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Based on observation made during the fire life safety tour of Building 1243, and interviews with FSH Fire Inspector, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.
The findings Include:
During the facility tour of Building 1243 with FSH Fire Inspector., on 06/14/2016, between 9am and 3:30pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly,
1) Double self-closing doors next to 1139 not closing properly, catching on floor
2) Double self-closing doors next to 1220 not closing properly
3) Room 1237 door not closing properly
4) Self-closing doors in radiology department not closing properly
5) Self-closing doors in outpatient clinics not closing properly
6) Room 2122 has roller latch
7) Room 2125 has roller latch
8) Room 2123 has roller latch

NFPA 101, (2000 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation made during the fire life safety tour of Building 1243, and interviews with FSH Fire Inspector, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2000 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.
Findings include:
During the facility tour of Building 1243 FSH Fire Inspector, on 06/15/2016, between 9am and 3:30pm , it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations,
1) Penetrations above double doors next to 1117
2) Penetrations above double doors at 1220, caused by sprinkler pipes
3) Penetrations above double doors next to 1132
4) Penetrations above double doors in radiology department caused by sprinkler pipes
5) Stairwell exit in radiology department needs ceiling tile replaced
6) Penetrations above double doors caused by sprinkler pipes and phone lines
7) Penetrations above double doors next to room 1146 caused by wires
8) Penetrations in wall above water fountain across from 1154 caused by junction box

All locations were not properly protected with the required fire caulk. Maintenance was shown the penetrations and confirmed the findings.
According to NFPA 101(2000 edition) 8.3 and 19.3.7

Based on observation made during the fire life safety tour , the facility failed to properly store compressed medical gas cylinders in accordance with NFPA 99, Health Care Facilities Code. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.
Findings include:
During the facility tour of Building 1028 with Florida State Hospital Fire Inspector on, 06/16/2016, between 9am and 3:30pm, the following were observed:
1) Oxygen cylinders were left unsecured in room # 206A
2) Oxygen cylinder were left unsecured in room # 120
Medical gas storage, handling of cylinders, and administration shall be in accordance with NFPA 99 (2000 edition) Chapters 5 and 11, and NFPA 101 (2000 edition) 18.3.2.4 & 19.3.2.4

Based on document review, the facility failed to maintain the annual fuel quality test for the generator. This could result in loss of power to the emergency generator thereby endangering the patients and occupants of the facility. Proper maintenance and inspection of the generator helps to ensure proper functioning in an emergency situation.

The findings include:
During document review and interview with Aramark Assistant Director, on 06/13/2016 at 1030am it was found that the Fuel Quality Check for the facilities Diesel Fuel had not been done; last test was done in May of 2015. Aramark Assistant Director advised he would have the test done as soon as possible.
NFPA 110, 8.3.3, "A fuel quality check shall be done according to ASTM Standards on a yearly basis."

Based on observation made during the fire life safety tour of Building 1243, and interviews with FSH Fire Inspector, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.
The findings Include:
During the facility tour of Building 1243 with FSH Fire Inspector., on 06/14/2016, between 9am and 3:30pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly,
1) Double self-closing doors next to 1139 not closing properly, catching on floor
2) Double self-closing doors next to 1220 not closing properly
3) Room 1237 door not closing properly
4) Self-closing doors in radiology department not closing properly
5) Self-closing doors in outpatient clinics not closing properly
6) Room 2122 has roller latch
7) Room 2125 has roller latch
8) Room 2123 has roller latch

NFPA 101, (2000 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation made during the fire life safety tour of Building 1243, and interviews with FSH Fire Inspector, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2000 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.
Findings include:
During the facility tour of Building 1243 FSH Fire Inspector, on 06/15/2016, between 9am and 3:30pm , it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations,
1) Penetrations above double doors next to 1117
2) Penetrations above double doors at 1220, caused by sprinkler pipes
3) Penetrations above double doors next to 1132
4) Penetrations above double doors in radiology department caused by sprinkler pipes
5) Stairwell exit in radiology department needs ceiling tile replaced
6) Penetrations above double doors caused by sprinkler pipes and phone lines
7) Penetrations above double doors next to room 1146 caused by wires
8) Penetrations in wall above water fountain across from 1154 caused by junction box

All locations were not properly protected with the required fire caulk. Maintenance was shown the penetrations and confirmed the findings.
According to NFPA 101(2000 edition) 8.3 and 19.3.7

Based on observation made during the fire life safety tour , the facility failed to properly store compressed medical gas cylinders in accordance with NFPA 99, Health Care Facilities Code. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.
Findings include:
During the facility tour of Building 1028 with Florida State Hospital Fire Inspector on, 06/16/2016, between 9am and 3:30pm, the following were observed:
1) Oxygen cylinders were left unsecured in room # 206A
2) Oxygen cylinder were left unsecured in room # 120
Medical gas storage, handling of cylinders, and administration shall be in accordance with NFPA 99 (2000 edition) Chapters 5 and 11, and NFPA 101 (2000 edition) 18.3.2.4 & 19.3.2.4

Based on document review, the facility failed to maintain the annual fuel quality test for the generator. This could result in loss of power to the emergency generator thereby endangering the patients and occupants of the facility. Proper maintenance and inspection of the generator helps to ensure proper functioning in an emergency situation.

The findings include:
During document review and interview with Aramark Assistant Director, on 06/13/2016 at 1030am it was found that the Fuel Quality Check for the facilities Diesel Fuel had not been done; last test was done in May of 2015. Aramark Assistant Director advised he would have the test done as soon as possible.
NFPA 110, 8.3.3, "A fuel quality check shall be done according to ASTM Standards on a yearly basis."