protected.

NOTE: These examples are not to be considered as the only unprotected penetrations of the facility's fire barrier walls. A thorough inspection of each barrier wall must be made along its full length and height to ensure that all penetrations are found and properly sealed. It is required that every breach (penetration) of a fire barrier wall be appropriately repaired and the wall brought back to its original one or two hour fire rated integrity. This is essential to restrict the movement of fire and smoke and to ensure the safety of occupants within the facility in a fire emergency. These penetrations must be sealed with a UL (Underwriters Laboratories) approved, expanding, fire rated caulking compound, on both sides of each penetration through the barriers and at both ends of each sleeve.

Based upon observations, staff interview, and record review, the facility failed to maintain hazardous area separation. This condition may allow smoke and/or smoke from a fire to enter adjacent areas, and endanger occupants.

Findings include:


1. While on tour of the North campus (0209) on 01/24/11 at 2:15 p.m., on the 2nd floor the fire rated door between main Kitchen and the Dining room, is damaged to the condition of not being capable of resisting the passage of smoke, nor closing to a positive latch.

2. On 1/26/11, in the Main Campus (0109) Central Building, Basement Machine room #1 had penetrations in the ceiling . These penetrations had combustible materials used as a barrier in the floor/ceiling assembly. Hazardous areas shall be built of a minimum one hour fire resistive construction.

3. On 1/27/11 at the Main Campus (0109) West Wing, Basement, at 2:26 p.m., the Pharmacy Storage area had Fork lift batteries being charged next to outlet at the only entrance and exit to the pharmacy.

4. On 1/25/11 at the Jackson South Campus (0309) at 2:25 p.m. three housekeeper floor cleaning units with lead-acid batteries charging in hallway.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that an adequate number of exits are provided for each fire section of the building.
The findings include:
On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:26 pm, Pharmacy Storage had a total floor space of 55 feet x 55 feet equaling 3,025 square feet, with only one exit. The room is divided by a impassable fence, and has another 55 feet by approximately 20 feet on that side of the fence. There is one exit on that side also.

Based on observations made during tour of the facility, it was determined that the facility failed to maintained stairs and stair towers in accordance with NFPA 101 Chapter 19.2.2.1. & chapter 7.

The findings include:

1.On 1/26/11, in the Main Campus (0109) South wing, the door latch was broken/ missing at stair #2, 8th floor.

2. On 1/26/11, in the Main Campus (0109) South wing, the floor level signage was missing at stair #2, 8th floor.

3. Inspection of the Prosthetic Orthotic Lab in the Rehab Center of the Main Campus (0109)revealed on 1/27/11 a 2:15pm that a stairwell had an enclosure wall built around it with a door. The facility was utilizing this space for storage of orthotic supplies. Storage is prohibited under stairwells and that compartment was sprinklered however the stair enclosure was not.

4. On 1/24/11 at the Main Campus (0109) West Wing, at 10:28 am, the stairs gap in stair balusters more than (4) four inches.

Based on observations during tour of Jackson Health System, it was determined that the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

The findings include:

1. On 01/27/11, at the Main Campus (0109) East Tower at 10:15 am, that the stairwell exit door ET 714 had a delayed egress locking device installed, however the door did not have the proper signage posted on the door indicating how the function works. The sign states "push until alarms sounds, door can be opened in 15 seconds". When tested it was determined that the door can be opened, but not until in 30 seconds has past.
NOTE: These examples are not to be considered as the only affected doors within the facility. A thorough inspection of each fire/smoke barrier ' s doors must be made to ensure that all doors are found and to function per Codes.

2. While on tour of the Holtz Center Pediatric Emergency Room (0109) on 01/28/11 at 1:45 p.m., the motion detector, horizontal sliding exterior door assembly, adjacent to room #1096-B, is not capable of breaking away manually in the event of a loss of normal power. At the exterior, a floor mounted track for the accordion style storm door assembly, impedes a full outward swing of the sliding door.

3. The Main entrance to the main building on the Main Campus (0109)was observed to have the automatic electronic doors. These doors were inoperable at 9:50am on 1/27/11. After utilizing other doors to the side of the main doors the surveyor stood in front of the sensor to test if the doors were functional for egress. They were not. The staff at the information desk stated that the doors were shut down by security because it was cold when the door opened. Security came and reactivated the electronics so the doors would open.


4. On 1/26/11, in the Main Campus (0109) Central Building North Stairwell door had two locking devices that were observed at the corridor exit to the stairwell.

Based on observations made during tour of the facility, it was determined that the facility failed to maintain illumination of the means of egress. Illumination of the means of egress is required to the extent that the failure of any single fixture will not leave the area in darkness. Lack of lighting in the stairwell could cause occupants of the building to experience delays in egress or result in possible fall and trip hazards.

The findings include:

On 1/25/11, in the Main Campus (0109) Central Building north stairwell, three lights within the stairwell were not functioning and therefore not illuminating the stairwell.

Based on a review of the facility records, and interview with the staff, 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. Emergency lighting is also required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator.

The findings include:

1. There was no documentation at the time of the survey to show that the emergency lights at the 9 Healthcare Occupancies, at the Main Campus (0109) were being tested for 30 seconds once a month and 90 minutes once a year.


2. On 1/24/11, in the Main Campus (0109)North wing inside the mobile hyperbaric unit, an emergency light failed to illuminate when the test switch was opened. Illumination of the means of egress is required to insure the safe egress of the building occupants.

3. On January 24, 2011 in the Main Campus (0109) North wing inside the generator transfer switch room, it was observed that emergency lights were not provided with battery back-up.

4. On 1/26/11 at the Main Campus (0109) West Wing, 3rd Floor Operating Rooms, at 3:06 p.m., O.R. 1 had Battery powered emergency light that failed to light when tested.

5. On 1/27/11 at the Main Campus (0109) West Wing, Basement, at 3:37 pm, the IV room Emergency lamp that was not functional.

Based on observations made during tour of the facility, and interviews with the staff, the facility failed to maintain exit signs in reliable operating condition. Exits shall be marked by an approved sign readily visible from any direction of exit access'. Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary. Signage indicating the location and direction to exits is required to insure the safe egress of the building occupants in the event of an emergency.

The findings include:

1. The Rehabilitation Center at the main campus(0109) was observed to have an exit light out or not illuminated. This was located at the Neurosurgery Rehab unit on the 1st floor at room 127.


2. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center wing, the corridor at the O.R. locker room did not have an exit sign.

3. On 1/27/11, in the Main Campus (0109) West Wing, 1st floor, at 11:15 am, room 107, the Gift shop had no exit signage.

4. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:52 pm, respiratory had no exit signage.

5. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 3:21 pm, the room B26A, Pharmacy had insufficient exit signage.

6. On 1/27/11 at the Main Campus (0109) East Wing, 4th Floor, at 10:00 am, HC-413 stair had incorrect exit sign placement.

7. On 1/27/11 at the Main Campus (0109) East Wing, 4th Floor, At 1:27 pm, O.R. 45, 44, 41, 43 had exit lights burned out.

Based on a review of the facility records, and interview with the staff, it was determined that the facility failed to ensure the staff was trained in emergency fire procedures a frequently as required, consisting of at least one fire drill per shift per quarter, and Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

The findings include:

During the record review process, and based upon staff interviews during the survey process, the South Hospital (0309) facility could not provide documentation that the required quarterly fire drills had been conducted for the Laboratory personnel.

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facilities, it was determined that the facility failed to ensure the the fire alarm system was tested and installed in accordance with NFPA 72 (the standard for the installation of fire alarm systems), and maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.

The findings include:

1. A review of the annual fire alarm certification reports for the main campus (0109)on 1/24/11 at 10am revealed that The last annual certification was conducted 2/16/10. This report includes a list of deficiencies noted during the inspection. There is a "corrected" ink stamp next to the deficiencies. There were a number of uncorrected deficiencies in these lists. When questioned the facilities director stated that he did not know if this meant they were not yet corrected. He then called the fire alarm technician, who works onsite year round and requested that he come to the conference room. The technician verified that these deficiencies remained uncorrected for all this time. The facilities director did not know why or how this could happen. The facilities director and the director of support services verified and acknowledged this issue, and did not know why these issues were not identified and resolved thru the monthly Quality Assurance Meetings.

2. The 2/16/10 deficiency report for the main campus (0109) indicated that Air Handling Unit 226 fails to shut down when a smoke detection alarm is initiated. This was not corrected.

3. The 2/16/10 deficiency report for the main campus (0109) indicated that after resetting the alarm from an initiation elevator 104 recalls and locks out. This was not corrected.

4. The 4/14/10 deficiency report for the main campus (0109) in the Southwing Penthouse, Air Handling Unit 7 fails to shut down. This unit controls floors 3 thru 7. The facility Director stated that this was for infection control purposes due to 2 Isolation Rooms on the 4th floor. Further investigation revealed that the Isolation Rooms have independent exhaust systems and there was no infection control issue. The alarm deficiency report further stated that the alarm point contact was in place and functional, however the air handler was disconnected from it. The facility director came to the conclusion that he did not know why this was not connected and would have this fixed immediately. at 11:45pm on 1/27/11 the facility staff and the Simplex technician demonstrated the Air Handler shut down. Upon activation of a smoke detector and a delay for reconfirmation the Air Handler again failed to shut down. at 1:15pm another test was demonstrated where the shut down was successful and the issue was attributed to two wires in reverse polarity. This deficiency was not corrected for 8 months. Although the facility director informed the surveyor that the Air Handler was now connected, there was no follow thru to ensure correction. The surveyor request for demonstration is how the deficiency was identified as still non-functional.

5. The 9/16/10 report for the main campus (0109) Diagnostic Treatment Center stated that there was a smoke detector mounted to the ceiling above the escalator that is not a listed device in the system and is not connected to anything. Further investigation revealed that this is a smoke detector from an old alarm system and is not connected but was never removed. This was uncorrected.

6. The 9/16/10 report for the main campus (0109) Diagnostic Treatment Center stated that Air Handling Unit 263 failed to shut down on activation of the system. This was uncorrected.

7. The 8/27/10 report for the main campus (0109) Ryder Trauma Center stated that elevators 113 and 114 did not recall upon activation of the alarm, and failed to alternate floors on alarm activations that were applicable. The report further stated that this was not a alarm system problem, it was an elevator problem. The facilities director stated that he directed the elevator company to disconnect from the elevator recall programming because the elevator bank serviced the hospital secured unit for prisoners. This was uncorrected.

8. The 2/26/10 report for the main campus (0109) Rehabilitation Center indicated that elevators 291, 292, 293, and 294 all failed to recall when tested in conjunction with the alarm system. This was not corrected.

9. The 7/20/10 deficiency report for the main campus (0109) Central Building indicated that six audio alarm devices were disconnected from system. The facility director stated that this was due to the audio devices being installed in the neonatal unit. The devices were incapable of adjustment for sound level so they were disconnected. No adjustable audio replacements were installed. No equivalencies were sought.

10. The 7/20/10 deficiency report for the main campus (0109) Central Building indicated that there were three fire alarm panels that were not connected to dedicated power and circuit breakers. The alarm technician stated that this arrangement has remained for a number of years, however the wires were traced this year, with the current determination. This was uncorrected.

11. While on tour of the North campus (0208) on 01/26/11 between 9:45 and 11:15 a.m., on the 1st floor in Rehabilitation space, the south and east exterior doors, do not have manual fire alarm pull stations located by them. In addition, the Information Technology department does not have a pull station at the south exit door in accordance with NFPA 72--National Fire Alarm Code (1999 Edition) 2-8.2.2 "Manual fire alarm boxes shall be located within 5 feet of the exit doorway opening at each exit on each floor."

12. While on tour of the Ryder Trauma Center (0109)on 01/27/11 at 3:00 p.m., at the ground floor level of elevator #TC116, there is no detector within vicinity of the elevator door. On 01/28 in the Holtz Center at 2:00 p.m., at the ground floor level Admitting area and the immediately east Security desk location, there are no manual fire alarm pull stations located within 5 feet of the exit doors.

13.On 1/26/11, in the Main Campus (0109) Central Building at the south entrance the pull stations for the fire alarm system were observed to be blocked from view by potted vegetation. The ability to easily locate fire alarm pull stations by occupants is necessary to insure efficient activation of the alarm in an emergency.

14. On 1/26/11, in the Main Campus (0109) Diagnostic Treatment Center, rooms D300 and D312 each had fire alarm control panels. The control panels were observed to be lacking labels indicating annual inspections. Interviews with staff failed to reveal where the panels were alarmed to.

15. On 1/26/11, in the Main Campus (0109) Diagnostic Treatment Center, room D300, the fire alarm panel was found to have a trouble code displayed. Staff interviews resulted in the determination that the trouble code was due to a discharged battery back-up.

16. On 1/24/11 at the Main Campus (0109) West Wing, 14th floor, at 2:35 pm, the linen closet 1454 smoke detector had been removed.

17. On 1/24/11 at the Main Campus (0109) West Wing, 11th floor, at 4:10 pm, room 1103 was missing the fire alarm strobe light.

18. On 1/25/11 at the Main Campus (0109) West Wing, 8th floor, at 1:56pm next to room 838 the strobe light was incorrect placed (ceiling mount type installed on wall).

19. On 1/25/11 at the Main Campus (0109) West Wing, 8th floor, at 2:32 pm, room 802 houses a Fire Alarm Panel with several items not secured and no breaker location identified on fire alarm panel.

20. On 1/26/11 at the Main Campus (0109) West Wing, 6th floor, at 10:30 am, across from room 647, the Strobe light was incorrectly placed, (ceiling mount type installed on wall).

21. On 1/26/11 at the Main Campus (0109) West Wing, 6th floor,at 11:00 am, room 604, Electrical room housing transformers missing heat or smoke detector.

22. On 1/26/11 at the Main Campus (0109) West Wing, 5th floor, at 11:45 am, next to room 554 is a Ceiling mount Strobe light installed on wall incorrectly.

23. On 1/26/11 at the Main Campus (0109) West Wing, 4th floor, at 1:58 pm,4th floor Critical Care Unit has no strobe lights.

24. On 1/26/11 at the Main Campus (0109) West Wing, 6th floor, at 2:03 pm, room 406B has a ceiling strobe light installed on wall.

25. On 1/26/11 at the Main Campus (0109) West Wing, 3rd floor, Operating rooms, at 2:45 pm, in the sterile area, the smoke detector was not installed correctly.

26. On 1/26/11 at the Main Campus (0109) West Wing, 6th floor, at 3:22 pm, next to the center stairwell, a ceiling mount strobe light ws used as wall mount.

27. On 1/26/11 at the Main Campus (0109) West Wing, 2nd floor, at 3:30 pm, the Electrical room W239 had no heat or smoke detector.

28. On 1/26/11 at the Main Campus (0109) West Wing, 2nd floor, at 3:34 pm, the hall in front of Interior stair had a Ceiling mount strobe light installed on wall.

29. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:00 am, across from rooms 289 & 287 were incorrectly installed smoke detectors.

30. On 1/26/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:54 am, room 267 is an Electrical room with transformers, had no heat or smoke detector.

31. On 1/26/11 at the Main Campus (0109) West Wing, 1st floor, at 1:23 pm, near fire door 07376 was a ceiling mount strobe light mounted on wall.

32. On 1/26/11 at the Main Campus (0109) West Wing, 2nd floor, at 2:12 pm, room 110, 112, 113, 114 had battery operated smoke detectors that were inoperable.

33. On 1/26/11 at the Main Campus (0109) West Wing, Basement, at 3:14 pm, room WWB-40 houses machine room 10, where the fire alarm breaker was missing the breaker lock.

34. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 10:23 am, room 4148 fire alarm strobe light was taped over.

35. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 10:25 am, room 4144 Medical Records had no smoke detector.

Based on a review of the facility records and interview with the staff, it was determined that the facility failed to test the smoke detectors as frequently as required, and maintain the detectors in reliable operating condition. This in the event of a malfunction could delay or deny the required early warning of an unsafe enviornment or fire.

The findings include:

1. There was no documentation to show that the smoke detectors had been tested in the last two years at the North Dade Health Center (0609), Rosie Lee Wesley North Health Center (0409), Reaves Health Center (0709), and Penalver Clinic (0809).

2. On 1/26/11, in the Main Campus (0108) North wing, the shaft enclosure at the juncture of the north wing and east wings on the 1st floor was observed to have a smoke detector fixture with a missing smoke detector and damaged base.

3. On 1/26/11 in the Main Campus (0108) South wing 8th floor, a smoke detector was observed to have been painted. The smoke detector identifier was noted M1-78.

Based upon observations and staff interview, the facility failed to maintain supervision of sprinkler system control valves. This condition may cause a valve to be inadvertently turned off, impacting the suppression systems capability in the event of a fire.

Findings include:

1. While on tour of the North campus (0209) on 01/24/11 at 3:00 p.m., at the exterior 8 inch fire supply line, Outside Screw & Yoke (O.S. & Y.) control valves as part of the double detector check valve assembly do not have electronic supervisory anti-tamper devices attached in accordance with NFPA 101 9.7.2.1 Supervisory Signals.

2. During a tour of the main campus (0109)on 01/27/11 between 10:00 and 11:30 a.m., a minimum of 8 fire pump installations do not have electronic anti-tamper supervisory devices, provided on the O.S. & Y. control valves for the (Jockey) maintenance pump suction and discharge lines in accordance with NFPA 101 9.7.2.1 Supervisory Signals.

3. The Rehabilitation Center at the main campus (0109)houses a fire sprinkler system isolation valve in the basement mechanical room. This valve was observed on 1/16/11 to not be equipped with a tamper switch to provide supervision of the valve in accordance with NFPA 101 9.7.2.1 Supervisory Signals.

Based on a review of the facility records, and interview with the staff , it was determined that the facility failed to ensure that the automatic fire sprinkler system was tested as required, installed and maintained as required, in accordance with NFPA 13 & 25. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.

The findings include:

1. The Rehabilitation Center at the main campus (0109) was observed to have different type of sprinkler heads in the same room. This was observed in the office of Neurosurgery Rehab.

2. The Rehabilitation Center at the main campus (0109) houses a fire sprinkler system isolation valve in the basement mechanical room. This valve was observed to be rusted and corroded to the point that it appeared to be non functional.

3. The Rehabilitation Center at the main campus (0109) was observed to have different type of sprinkler heads in the same room. This was observed in the Orthopedic Billing Office.

4. While on tour of the North campus (0209) on 01/24/11 at 2:00 p.m., the Kitchen walk,in coolers and freezers, have dry type sprinklers that have exceeded the 10 year inspection requirement. They are dated 1994 and are not in accordance with NFPA 25 5.3.1.1.1.5

5. While on tour of the North campus (0209) on 1/25/11 between 11:00 a.m. and 4:00 pm., at the 3rd floor Family Lounge north end of room, 2 sprinklers are too close together. For the type of sprinklers installed they shall be a minimum of 5 feet apart, or during activation one will wet the other causing it to malfunction, and the installation was not being in accordance with NFPA 13 8.5.3.4 .

6. While on tour of the North campus (0209) on 1/25/11 between 11:00 a.m. and 4:00 pm, inspection of the Finance office (closet) revealed that there is no sprinkler protection provided.

7. While on tour of the North campus (0209) on 1/25/11 between 11:00 a.m. and 4:00 pm inspection of the Medical Records room revealed that the area over the sliding files exceeds approved maximum spacing coverage for the hazard involved.

8. While on tour of the North campus (0209) on 1/25/11 between 11:00 a.m. and 4:00 pm, inspection of the Pediatric Emergency room revealed that the sprinkler protection is missing by the north exit door.

9. While on tour of the North campus (0209) on 1/25/11 between 11:00 a.m. and 4:00 pm, inspection of the Triage room revealed that protection is missing at the alcove.


10. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., at the 1 st floor Rehabilitation Records office, sprinkler protection exceeds allowable maximum spacing coverage.

11. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., in the pool area, the 4 dressing rooms on the north side do not have sprinkler protection provided.

12. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., at the Pavilion Material Management offices, there is no sprinkler protection provided in the south west corner.

13. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., in the corridor by the Operating Room Condenser closet, a sprinkler has a coating of foreign matter.

14. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., at the exterior Receiving Dock, the Soiled Linen holding room has only one horizontal sidewall sprinkler, thus exceeding approved coverage for the hazard involved.

15. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., a Pre,action system (formerly used for a Radiology room) controlling valve assembly, installed in a mechanical room opposite the main plant engineering., has been turned " Wet, " and the equipment has not been removed that is no longer in service, including an out of date (1987) pressure gauge. Gauges are required to be replaced or re-calibrated every 5 years.

16. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., in the plant engineering. office, there is no sprinkler protection provided at the electrical panel closet.

17. While on tour of the North campus (0209) on 1/26/11 between 9:45 a.m. and 2:30 p.m., in the Pavilion on the 3rd floor, at the northwest stairwell foyer, there is no sprinkler protection provided.

18. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m., gauges installed at fire pumps in Machine room #16, Diagnostic Treatment Center, Ryder Trauma Center, West Wing, South Wing, East Tower, Park Plaza East, and Highland Park garage, are not of a type approved for use on fire protection equipment. They have been installed at the main pump suction and discharge lines.

19. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m.,inspection of the gauges revealed that the sensing lines are not of an approved type.

20. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m. at the Diagnostic Treatment Center, the Pump Test header is identified by a sign labeled " fire Hose Connection. " Approximately 20 feet away from the Test header, are 2 fire Department Connections without any identification signs, one of which has a significant accumulation of sediment upon an interior inspection.

21. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m. at the West Wing, the sensing line is of galvanized piping, only Copper, Brass or Stainless 300 materials with equivalent fittings may be used, and it is connected at the wrong point. Connection is required past the discharge check valve of the main pump.

22. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m. at the East Tower (1500 GPM) pump, there is only one connection for the sensing line, which then is split at the main controller, with a line continuing to the jockey pump controller. It is of only ¼ inch in size, and ½ inch is the minimum required. A new jockey pump was installed approximately 3 years ago, which is considered a major renovation, therefore at such time the sensing lines connections and routing were required to be installed to the then current code Standard.

23. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m. at the majority of the pump installations, sensing line installations do not meet the requirement for ground face unions or check valves within the piping runs.

24. On 01/27/11, at the Main Campus (0109) between 10:00 a.m. and 3:15 p.m. in the West Wing there are 2 Pre,action systems that do not have information relative to what areas they are protecting. In addition, a Pre,action system in the Ryder Trauma Center for Computer room #T256C, has been " Red,Tagged " by the servicing contractor for a non-signal code to the fire Alarm system if it became activated. Staff had no knowledge of what remedies have been taken to repair same.

25. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., in the East Tower at the 5th floor, room #5008 has sprinklers over spaced at the north end.

26. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., in Pantry #5108, there is no sprinkler protection over the appliances, or in the Hopper closet.

27. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., in Trash room #5101A, the concealed sprinkler cover plate has been painted over.

28. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., adjacent to Telephone closet #5050T, 2 sprinklers are only 4 feet apart and the minimum separation is 5 feet.

29. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., at the 3rd floor, #5108, at Pantry #3187, in closets #3130C and #3152, there is no sprinkler protection provided.

30. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., at the 2nd floor Computer room, a Halon clean agent suppression system is installed. However, the automatic sprinkler system devices are still in service and are required to be removed. The closet containing the Halon cylinders does not show evidence of inspection tags for the cylinders.

31. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., in Transfusion Medical Services room #2014, there is no sprinkler protection provided in the auxiliary exit alcove.

32. On 01/28/11, at the Main Campus (0109)between 10:15 a.m. and 1:45 p.m., there was no sprinkler protection in Telephone closet #2011T.

33. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., on the 1st floor, a sprinkler over the sink in Staff Lounge #1095B, has a foreign matter coating on it.

34. On 01/28/11, at the Main Campus (0109) between 10:15 a.m. and 1:45 p.m., the Staff lockers alcove across from room #1078 has no sprinkler provided.

35. On 1/24/11, in the Main Campus (0109) North wing rooftop, the fire sprinkler pressure gauge (south end) was damaged and observed to be inoperative. It could not be determined if there was pressure in the sprinkler piping due to the condition of the gauge.

36. On 1/24/11, in the Main Campus (0109) North wing rooftop, the gauge at the FDC standpipe did not indicate an installation date. Facility staff could not provide supporting evidence of calibration or replacement of these gauges as required by NFPA 25.

37. On 1/24/11, in the Main Campus (0109) Central penthouse, a FDC connection valve was observed to be missing its handle rendering the valve inoperable.

38. On 1/25/11, in the Main Campus (0109) Central wing in room C104, a sprinkler head was observed to be missing its escutcheon. It was also observed to be located above the level of the ceiling which would render it ineffective in the event of a fire .

39. On 1/26/11, in the Main Campus (0109) South wing inside room 609A, sprinkler piping was observed to be altered. The sprinkler head had been removed and the piping terminated with a cap.

40. On 1/26/11, in the Main Campus (0109) South wing inside room S106, a sprinkler head was observed to be obstructed by fire stop caulk that had fallen from a conduit above the sprinkler head.

41. On 1/27/11, in the Main Campus (0109) South wing basement inside room B08, upright style sprinkler heads were installed in a pendant configuration.

42. On 1/26/11, in the Main Campus (0109) South wing at the central elevator lobby on the 3rd floor near room C301, (1) sprinkler head was observed. This portion of the building is fully sprinkled and there were no additional heads observed in either direction in that lobby corridor.

43. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center rooftop, the sprinkler gauges installed at the FDC standpipe did not indicate an installation date. Facility staff could not provide supporting evidence of calibration or replacement of these gauges as required by NFPA 25.

44. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center, on the 2nd floor kitchen storage room, storage of combustible materials were observed above the 18 " horizontal plane of the sprinkler head deflectors.

45. On 1/27/11, in the Main Campus (0109) East wing, room 2027, storage of combustible materials were observed above the 18 " horizontal plane of the sprinkler head deflectors.

46. On 1/24/11, in the Main Campus (0109) West Wing, Penthouse & Roof, at 10:25am, the West wing Elevator Stairway near the sunroof had a painted sprinkler head.

47. On 1/24/11, in the Main Campus (0109) West Wing, Penthouse & Roof, at 10:34 am, Elevator equipment room had no fire sprinkler protection.

48. On 1/24/11, in the Main Campus (0109) West Wing, Penthouse & Roof, at 10:39 am, the Roof fire Department Connection gauges have not been changed out.

49. On 1/24/11, in the Main Campus (0109) West Wing, 15th floor, at 11:01 am, linen closet 1546 had a fire sprinkler missing an escutcheon ring.

50. On 1/24/11, in the Main Campus (0109) West Wing, 15th floor, at 11:08 am, patient room 1549 had a closet not sprinklered.

51. On 1/24/11, in the Main Campus (0109) West Wing, 15th floor, at 11:09 am, patient room 1551, the fire sprinkler needs adjustment.

52. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 11:15 am, lounge room 1500, the fire sprinkler is missing the an escutcheon ring.

53. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 11:34 am, Medication room 1540A has a ceiling tile cut too large for fire sprinkler over medication dispensing area.

54. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 11:53 am, the Transplant on call restroom fire sprinkler was missing the an escutcheon ring.

55. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 11:55 am, room 1527 has a fire sprinkler closer than (4) four inches from wall.

56. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 11:57 am, room 1528 had open ceiling tiles.

57. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 2:04 pm, room 1532 had open ceiling tiles.

58. On 1/24/11, in the Main Campus (0109) West Wing,15th floor, at 2:08 pm, the pantry room 1536 had a loose fire sprinkler.

59. On 1/24/11, in the Main Campus (0109) West Wing,14th floor, at 2:29 pm, the Medication room had ceiling tile cut too large for fire sprinkler over medication dispensing area.

60. On 1/24/11, in the Main Campus (0109) West Wing,14th floor, at 2:47 pm, room 1403 had two fire sprinklers missing an escutcheon rings.

61. On 1/24/11, in the Main Campus (0109) West Wing,14th floor, at 2:56 pm, room 1424 had a loose fire sprinkler.

62. On 1/24/11, in the Main Campus (0109) West Wing,14th floor, at 3:00 pm, restroom 1430 had a fire sprinkler missing an escutcheon ring.

62. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 3:11 pm, in front of room 1242 there was a fire sprinkler missing an escutcheon ring.

63. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 3:15 pm, Nurse Station fire sprinklers missing an escutcheon rings.

64. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 3:17 pm, Medication room 1206A had a ceiling tile cut too large for fire sprinkler over medication dispensing area.

65. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 3:33 pm, room 1265 had a fire sprinkler missing an escutcheon ring.

66. On 1/24/11, in the Main Campus (0109) West Wing,11th floor, at 3:53 pm, room 1106B had a ceiling tile cut too large for fire sprinkler over medication dispensing area.

67. On 1/24/11, in the Main Campus (0109) West Wing,12th floor,at 3:58 pm, room 1104 had a fire sprinkler missing an escutcheon ring.

68. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 4:02 pm, room 1159 had 2 fire sprinklers missing escutcheon rings.

69. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 4:04 pm, room had a fire sprinkler missing an escutcheon ring.

70. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 4:07 pm, room 1101 had a fire sprinkler missing an escutcheon ring.

71. On 1/24/11, in the Main Campus (0109) West Wing,12th floor, at 4:15 pm, across from 1127 in hall there was a fire sprinkler missing an escutcheon ring.

72. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 9:25 am, room 1027 had a fire sprinkler missing an escutcheon ring.

73. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 9:40 am, pantry room 1016 has closet not fire sprinkled.

74. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 9:42 am, Report Room has fire sprinkler missing an escutcheon ring.

75. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 9:52 am, patient room 1007 has fire sprinkler missing an escutcheon ring.

76. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 10:06 am,Visitors lounge 1057 has Restroom fire sprinkler missing an escutcheon ring.

77. On 1/25/11, in the Main Campus (0109) West Wing,10th floor, at 10:29 am, next to staff lounge was a fire sprinkler missing an escutcheon ring.

78. On 1/25/11, in the Main Campus (0109) West Wing,9th floor, at 10:35 am, room 922 had fire sprinkler missing an escutcheon ring.

79. On 1/25/11, in the Main Campus (0109) West Wing,9th floor, at 10:42 am, room 935 had a fire sprinkler installed closer than 4 inches to wall and missing an escutcheon ring.

80. On 1/25/11, in the Main Campus (0109) West Wing,9th floor, at 11:25 am, room 963 had restroom fire sprinklers 4 feet apart, installed incorrectly.

81. On 1/25/11, in the Main Campus (0109) West Wing,9th floor, at 11:40 am, room 928 had a Communication room with no fire sprinkler protection.

82. On 1/25/11, in the Main Campus (0109) West Wing,8th floor, at 1:33 pm, room 820 had a fire sprinkler missing an escutcheon ring.

83. On 1/25/11, in the Main Campus (0109) West Wing,8th floor, at 1:40 pm, room 824 had a fire sprinkler missing an escutcheon ring.

84. On 1/25/11, in the Main Campus (0109) West Wing,8th floor, at 1:53 pm, Stair WW801 was missing a fire sprinkler.

85. On 1/25/11, in the Main Campus (0109) West Wing,8th floor, at 1:57 pm, room 840 had fire sprinkler missing an an escutcheon ring.

86. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 1:58 pm, hall next to elevator WW,EL,5 has fire sprinkler missing an escutcheon ring.

87. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 2:08 pm, room 801D has large column that blocks fire sprinkler protection, and the fire sprinkler is missing an escutcheon ring.

88. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 2:10 pm, room 801C has a fire sprinkler missing an escutcheon ring.

89. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 2:12 pm, next to 801 storage room there is a fire sprinkler missing an escutcheon ring.

90. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 2:17 pm, room 805 has a fire sprinkler painted concealed cap, and large column that blocks fire sprinkler protection (8 inches x24 inches).

91. On 1/25/11, in the Main Campus (0109) West Wing,8th floor,at 2:26 pm, room 810 has a fire sprinkler missing an escutcheon ring.

92. On 1/25/11, in the Main Campus (0109) West Wing, 7th floor, at 3:06 pm, room 712A has a ceiling tile cut too large for fire sprinkler over medication dispensing area.

93. On 1/26/11, in the Main Campus (0109) West Wing, 7th floor, at 9:35 am, room 756A restroom has fire sprinklers incorrectly installed at 5 ' 6 ' ' apart.

94. On 1/25/11, in the Main Campus (0109) West Wing, 7th floor,at 10:05 am, room 727 , fire sprinkler recessed cover painted.

95. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:15 am , across from room 635 there was no fire sprinkler.

96. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:21 am, the Pantry closet was missing a fire sprinkler.

97. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:45 am, room 653 has a fire sprinkler with inadequate coverage due to column and storage behind column.

98. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:47 am, room 659 has a fire sprinkler loose, possibly from branch line.

99. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:50 am, hall outside of room 659 has fire sprinklers 17 feet apart.

100. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:51 am, room 657A has a fire sprinkler 4 ' 8" apart.

101. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 10:53 am, Room 657 has fire sprinkler missing an escutcheon ring.

102. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 11:05 am, room 609 has a fire sprinkler missing an escutcheon ring.

103. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 11:11 am, next to 618, the 18 " rule violated.

104. On 1/25/11, in the Main Campus (0109) West Wing, 6th floor, at 11:12 am, room 627 has a fire sprinkler missing an escutcheon ring.

105. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor,

106. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor, at 11:43 am, room 504 has a fire sprinkler missing an escutcheon ring.

107. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor, at 11:52 am, room 557 has 2 fire sprinklers missing an escutcheon rings.

108. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor, at 11:58 am, room 563A has inadequate fire sprinkler coverage due to large column obstruction.

109. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor, at 1:19 pm, near fire door 07327 are 3 ceiling tiles have been changed to open the mesh type. The ceiling envelope is a not maintained for fire sprinkler protection.

110. On 1/25/11, in the Main Campus (0109) West Wing, 5th floor, at 1:29 pm, room 536 has a fire sprinkler missing an escutcheon ring.

111. On 1/25/11, in the Main Campus (0109) West Wing, 4th floor, at 1:58 pm, the Critical Care Unit had no fire sprinklers.

112. On 1/25/11, in the Main Campus (0109) West Wing, 4th floor, at 2:18 pm, WW422 has 2 fire sprinklers missing escutcheon rings, open ceiling tiles, and ceiling wall blocking the fire sprinkler.

113. On 1/25/11, in the Main Campus (0109) West Wing, 3rd floor Operating rooms 1 thru 14, at 2:30 pm, hallway towards Operating rooms have 3 fire sprinklers missing escutcheon rings.

114. On 1/25/11, in the Main Campus (0109) West Wing, 3rd floor Operating rooms, at 2:54 pm,O.R. 11 has sterile area Ceiling metal door missing.

115. On 1/25/11, in the Main Campus (0109) West Wing, 3rd floor Operating rooms, at 3:04 pm,OR 9 has a fire sprinkler missing an escutcheon ring.

116. On 1/25/11, in the Main Campus (0109) West Wing, 3rd floor Operating rooms, at 3:06 pm, O.R. 1 has a fire sprinkler missing an escutcheon ring.

117. On 1/25/11, in the Main Campus (0109) West Wing, 3rd floor Operating rooms, at 3:11 pm, in the Emergency cart room, the fire sprinkler missing an escutcheon ring.

118. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:31 pm, hall across from W239 has a fire sprinkler missing an escutcheon ring.

119. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:32 pm, across from W239 Bio hazard room there are 2 fire sprinklers missing escutcheon rings.

120. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:42 pm, room W200A is a Restroom with no fire sprinklers.

121. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:50 pm, room W231 has open ceiling tiles.

122. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:51 pm, room 209 has open ceiling tiles.

123. On 1/25/11, in the Main Campus (0109) West Wing, 2nd floor, at 3:53 pm, Suite B & C have open ceiling tiles.

124. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 9:32 am, room W205 has open ceiling tiles.

125. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:00 am, across from 289 & 287 are open ceiling tiles.

126. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:09 am, the Storage room next to 03136 has a fire sprinkler missing an escutcheon ring., and 18 " fire sprinkler rule not adhered to.

127. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:11 am, room 283 has a fire sprinkler missing an escutcheon ring.

128. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:12 am, in front of room 283 the fire sprinkler is missing an escutcheon ring.

129. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:13 am, room 282 has fire sprinklers installed within 3 inches from each other.

130. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:16 am, room 281 has a fire sprinkler with the 18 inch rule violated.

131. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:29 am, Office communication closet has open ceiling tiles.

132. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:30 am, Office environmental closet has fire sprinkler 18" rule violated, and fire sprinkler missing an escutcheon ring.

133. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:32 am, Radiology Education Room has a fire sprinkler missing an escutcheon ring, and fire sprinklers installed 4 ' apart.

134. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:43 am, room has a fire sprinkler missing an escutcheon ring.

135. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:46 am, hall next to WW240 has open ceiling tiles.

136. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:50 am, WW270 has fire sprinklers missing an escutcheon rings.

137. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:54 am, room 267 has fire sprinklers missing an escutcheon rings.

138. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 10:57 am, room 271 has a fire sprinkler missing an escutcheon ring.

139. On 1/27/11, in the Main Campus (0109) West Wing, 2nd floor, at 11:09 am, next to 271 C, the closet built for storage blocks fire sprinkler protection.

140. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, 124 has no fire sprinklers.

141. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 11:36 am, room 126 has no fire sprinklers.

142. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 11:36 am, hall in front of 126 has 2 metal mesh ceiling tiles installed for fire dampers, envelope not maintained for fire sprinkler protection.

143. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:20 pm, hall next to WW385 has fire sprinklers missing an escutcheon rings.

144. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:30 pm, Chute room 107 has fire sprinkler caked with foam.

145. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:36 pm, room 108 has a fire sprinkler missing an escutcheon ring.

146. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:40 pm, room 108 , SR UP has a fire sprinkler installed 15 feet from wall.

147. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:43 pm, room 108 , CNO Office has fire sprinkler 14 feet from wall.

148. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:45 pm, room 108 , C med Officer has fire sprinklers installed 17 feet apart.

149. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:50 pm, room 108 has 2 fire sprinklers missing escutcheon rings.

150. On 1/27/11, in the Main Campus (0109) West Wing,1st floor, at 1:59, room 109 attorney's office has fire sprinklers missing, escutcheon rings missing, and a painted fire sprinkler.

151. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:19 pm, room WW387 has fire sprinklers missing, and an escutcheon ring missing.

152. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:21 pm, the air handler room had no fire sprinklers.

153. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:26 pm, Pharmacy Storage had a fire sprinkler branch line loose, fire sprinklers missing escutcheon rings, walk- in cooler had no fire sprinkler protection, the 18 inch fire sprinkler rule was violated.

154. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 2:52 pm, in respiratory, the fire sprinkler branch line needs repair.

155. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 3:21 pm, room B26A in the Pharmacy, had fire sprinklers missing escutcheon rings, and wall sectionals block fire sprinkler operation.

156. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 3:27pm, room WWB26C, had 18 inch fire sprinkler rule violated.

157. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 3:27 pm, The Vault 1, had no fire sprinkler, and the walk in cooler had no fire sprinkler protection.

158. On 1/27/11, in the Main Campus (0109) West Wing, Basement, at 3:53 pm, restroom WWB40, the fire sprinkler was missing an escutcheon ring.

159. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:06 am, room Restroom 4156 had a fire sprinkler painted cover.

160. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:09 am, room 4163 had a Medication dispensing machine room with no fire sprinkler.
161. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:13 am, room 4154 had a fire sprinkler missing an escutcheon ring.

162. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:17 am, room 4152 had a ceiling tile opening cut too large for fire sprinkler.

163. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:21 am, room 4150 ceiling tile opening cut too large for the fire sprinkler.

164. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:27 am, room 4153 is a Patient room with no fire sprinklers.

165. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:29 am, room 4142 is the Mid wife office. Storage within 18 inches of the fire sprinkler was observed.

166. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:30 am, the office environmental closet had a fire sprinkler 18" rule violated, and a fire sprinkler missing an escutcheon ring.

167. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:41 am, across from 4149, the ceiling tile opening was cut too large for fire sprinkler.

168. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:50 am, room WW270 had fire a sprinkler missing an escutcheon ring.

169. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 10:58 am, room 4128 had ceiling tile opening too large for fire sprinkler.

170. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 11:17 am, room 4116, fire sprinklers missing an escutcheon ring.

171. On 1/27/11, in the Main Campus (0109) East Wing, 4th floor, at 11:25 am, the waiting room for labor and delivery had no fire sprinklers.

172. On 1/27/11, in the Main Campus (0109) East Wing, at 11:28 am, room 4113A, a fire sprinkler missing an escutcheon ring.

173. On 1/27/11, in the Main Campus (0109) East Wing, at 11:39 am, room 4000, had a painted fire sprinkler.

174. On 1/27/11, in the Main Campus (0109) East Wing, at 11:45 am, room 4091, a ceiling tile opening was too large for fire sprinkler.

175. On 1/27/11, in the Main Campus (0109) East Wing, at 1:10 pm, room 4050, fire sprinkler obstructed by ceiling partition wall at ceiling height.

176. On 1/27/11, in the Main Campus (0109) East Wing, at 1:44 pm, room 4003, the fire sprinkler had a painted cover plate.

177. On 1/27/11, at the Main Campus (0109) East Wing, at 10:00am, room 7007E is an office with no sprinkler protection, in a sprinklered compartment.

178. On 1/27/11, at the Main Campus (0109) East Wing, at 10:10am, room 7088T is a telecommunications closet was not sprinklered.

179. On 1/27/11, at the Main Campus (0109), a final review of the documentation for sprinkler inspections revealed that the 5th year items on the inspection reports had not been addressed in the last five years. The Director of Facilities and his assistant verified and confirmed that 5th year items have not been addressed at any of the 9 Healthcare Occupancy buildings, at the main campus.

180. On 1/28/11, at the Main Campus (0109), during the Campus Life Safety tour with a designated staff representatives, it was observed that a number of brass fire department connection caps throughout the facility were missing. If fire department connection caps or plugs are not in place, the interior of the connection could be obstructed and thereby rendering the unit non-operational in the event of a fire emergency.

181. On 1/28/11, at the Main Campus (0109), East Building, Room # 2147 had escutcheons missing.

182. On 1/24/11, at the South Campus (0309), the O.B. Nurses station on the second floor corridor had loaded heads.

183. On 1/24/11, at the South Campus (0309), second floor loaded heads in O.B. and in the O.R.

184. On 1/24/11, at the South Campus (0309), second floor, the Dialysis room had loaded heads.

185. On 1/24/11, at the South Campus (0309), second floor, OB Nursery had loaded heads.

186. On 1/25/11, at the South Campus (0309), in dietary kitchen, the coolers, and main dining areas all had rusted or corroded heads.

187. On 1/27/11, at the Main Campus (0109), Mental Health building, the Lobby had loaded heads.

188 .On 1/25/11, at the South Campus (0309), second floor corridor by room 242 and corridor by room 207 had a mix of standard and quick response heads.

189. On 1/25/11, at the South Campus (0309), 2nd floor, the O.R. had mix of s

Based upon observations made during tour the facilities, and a review of the facility records, it was determined that the facility failed to inspect the fire extinguishers as frequently as required, and maintain the extinguishers in reliable operating condition, in accordance with NFPA 101 and NFPA 10.

The findings include:

1. During the South facility (0309) tour on 1/24/11, at 2:00 p.m. it was observed that all of the portable fire extinguishers in the newly opened Emergency Department corridors were in recessed flush-mounted cabinets. It was further observed that from approximately 20 feet down the corridor from these locations, the fire extinguishers were not visible and there were no signs or other indications of their locations. The finding was acknowledged by the administrative staff and verified by the Maintenance Director at the time of the tour. It was further noted that the installed units were not tagged, current or inspected by the facility as they had been placed in service by the contractors. The tags indicated the last inspections were September 2010 or April 2010 respectively.

2. Four (4) flush mount units were also noted in the Dietary section of the South facility as unmarked. In the Jefferson Reaves Health Center (off-site) on 1/26/11, it was observed that all of the mounted fire extinguishers in the first floor hallways and the Atrium were flush mount and there was no identifiable signage.

3. On 1/24/11, in the Main Campus (0109) Northwing electric equipment room, a fire extinguisher service tag was observed to be out of date.

4. On 1/26/11, in the Main Campus (0109) Northwing elevator equipment room, a CO2 fire extinguisher service tag was observed to be out of date.

5.On 1/27/11,in the Main Campus (0109) South wing room SW B20/MR15, a fire extinguisher service tag was observed to be out of date.

6. On 1/27/11, in the Main Campus (0109)West Wing, 1st floor, at 11:15 am, room 107, the Gift shop Fire extinguisher was obstructed.

7. On 1/27/11, in the Main Campus (0109) Basement, at 2:52 pm, in respiratory, the fire extinguisher was obstructed.

8. On 1/27/11, at the Main Campus (0109) 1st floor, at 1:36 pm, room 108 had a obstructed fire extinguisher.

9. On 1/27/11, at the Main Campus (0109) Basement, at 2:26 pm, Pharmacy Storage had 2 fire extinguishers obstructed.

10. On 1/27/11, at the Main Campus (0109) Basement, at 3:21 pm, room B26A, Pharmacy had a fire extinguisher obstructed.

11. On 1/27/11, at the Main Campus (0109) Basement, at 3:27 pm, Vault 1, had a fire extinguisher mounted 6'6" high.

12. On 1/26/11, at the Main Campus (0109) Ryder Trauma Center, at 10:55am, in room T487 or the Pantry had a portable fire extinguisher with a certification date of December 2008.

Based on observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to provide ashtrays of safe design in the designated outdoor facility smoking area in accordance with NFPA 101 19.7.4.

The findings include:

Based upon observations at 2:30 pm on 1/27/11, at the Main Campus (0109) Mental Health Unit Building allows smoking in the interior open air courtyard. It was further observed that the provided receptacle did not meet the standards of NFPA 101 (2000 Edition) and there was evidence of smoking material debris in the mulch, grassy areas and walkways. The facility has a written no smoking campus policy and there are no provisions for this smoking area in it.

Based on observations made during tour of Jackson Health System, it was determined that the facility failed to ensure the Ventilation System was maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.

The findings include:

1. On 1/25/11 at the Main Campus (0109) West Wing, 4th floor, at 1:41 pm, the Soiled Utility Room exhaust fan was not working.

2. While on tour of the Main Campus (0109), in the East Tower, on 1/28/11 at 1:15 p.m., in the 2nd floor Stem Cell Pathology room, the exhaust ventilation is not in an operable condition. The room contains 4 cylinders of (230 liters each) Liquid Nitrogen. A simple tissue test revealed there is no air draw at the ceiling exhaust grille.

3. On 1/25/11 in the Main Campus (0109) Central Building shaft enclosure a fire damper was observed to be damaged, rendering it inoperable and in the open position.

4. On 1/26/11, in the Main Campus (0109) South wing room 316A a fire damper was observed to be obstructed by ceiling tiles that had been displaced by negative pressure in the ceiling plenum. This situation could render the damper inoperable and would be ineffective in the event of a fire.

5. On 1/24/11 at the Main Campus (0109) West Wing, 14th floor, at 14:41 pm, restroom 1463 had no exhaust fan installed.

6. On 1/24/11 at the Main Campus (0109) West Wing, 14th floor, at 3:00 pm, the restroom 1430 exhaust fan was observed to be falling from ceiling.

7. On 1/25/11 at the Main Campus (0109) West Wing, 10th floor, at 10:06 am, the Visitors lounge 1057 exhaust fan was observed to be falling.

8. On 1/25/11 at the Main Campus (0109) West Wing, 9th floor, at 10:40 am, the room 920 exhaust fan was missing the grille.

9. On 1/25/11 at the Main Campus (0109) West Wing, 8th floor, at 2:06 pm, room 801A and 801B had no exhaust fan in restroom.

10. On 1/25/11 at the Main Campus (0109) West Wing, 7th floor, at 3:04 pm, room 728 had an exhaust fan falling.

11. On 1/26/11 at the Main Campus (0109) West Wing, 7th floor, at 9:40 am - the room 756B air condition vent was covered with paper and tape.

12. On 1/25/11 at the Main Campus (0109) West Wing, 10th floor, at 9:46 am, room 704 electrical room with 2 transformers and air condition vent had no fire damper.

13. On 1/25/11 at the Main Campus (0109) West Wing, 10th floor, at 10:06 am, room 728 am had an exhaust fan falling.

14. On 1/25/11 at the Main Campus (0109) West Wing, 6th floor, at 11:00 am, room 604 - Electrical room had Transformers and the Air condition duct has no fire damper.

15. On 1/25/11 at the Main Campus (0109) West Wing, 6th floor, at 11:14 am, the room 628 exhaust fan was not working.

16. On 1/25/11 at the Main Campus (0109) West Wing, 6th floor, at 11:16 am, the room 630 restroom exhaust fan was not working.

17. On 1/25/11 at the Main Campus (0109) West Wing, 5th floor, at 11:24 am, the room 538 restroom exhaust fan was not working.

18. On 1/25/11 at the Main Campus (0109) West Wing, 5th floor, at 12:09 pm, the room 502 had electrical transformers in the room and the air condition vent had no fire damper.

19. On 1/25/11 at the Main Campus (0109) West Wing, 5th floor, at 1:29 pm, the room 536 exhaust fan was not working.

20. On 1/25/11 at the Main Campus (0109) West Wing, 4th floor, at 1:41 pm, the Soiled Utility Room exhaust fan was not working.

21. On 1/25/11 at the Main Campus (0109) West Wing, 5th floor, at 1:47 pm, the employee restroom exhaust fan was not working.

22. On 1/25/11 at the Main Campus (0109) West Wing, 2nd floor, at 3:42 pm, the restroom W200A exhaust fan was not working.

23. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:30 am, the office environmental closet exhaust fan was not working.

24. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:45 am, next to room 263, the environmental closet has no exhaust fan.

25. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 10:54 am, room 267 is an Electrical room with transformers, and the air condition vent has no fire damper.

26. On 1/27/11 at the Main Campus (0109) West Wing, 2nd floor, at 11:12 am, the restroom exhaust fan was not working.

27. On 1/27/11 at the Main Campus (0109) West Wing, 1st floor, at 1:59, room 109 is the Attorney's office had Tape covering the 6 air condition registers.

28. On 1/27/11 at the Main Campus (0109) West Wing, 1st floor, at 2:12 pm, room 110, 112, 113, and 114 had exhaust fans not working or installed.

29. On 1/27/11 at the Main Campus (0109) West Wing, Basement, at 3:27 pm, the restrooms have no exhaust fans.

30. On 1/27/11 at the Main Campus (0109) West Wing, Basement, at 3:27 pm, both restrooms in WWB40 exhaust fans that were not working.

31. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 10:29 am, room 4142 is a Mid wife office and the exhaust fan was not working.

32. On 1/27/11 at the Main Campus (0109) East Wing, 4th floor, at 10:43 am, the room 4145 exhaust fan was not working,

Based on observations made during tour of the facility, it was determined that the facility failed to maintain the commercial cooking equipment in reliable operating safe condition, and to test the equipment in accordance with NFPA 96. This renders the equipment unreliable and could delay or deny extinguishment of a fire.

The findings include:

1. The Main Kitchen at the Main Campus (0109) Diagnostic Treatment Center Basement houses a fire suppression system for the commercial cooking equipment. Inspection of the system revealed that the equipment under the hood was not aligned with the nozzles in the suppression system.

2. The Main Kitchen at the Main Campus (0109) Diagnostic Treatment Center Basement fire suppression system had nozzles that were in excess of 42 inches above the flame charbroiler making them in effective. The company that inspects and certifies the system verified and confirmed that this is an unacceptable installation.

3. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., the Kitchen exhaust hood does not have liquid tight joints to contain grease laden vapors which develop from cooking processes.

4. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., observation of the appliances located below the hood perimeter are not at least 6 inches horizontally or more inside the hood outline.

5. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., a manual over ride emergency fuel cut-off switch is located on the wall immediately above the deep fat fryer, which is not an approved location.

6. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., the suppression system is listed on the contracting vendor inspection reports, as meeting all requirements of an Underwriters Laboratories 300 wet chemical installation. It does not. The reports from calendar year 2009 indicate that all of the cooking appliances are electric. They are not, as the range is natural gas fueled. Staff did not have knowledge of where the gas solenoid valve was located, which generally is as close as possible to the equipment. Through an investigative procedure, the solenoid was found to be above the hard surface ceiling adjacent to the cooking area. The facility, when requested, could not provide any inspection reports from calendar year 2010. The system has a (one only) spare Grinnell type EA-1 Protecto-spray nozzle, in the event of a need for replacement of any nozzle currently in service. Without a spare nozzle the cooking equipment is prohibited from being used.

7. On 1/28/11, at the Main Campus (0109) Diagnostic Treatment Center, in the main cafeteria, at 1:35 pm, it was determined that the commercial kitchen equipment was not properly positioned under the hood system. It was observed that the deep fat fryer was not being fully protected by the suppression system. Staff indicated that this equipment was moved for cleaning and was not placed back in the original position which renders the suppression system ineffective. This condition was confirmed by the director of the kitchen.

8. On 1/24/11 at the South Campus (0309) at 3:15 pm grease laden hoods and filters were observed, and on 1/25/11 during kitchen tour from 1-2:30 pm, this condition remained.

9. On 1/26/11, at the Main Campus Mental Health Building, the dietary cooler with sprinkler heads were dated 1999 rendering them expired..

10. On 1/26/11, at the Main Campus (0109) Mental Health Building, a K -Series extinguisher with wand was observed in the kitchen. These wand on the extinguisher is no longer in compliance.

11. On 1/25/11, at the South Campus (0309), a K -Series extinguishers with wand was observed in the kitchen. The wand on the extinguishers are no longer in compliance.

Based on observations made during tour of the facility failed to ensure that prohibited space heaters were in use, and to follow the facility policy regarding space heaters. Space heaters with elements which exceed 212 degrees Fahrenheit are prohibited in health care facilities.

The findings include:

1. The facility has a written policy prohibiting space heaters of any type.

2. On 1/27/11, in the Main Campus (0109) South wing and the Diagnostic Treatment Center wings in rooms S100, S117, and D307 space heaters were observed.

3. On 1/28/11, in the Main Campus (0109) Diagnostic Treatment Center and East wings , East 1142in rooms D262, D222, and East 1195 space heaters were observed.

4. While on tour of the Main Campus (0109) on 1/28/11, in the East Tower at 1:30 p.m., in room #2014 Transfusion Medical Services, a portable space heating device is in use. An interview with the staff person using the device, replied they didn't know heaters were prohibited. A further interview with a Supervisor of the unit, advised the Surveyor the employee has been working there for approximately 6 years.


5. While on tour of the Main Campus Main Campus (0109) West Wing, 14th floor, on 1/24/11, at 2:44 pm, the social worker office 1405 had a Space Heater in use.

6. While on tour of the Main Campus Main Campus (0109) West Wing, 11th Floor, at 4:05 pm, room 1161 had a space heater in use.

7. While on tour of the Main Campus Main Campus (0109) West Wing, on 1/25/11, at 2:00pm, room 861C had a space heater in use.

8. While on tour of the Main Campus Main Campus (0109) West Wing, on 1/27/11, on the 1st floor, at 1:59 pm, Room 109, the Attorney's office had a space heater.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the integrity of laundry and trash chutes are maintained in accordance with NFPA 82.
The findings include:

1. On 1/26/11, in the Main Campus (0109) South wing 8th floor, a linen room door was observed to not self close.

2. On 1/26/11, in the Main Campus (0109) South wing 2nd floor, the door to the linen chute was observed to have a broken closer and would not self close and latch.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

The findings include:

1. While on tour of the Main Campus (0109) on 1/28/11, in the East Tower at 2:00 p.m., in the Pediatric Emergency Room area, the corridor where access to room #1096B may be gained, is in use with a staff computer on wheels. Following a discussion with a staff person using the computer, it was determined that the location is always used for transmitting data and that there is no other location to be utilized. Corridor storage is prohibited, and they are to be kept clear and unobstructed at all times.

2.On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center, on the 2nd floor, stretchers and beds were observed stored in the hallway near the Operating Room.

3. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center, on the 2nd floor in the hallway at the Operating Room locker room/ break room, items were observed stored in front of the exit leading to the Central wing. These items made passage through the exit impossible.

Based on observations made during tour of Jackson Health System, a review of the facility records and interviews with the staff it was determined that the facility could not confirm the flammability ratings of the decorations in use in the facility in accordance with NFPA 101-2000 19.7.5.2, 19.7.5.3, 19.7.5.4. The facility personnel had no available verification that the decorations had been treated or were effectively flame retardant or flame resistant. With no available documentation, flame retardant labels or purchasing records for the decorative plastic plants and moss-like substances, the flame retardant ratings could not be substantiated or confirmed.

The findings include:

On 01/27/11 at the Main Campus (0109) East Tower on the 7th floor at 9:55 am, room 7007 was observed four plastic plants or trees with a moss-like substances.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

The findings include:

1. The Rehabilitation Center at the main campus (0109) was observed to have 2 oxygen cylinders in the Therapy Department that were left unsecured. The cylinders were located in two wheel dolly's and the retension screw was not tightened to hold the cylinders in.

2. On 1/24/11, in the Main Campus (0109) North wing compressor room, medical gas cylinders were observed to be free standing. Unsecured cylinders have the potential if knocked over to rupture at the neck of the cylinder causing the cylinder to become a projectile endangering all building occupants.

3. On 1/26/11, in the Main Campus (0109) South wing penthouse, flammable gas and oxygen cylinders were found to be commingled in the same room. Oxidizing gasses shall not be stored with any flammable gas, liquid or vapor. Cylinders shall be protected from damage in accordance with NFPA 99 5.3.13.1.3; 9.4.2.2

4. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center, on the 3rd floor room D370 oxygen cylinders were observed stored in a room not labeled or identified as being used for oxygen storage. Rooms used for storing oxygen cylinders shall be identified with a sign to include the following wording as a minimum; "CAUTION OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING " NFPA 99 8.3.1.11.3.

5. On 1/24/11, at the Main Campus (0109) West Wing,15th floor, at 11:37 am, supply room 1540A , full and empty oxygen cylinders mixed, not labeled.

6. On 1/24/11, at the Main Campus (0109) West Wing,15th floor, at 2:29 pm, the Medication room had full and empty oxygen cylinders mixed, and not labeled.

7. On 1/24/11, at the Main Campus (0109) West Wing, 12th floor, at 3:17 pm, the Medication room 1206A had full and empty oxygen cylinders mixed, and not labeled.

8. On 1/24/11, at the Main Campus (0109) West Wing,11th floor, at 3:53 pm, room 1106B had full and empty oxygen cylinders mixed not labeled.

9. On 1/25/11, at the Main Campus (0109) West Wing,10th floor, at 9:44 am, the Medications room 1010B had full and empty oxygen cylinders mixed, not labeled.

10. On 1/24/11, at the Main Campus (0109)West Wing, 9th floor, at 11:05 am the Medication room had full and empty oxygen cylinders mixed, not labeled.

11. On 1/27/11, at the Main Campus (0109) West Wing,1st floor, at 11:15 am, the room 107 Gift shop had a Helium H cylinder not secured.

12. On 1/27/11, at the Main Campus (0109) West Wing, Basement, at 2:52 pm, the respiratory room had a nitric oxide cylinders unsecured.

13. On 1/27/11, at the Main Campus (0109) West Wing, Basement, at 3:37 pm, Respiratory room WWB-15 had Oxygen cylinders not secured in wheel carts.

14. On 1/27/11, at the Main Campus (0109) East Wing, 4th floor, at 11:14 am, room 4120 had 4 oxygen cylinders not secured.

15. On 1/27/11, at the Main Campus (0109) East Wing, Lab # 2-23A an e tank oxygen cylinder was unsecured.

16. On 1/24-25/11 at the South Campus (0309) on the 1st floor, the O2 Storage room had 6 unsecured E tanks.

17. On 1/24-25/11 at the South Campus (0309) O.B. Hallway had 2 unsecured E tanks.

18. On 1/24-25/11 at the South Campus (0309) Second floor, the South hallway had an unsecured E tank.

19. On 1/24-25/11 at the South Campus (0309) Minor Care area had 2 E tanks unsecured.

20. On 1/24-25/11 at the South Campus (0309) Gift Shop on 1st floor, had an H tank of Helium sitting on the floor with no chain.

21. On 1/24-25/11 at the South Campus (0309) Dietary had 3 CO2 tanks not chained or secured.

22. On 1/24-25/11 at the South Campus (0309) 2nd floor, I.C.U. had a E cylinders not secured.

23. On 1/24-25/11 at the South Campus (0309) O.B. recovery area had 2 E cylinders not secured.

24. On 1/24-25/11 at the South Campus (0309) 2nd floor ICU had 2 unsecured E tanks.

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that medical gas is handled and stored in accordance with NFPA 99.

The findings include:

On 1/25/11, in the Main Campus (0109) Central Building room 4C Dialysis, pendant type nurse call devices not listed for use in oxygen enriched atmospheres were found in areas where oxygen is administered. Appliances or parts of appliances to be used in the site of intentional expulsion shall be listed for use in oxygen-enriched atmospheres.

Based on an observations made during tour of the facility, interviews with the staff, and a review of the facility records, conducted during the survey of Jackson Health System, it was determined that the facility failed to maintain the fire/smoke dampers in reliable operating condition. This condition could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

The findings include:
1. During the document review on 01/26/11 with staff revealed that the fire/smoke dampers were inspected December 2009 thru February 2010, by an outside contractor. The documents indicated that 2,910 dampers were inspected. This resulted in 426 of these dampers failing, or were into inspected because they were inaccessible. The corrective action and status documents revealed that the facility have repaired 151 to date, and the remaining 275 dampers remain uncorrected. The Facilities Director verified and confirmed that none of the remaining non-compliant dampers are scheduled for repair at the present time. The Facility monthly Quality Assurance meetings failed to identify and this issue and provide corrective action.

2. On 1/24/11, at the Jackson South Hospital Campus (0309) the damper inspection form presented from CT Mechanical on 4/6/10 revealed approximately 30 dampers that failed which were left uncorrected to the date of survey. The Facility monthly Quality Assurance meetings failed to identify and this issue and provide corrective action.

Based on an observation, a defunct Life Safety system and its components have not been removed from the facility. The area of concern is the former roof top fire protection equipment for a Heliport landing pad at the East Tower.

Findings include:

1. While on tour of the Main Campus (0109) on 1/27/11 at 1:45 p.m., in the 8th floor mechanical room, the abandoned foam system and all of the controlling devices are in place.

2. The 9/16/10 report for the main campus (0109) Diagnostic Treatment Center stated that there was a smoke detector mounted to the ceiling above the escalator that is not a listed device in the system and is not connected to anything. Further investigation revealed that this is a smoke detector from an old alarm system and is not connected but was never removed.

Reference: NFPA 101--Life Safety Code (2000 Edition)
4.6.12.2 " Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. "

Based on observations during tour of the facility, and interviews with facility staff, the facility failed to adequately protect the building occupants from flammable and combustible liquids. The facility further failed to maintain fire protection and occupancy features necessary to minimize danger to life in accordance with NFPA 101-19.3.2, 10.3.5., and the NFPA 30 (Flammable Liquid Code).

The findings include:

1. On 1/27/11, in the Main Campus (0109) Diagnostic Treatment Center, on the 2nd floor room D35, had more than 2 gallons of flammable aerosols were observed on a shelf and not located in a flammables storage cabinet. These aerosols were stored in an electrical equipment room with combustible materials. Any area, with storage of quantities of flammables, combustibles or hazardous materials, shall be protected.

2. On 1/27/11, at the Main Campus (0109) West Wing, Basement, at 2:26 pm, the Pharmacy Storage area had a Storage cabinet. When opened strong fumes vented from the cabinet indicating that a chemical in the cabinet di not have a sealed container, and the cabinet was not vented.

Based upon a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with NFPA 101 and NFPA 110 " Standard for Emergency and Standby Power Systems ". NFPA 110- 8.4.9: Level 1 EPSS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months. Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8 "A fuel quality test shall be performed at least annually using tests approved by ASTM standards."

The findings include:

1. There was also no documentation at the time of the survey to verify that the facility had performed the four (4) hour Load Bank test at the South Hospital (0309) for either generator.

2. Subsequent to records review, during 1/24/11 at the North Campus (0209) , the facility could not substantiate an annual fuel quality test has been performed for the emergency power generators.

3. On 1/26/11 at the North Dade Health Center (0609) a 75 KW diesel generator for the facility was observed. No available documents for weekly inspection, monthly 30 minute load run, and no Load Bank test.

Based on a review of the facility records, and interview with the staff during the Fire Life Safety survey, it was determined that the facility failed to ensure that all electrical wiring and electrical equipment are properly installed, tested as frequently as required, and maintained in reliable operating condition, tested as frequently as required, and maintained in accordance with NFPA 101, and NFPA 70.

The findings include:

1. While on tour of the North campus (0209), on 1/25/11, at 2:45 p.m., in the 2nd floor Lab Microbiology room, 2 electric circuit breaker panels, are missing a legend on the panel doors, and there are no labeled numbers adjacent to the circuit breakers.

2. While on tour of the North campus (0209), on 1/25/11, at 2:45 p.m., subsequent to the records review, the facility could not substantiate that required monthly testing of the (Surgery area) Line Isolation Monitors, is being conducted. Documentation revealed that only quarterly tests were performed. The panels are of the manual type that requires monthly, and then yearly testing. The Facility monthly Quality Assurance meetings failed to identify and this issue and provide corrective action.

3. On 1/28/11, between 10:00 a.m. and 1:00 p.m. at the Main Campus (0109), in the East Tower, at the 5th floor room #5009H, had a 6 outlet surge protected power strip with one side damaged exposing the electrical contacts.

4. On 1/28/11, between 10:00 a.m. and 1:00 p.m. at the Main Campus (0109), in the electrical Panel room opposite room #5115, panel #5BCL1 has no legend.

5. On 1/28/11, between 10:00 a.m. and 1:00 p.m. at the Main Campus (0109), on the 3rd floor, closet #3130C has a Life safety Branch panel with no legend.

6. On 1/28/11, between 10:00 a.m. and 1:00 p.m. at the Main Campus (0109), on the 2nd floor, Pathology Services room #2029 has a single tube fluorescent ceiling fixture, with the tube held in place by twisted electrical wire, and the fixture has a missing end cap exposing the interior wiring.


7. On 1/24/11, at the Main Campus (0109) West Wing, Penthouse & Roof, at 10:32 am, the Elevator equipment room had florescent lamps not protected.

8. On 1/24/11, at the Main Campus (0109) West Wing, Penthouse & Roof, at 10:41 am, the roof, air handler unit 221 had exposed live electrical wires.

9. On 1/24/11, at the Main Campus (0109) West Wing, 15th floor, at 10:52 am, the Communications room had electrical panels WWPHNH-2 and WWPHNL-3 that were not labeled.

10. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 2:22 pm, Nurse Liaison room 1440 had a Multi tap electrical cord in use.

11. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 2:42 pm, the staff lounge 1401 had electrical receptacle missing protective cover, exposing the live wires.

12. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 2:53 pm, electrical closet 1402 had electrical panels incorrectly labeled.

13. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 3:00 pm, the Restroom 1430 had light fixture with exposed lamps not protected.

14. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 3:02 pm, room 1435 had electrical extension cord used as permanent power.

15. On 1/24/11, at the Main Campus (0109) West Wing, 12th floor, at 3:17 pm, the Medication room 1206A had electrical cords run through ceiling tiles.

16. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 3:32 pm, the Patient room 1261 had a non hospital grade surge protector in use.

17. On 1/25/11, at the Main Campus (0109) West Wing, 10th floor, at 9:25 am, room 1027 had two surge protector's connected to each other.

18. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 10:08 am, room 1053 had florescent lamps with no protective cover.

19. On 1/24/11, at the Main Campus (0109) West Wing, 14th floor, at 10:22 am, room 1032 had electrical outlet with a multi plug adapter plugged into it.

20. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 10:42 am, room 935 had surge protectors connected to each other.

21. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 10:58 am, room 908 had a missing electrical outlet cover plate.

22. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 11:11 am, the hall electrical panel was in the open position, in patient corridor.

23. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 11:13 am, the 902 room electrical room had electrical panels not labeled correctly.

24. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 11:15 am, room 903 had surge protectors connected together.

25. On 1/24/11, at the Main Campus (0109) West Wing, 9th floor, at 11:27 am, the room 961 had an electrical extension cord used as permanent wiring.

26. On 1/24/11, at the Main Campus (0109) West Wing, 8th floor, at 1:32 pm, room 822 has electrical room panels labeled incorrectly.

27. On 1/24/11, at the Main Campus (0109) West Wing, 8th floor, at 1:36 pm, Nurse Station had surge protectors connected together.

28. On 1/24/11, at the Main Campus (0109) West Wing, 8th floor, at 2:17 pm, room 805 had florescent lamps with no protective covers.

29. On 1/24/11, at the Main Campus (0109) West Wing, 8th floor, at 2:32 pm, room 802 electrical panel WW8CL-1 had open spaces, without blank covers in them.

30. On 1/24/11, at the Main Campus (0109) West Wing, 8th floor, at 2:46 pm, room 823 is a Patient room with 2 electrical panels not locked (ww8nl-39, ww8nl-40).

31. On 1/24/11, at the Main Campus (0109) West Wing, 7th floor, At 3:21 pm, room 753 had surge protectors connected together.

32. On 1/26/11, at the Main Campus (0109) West Wing, 7th floor, at 9:46 am, room 704 had an open electrical junction box with live wires.

33. On 1/26/11, at the Main Campus (0109) West Wing, 6th. floor, at 10:26 am, at the Nurse Station under desk was exposed live electrical wires.

34. On 1/26/11, at the Main Campus (0109) West Wing, 5th floor, at 11:26 am, across from 543 had an Open electrical panel in Hall way. The panel also had a blank space in it.

35. On 1/26/11, at the Main Campus (0109) West Wing, 5th floor, room 502 had an electrical panels not labeled correctly.

36. On 1/26/11, at the Main Campus (0109) West Wing, 5th floor, at 1:26 pm, room 535 had a electrical cord run through ceiling tiles.

37. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 1:33 pm, the west stairway electrical lights were not working.

38. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 1:41 pm, Soiled Utility room had an electrical cord through ceiling tiles.

39. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 1:45 pm, the Oxygen room had an electrical cord through ceiling tile.

40. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 1:50 pm, the Nurses station on the B side had an electrical cord through ceiling tile.

41. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 2:03 pm, room 406B had an open electrical junction boxes with exposed live wires.

42. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 2:13 pm, room 418 had florescent lamps missing protective lens covers.

43. On 1/26/11, at the Main Campus (0109) West Wing, 4th floor, at 2:18 pm, room WW422 had an Incandescent light bulb no protective cover,

44. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor Operating rooms, at 2:45 pm, in the sterile area, there were florescent lamps no protective covers.

45. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 2:46 pm, the Line Isolation Monitor Panels of the O.R. were not identified as to which O.R. they protect. 9 of 14 were labeled incorrectly.

46. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 3:00 pm, O.R. 10 & 11 Storage area had a Surge protector hanging from cord, and is a temporary extension cord used for permanent power.

47. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 3:04 pm, O.R. 9 had a non hospital grade surge protector in use.

48. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 3:11 pm, Emergency cart room had 2 Line Isolation Monitor electrical panels blocked.

49. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 3:16 pm, next to the O.R. 2 had electrical panels blocked.

50. On 1/26/11, at the Main Campus (0109) West Wing, 3rd floor, at 3: 19 pm, the corridor electrical panels electrical panels had broken locks that will not open.

51. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 3:30 pm, the electrical panels next to room w239 were labeled incorrectly.

52. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 3:30 pm, the electrical room W239 had florescent lamps with incorrect lens covers.

53. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 3:39 pm, room 203C is a electrical room electricals that have open spaces.

54. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 3:45 pm, room W202A had live exposed electrical wires.

55. On 1/27/11, at the Main Campus (0109) West Wing, 2nd floor, at 9:32 am, room W205 had an open space on electrical disconnect with exposed live wires.

56. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 10:16 am, room 281 had a wall florescent lamp with unprotected lens covers.

57. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 10:30 am, the office environmental closet has incandescent light bulb with no protective lens covers.

58. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 10:42 am, fire door 03140 has exposed live electrical wires above ceiling tile.

59. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 10:54 am, room 267 has electrical panel schedules that are not complete.

60. On 1/26/11, at the Main Campus (0109) West Wing, 2nd floor, at 11:03 am, room 203C has electrical panels with open spaces.

61. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor,

62. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 11:33 am, room 124 of the Command center there were surge protectors connected together.

63. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:23 pm, Fire door 07376, above ceiling had exposed live electric wires.

64. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:41 pm, room 108, across from SR UP secretary, there were surge protectors connected together.

65. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:46 pm, room 108 is a conference room. Next to entry, the electrical panel used as junction box and is not locked.

66. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:51 pm, room 108 the Copier room, had an electrical outlet with no protective cover.

67. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:53 pm, the secretary desk had Multiple daisy chained surge protectors.

68. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 2:16 pm, room 119 had florescent lamps with no protective covers.

69. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 2:21 pm, the air handler room had florescent lamps missing protective covers.

70. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 2:26 pm, the Pharmacy Storage walk in cooler light bulb had no protective lens cover and no cage protection, daisy chained surge protectors, 5 all together in one group, and broken electrical outlets that need repair due to exposed live wires.

71. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 2:52 pm, the respiratory electrical switch had no protective cover, and daisy chained surge protectors.

72. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:05 pm, room WWB-41 houses Machine room 11 that had an electrical panel with incorrect labels.

73. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:14 pm, WWB-40 Machine room 10 had electrical panels that need labels corrected, and open spaces on electrical panels.

74. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:18 pm, the electric fire pump controller room had a Controller broken and a damaged cabinet door with exposed live electric components.

75. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:27 pm, the Vault 1 had a multi-tap electrical cord used, (2) lights in cooler had no lamp protection, and a missing metal cage protector.

76. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:53 pm, the WWB40 Restrooms had florescent lamps missing protective lens covers.

77. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 3:55 pm, the WWB39 Linen chute room had live electrical wires exposed.

78. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 4:00 pm, the WWB21 Restroom had exposed live electrical wires.

79. On 1/27/11, at the Main Campus (0109) East Wing, 4th floor, at 10:09 am, room 4163 had an electrical junction box missing the cover plate.

80. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 10:13 am, room 4154 had a broken light fixture.

81. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 10:43 am, room 4145 had a florescent lamp with no protective lens cover.

82. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 11:17 am, room 4116 had florescent lamps with no protective lens covers.

83. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 11:46 am, across from 4052C there was an Exam room with a non approved surge protector in use.

84. On 1/26/11, at the Main Campus (0109) West Wing, Basement, at 1:19 pm, the O.B./O.R. Nurse Station had open exposed live electrical wires on floor under the desk.

85. On 1/26/11, at the Main Campus (0109) West Wing, 1st floor, at 1:30 pm, the trash/linen chute room 107 had florescent lamps with no protective covers.

86. There was no documentation available at the time of the survey to show that the main and feeder circuit breakers are inspected and exercised annually in accordance with NFPA 99 3-4.4.1.2.(a) as required. The engineering staff verified and confirmed that this testing was not performed. This affects all 9 Health Care Occupancies at the Main Campus (0109). The Facility monthly Quality Assurance meetings failed to identify and this issue and provide corrective action.

87. During the survey, when requested, the facility was unable to provide documentation to verify that the Main Breakers and Feeder Circuit Breakers at the South Campus (0309) had been inspected and exercised annually in accordance with NFPA 99 3-4.4.1.2.(a) as required. The engineering staff verified and confirmed that this testing was not performed.

88. Based upon record review, interviews and observations with staff representatives during the facility Life Safety tour on 1/24 & 25/11, the South Hospital (0309) facility could not provide documentation to verify that the two (2) Line Isolation Monitors in Operating Room #4 had been tested monthly since 2009. The Facility monthly Quality Assurance meetings failed to identify and this issue and provide corrective action.

Based on observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to correctly install mounted alcohol dispensers in accordance with NFPA 101- 19.3.2.7 and CFR 403.744.

The findings include:

1. On 1/24/11 at the Main Campus (0109) North wing room 215B, alcohol based hand sanitizer dispensers were located in the vicinity of and directly above sources of ignition.

2. On 1/24/11at the Main Campus (0109) Central building room C646, alcohol based hand sanitizer dispensers were located in the vicinity of and directly above sources of ignition.

3. On 1/24/11 at the Main Campus (0109) Central building room C646, alcohol based hand sanitizer dispensers were located in the vicinity of and directly above sources of ignition.

4. On 1/24/11 at the Main Campus (0109) West Wing, 14th floor, at 2:44 pm, the social worker office 1405 had an Alcohol hand dispenser over electrical switch.

5. On 1/24/11 at the Main Campus (0109) West Wing, 12th floor, at 3:35 pm, room 1267 had a Alcohol hand dispenser installed adjacent to electrical switch.

6. On 1/24/11 at the Main Campus (0109) West Wing, 12th floor, at 3:46 pm, room 1226A had a alcohol hand dispenser installed adjacent to electrical switch.

7. On 1/24/11 at the Main Campus (0109) West Wing, 11th floor, at 4:07 pm, room 1101 had a alcohol hand dispenser adjacent to electrical switch.

8. On 1/25/11 at the Main Campus (0109) West Wing, 8th floor, at 1:50 pm, room 847 had an alcohol dispenser over electrical outlet.

9. On 1/24/2011 at the Main Campus (0109) West Wing, 8th floor, at 2:03 pm, room 801 had an alcohol hand dispenser installed adjacent to electrical switch.

10. On 1/24/2011 at the Main Campus (0109) West Wing, 8th floor, at 2:25 pm, room 817 had an alcohol hand dispenser installed over electrical outlet.

11. On 1/24/2011 at the Main Campus (0109) West Wing, 8th floor, at 2:48 pm, room 825 had an alcohol hand dispenser installed over receptacle outlet.

12. On 1/24/2011 at the Main Campus (0109) West Wing, 6th floor, at 10:23 am, the Nurse Station educator ' s office had an alcohol adjacent to electrical switch.

13. On 1/24/2011 at the Main Campus (0109) West Wing, 6th floor, at 10:53 am, room 657 had an alcohol adjacent to electrical switch.

14. On 1/24/2011 at the Main Campus (0109) West Wing, 6th floor, at 11:08 am, room 618 had an alcohol hand dispensers over electrical switch.

15. On 1/24/2011 at the Main Campus (0109) West Wing, 5th floor, at 11:43 am, room 504 had 2 alcohol hand dispensers above electrical switches.

16. On 1/24/2011 at the Main Campus (0109) West Wing, 5th floor, at 11:52 am, room 557 had an alcohol hand dispenser installed adjacent to electrical switch.

17. On 1/24/2011 at the Main Campus (0109) West Wing, 5th floor, at 12:05 pm, room 503 had an alcohol hand dispenser over class "A" flammable products.

18. On 1/24/2011 at the Main Campus (0109) West Wing, 5th floor, at 1:30 pm, next to room WW387, a alcohol hand dispenser was leaking onto open trash container.

19. On 1/24/2011 at the Main Campus (0109) West Wing, 4th floor, at 2:13 pm, room 418 had an alcohol hand dispenser over electrical switch.

20. On 1/24/2011 at the Main Campus (0109) West Wing, 5th floor, at 3:35 pm, room W203 had an alcohol hand dispenser over electrical switch.

21. On 1/27/2011 at the Main Campus (0109) West Wing, 2nd floor, at 10:20 am, Theater seating had an alcohol hand dispenser over electrical switches.

22. On 1/27/2011 at the Main Campus (0109) West Wing, 2nd floor, at 11:07 am, 271B had an alcohol hand dispenser over electrical switch.

23. On 1/27/2011 at the Main Campus (0109) West Wing, 1st floor, at 1:34 pm, next to Room 108 an alcohol hand dispensers with no catch basin dripping on to carpeted floor.

24. On 1/27/2011 at the Main Campus (0109) West Wing, 1st floor, at 1:59pm, room 109 Attorney's office had an alcohol hand dispenser with no catch basin over carpeted floor.

25. On 1/27/2011 at the Main Campus (0109) West Wing, Basement, at 3:40 pm room WWB11B had alcohol hand dispensers adjacent to electrical switches.

26. On 1/27/2011 at the Main Campus (0109)East Wing, 4th floor, at 10:50 am, room 4138 had an alcohol adjacent to electrical switch.

27. On 1/27/2011 at the Main Campus (0109) West Wing, at 11:51 am, Labor and recovery has an alcohol adjacent to electrical switch.

28. On 1/24 thru 28/11, at the the South Hospital (0309) Endo Rooms #1 and #2 had alcohol hand dispensers adjacent to electrical switches.

29. On 1/24 thru 28/11, at the the South Hospital (0309) PACU Wall area (3 units) had alcohol hand dispensers adjacent to electrical switches.

30. On 1/26/11, at the Rosie Lee Wesley Health Center (0409), in the Administration area, on the wall and in the lobby area both had alcohol hand dispensers adjacent to electrical switches.

31. On 1/26/11at the Main Campus (0109) East Building by #2003 Lab had alcohol hand dispensers adjacent to electrical switches.

32. Main Campus Morgue entry wall area had alcohol hand dispensers adjacent to electrical switches.

33. On 1/26/11at the Main Campus (0109) East Building Nurses Station on the 4th floor wall area there was alcohol hand dispensers adjacent to electrical switches.