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Based on observations and staff interview, the facility failed to maintain ceiling tiles and penetrations for cables, conduits, and pipes through fire/smoke rated wall/ceiling assemblies and failed to maintain the integrity of the fire/smoke wall/ceiling system, which could allow for the penetration of smoke and fire gases from one compartment to another, endangering the patients, staff, and other building occupants.


The findings include:


1. On July 12, 2016 at 1:30 PM while on tour, it was observed, on the 4th Floor, just inside Room 407, that two ceiling tiles of the fire/smoke resistive ceiling had signs of staining and damage, which could allow for the failure of the ceiling system to resist the passage of smoke or flames in the event of a fire. It was acknowledged by the Operations Manager at time of finding that the ceiling tiles had become damaged and have not been properly maintained in accordance with of NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 19.3.7.1, 19.7.6.


2. On July 12, 2016 at 1:53 PM while on tour, it was observed on the 4th floor in the ICU Mechanical Room, multiple cable conduit penetrations, removed from use and only stuffed with mineral wool material, not properly sealed, maintaining the 2-hour fire/smoke barrier. It was acknowledged by the Operations Manager at time of finding that the cable conduit penetrations have not been properly provided with an approved fire stop system to maintain the fire/smoke wall assembly in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 8.2.3.2.4.1, 8.2.3.2.4.2(1-4), 8.2.3.2.4, 19.3.7.1, 19.7.6.


3. On July 12, 2016 at 2:07 PM while on tour, it was observed, on the 3rd floor just inside Room 303, that two ceiling tiles of the fire/smoke resistive ceiling, had signs of staining and damage, which could allow for the failure of the ceiling system to resist the passage of smoke or flames in the event of a fire. It was acknowledged by the Operations Manager at time of finding that the ceiling tiles had become damaged and have not been properly maintained in accordance with of NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 19.3.7.1, 19.7.6.


4. On July 12, 2016 at 2:56 PM while on tour, it was observed on the 2nd floor in the IT Closet by Room 202, cable and conduit penetrations not properly sealed, maintaining the 2- hour fire/smoke barrier. It was acknowledged by the Operations Manager at time of finding that the cable and conduit penetrations installed are not provided with an approved fire stop system to maintain the fire/smoke wall assembly in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 8.2.3.2.4.1, 8.2.3.2.4.2(1-4), 8.2.3.2.4, 19.3.7.1, 19.7.6.


5. On July 12, 2016 at 2:56 PM while on tour, it was observed on the 2nd Floor in the IT Closet by Room 202, a ceiling tile of the fire/smoke resistive ceiling, which had signs of staining and damage, which could allow for the failure of the ceiling system to resist the passage of smoke or flames in the event of a fire. It was acknowledged by the Operations Manager at time of finding that the ceiling tiles had become damaged and have not been properly maintained in accordance with of NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 19.3.7.1, 19.7.6.


6. On July 12, 2016 at 2:59 PM while on tour, it was observed on the 2nd Floor, just inside Room 206, a ceiling tile of the fire/smoke resistive ceiling, which had signs of staining and damage, which could allow for the failure of the ceiling system to resist the passage of smoke or flames in the event of a fire. It was acknowledged by the Operations Manager at time of finding that the ceiling tiles had become damaged and have not been properly maintained in accordance with of NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 19.3.7.1, 19.7.6.


These findings were confirmed with the Chief Operating Officer, Operations Director, and Engineer Director during the exit conference on July 12, 2016 at 4:45 PM.

Based on records review and staff interview, the facility failed to provide evidence of fire drills being conducted at unexpected times under various conditions at least once per shift per quarter for all staff, which can lead to failure of facility staff to perform properly during emergency events, which can lead to injury or loss of patients, staff, or other building occupants.


The findings include:


On July 12, 2016 from 8:30 AM to 12:00 PM during records review, the facility fire drill records reflected that the drills being conducted for the staff training were only identified for those staff on the floor where the drill took place. In discussion with the the Operations Manager and Engineer Director at time of finding, it was explained that the facility sets off the alarm system and the entire facility is notified and participates in response. However, even though all staff and the entire facility participate, the only signatures obtained, to document drill conducted and staff, have been those from the direct location the drill was conducted. It was acknowledged at time of discussion that no records were available to show that all facility staff had received fire drill training. Drills shall be held one per shift per quarter at unexpected times under various conditions for all staff in accordance with NFPA 101 (2000) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.2.



These findings were confirmed with the Chief Operating Officer, Operations Director, and Engineer Director during the exit conference on July 12, 2016 at 4:45 PM.

Based on records review and staff interview, the facility failed to maintain their fire alarm system records with regard to the records indicating all alarm and initiation devices controlled by the system to show devices were inspected, tested, and maintained in accordance with NFPA 72, to maintain the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of patients, staff, or other building occupants, which could result in injury or loss.


The findings include:


On July 12, 2016 from 8:30 AM to 12:00 PM during records review, the provided documentation for the facility's fire alarm system's annual testing failed to show that the water-flow, supervisory, and tamper switches were tested and verified by the fire alarm contractor. It was acknowledged at time of finding, with the Operations Manager and Engineer Director, they were not aware that the devices had not been logged on the documented testing report as being tested for integrity by the fire alarm contractor. All alarm-initiating devices & circuits, to include interface equipment devices shall be properly documented and verified for integrity and operation by the facility's licensed fire alarm contractor, in accordance with Florida State Statute 633.348 (5-6), 633.3482 (3-4), NFPA 72 (1999) 7-1.1, 7-1.1.1, 7-1.1.4, 7-5.2.2, NFPA 101 (2000) 9.6.1.4, 9.6.1.7, 19.3.4.


These findings were confirmed with the Chief Operating Officer, Operations Director, and Engineer Director during the exit conference on July 12, 2016 at 4:45 PM.

Based on observations and staff interview, the facility failed to maintain proper storage practices of medical gas cylinders. Failure to maintain proper storage practices can result in endangerment to patients, staff, and other building occupants.


The findings include:


1. On July 12, 2016 at 2:00 PM while on tour, it was observed, on the 4th Floor in the Oxygen Storeroom by Room 428, a medical gas e-sized oxygen cylinder stored in a wheeled hand cart unit device, with no securing screw in place. It was acknowledged at time of finding by the Operations Manager that the bottle was not being properly stored. Carts and hand trucks for cylinders and containers shall be constructed for the intended purpose, be self-supporting, and be provided with appropriate chains or stays to retain cylinders or containers in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2(h), 8-5.2.1, 8-5.2.1.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12, 19.3.2.4, 19.7.6.


2. On July 12, 2016 at 2:29 PM while on tour, it was observed, on the 3rd Floor in the Cath Lab Equipment storage, a medical gas e-sized oxygen cylinder stored in a wheeled hand cart unit device with no securing screw in place. It was acknowledged at time of finding by the Operations Manager that the bottle was not being properly stored. Carts and hand trucks for cylinders and containers shall be constructed for the intended purpose, be self-supporting, and be provided with appropriate chains or stays to retain cylinders or containers in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2(h), 8-5.2.1, 8-5.2.1.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12, 19.3.2.4, 19.7.6.


4. On July 12, 2016 at 3:58 PM while on tour, it was observed on the 1st Floor in the Cardio Therapy/Pulminary Function Room, a medical gas e-sized oxygen cylinder stored in a wheeled hand cart unit device, with no securing screw in place. It was acknowledged at time of finding by the Operations Manager that the bottle was not being properly stored. Carts and hand trucks for cylinders and containers shall be constructed for the intended purpose, be self-supporting, and be provided with appropriate chains or stays to retain cylinders or containers in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2(h), 8-5.2.1, 8-5.2.1.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12, 19.3.2.4, 19.7.6.


These findings were confirmed with the Chief Operating Officer, Operations Director, and Engineer Director during the exit conference on July 12, 2016 at 4:45 PM.

Based on observations and staff interview, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger residents, staff, or other building occupants.


The findings include:


1. On July 12, 2016 at 1:31 PM while on tour, it was observed on the 4th Floor in the Electrical Room 004-1, Electrical Panel 4NL2B - the breakers 20, 21, 22, 24, 25, 27, and 28 were designated as spares on the panel legend. These breakers were found in the energized position. At time of finding, it was acknowledged by the Operations Manager that the breakers were energized and did not indicate the location or control function of the breaker in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.1, 19.7.6.


2. On July 12, 2016 at 1:32 PM while on tour, it was observed on the 4th Floor in the Electrical Room 004-1, Electrical Panel 4NL2A - the breakers 1, 3, 5, 7, 9, 11, 13, 15, and 17 were designated as spares on the panel legend. These breakers were found in the energized position. At time of finding, it was acknowledged by the Operations Manager that the breakers were energized and did not indicate the location or control function of the breaker in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.1, 19.7.6.



3. On July 12, 2016 at 1:37 PM while on tour, it was observed on the 4th Floor in the IT Room by Room 413, in use a multi-plug relocatable powertap device powering multiple electrical devices, while also powering another multi-plug relocatable powertap device, powering multiple electrical devices in lieu of properly provided power receptacles. The Operations Manager acknowledged the use of the multi-plug relocatable power tap devices, one off another, loaded with multiple electrical devices at time of finding, which can result in overloading of the electrical system. Multi-plug relocatable powertap adapters shall not be utilized in lieu of permanent household power or in series one of another in accordance with NFPA 70 (1999) Article 400-4, 400-7(b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


4. On July 12, 2016 at 1:37 PM while on tour, it was observed on the 4th Floor in the North Mechanical/Elevator Room, in use an extension cord powering an emergency power supply multi-plug power device, powering multiple electrical devices, in lieu of properly provided power receptacles. The Operations Manager acknowledged the use of the extension cord in lieu of properly provided power for the emergency power supply multi-plug device. A new power outlet had been recently installed and the device had not yet been relocated. Extension cords and multi-plug relocatable powertap adapters shall not be utilized in lieu of permanent household power in accordance with NFPA 70 (1999) Article 400-4, 400-7(b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


5. On July 12, 2016 at 3:05 PM while on tour, it was observed on the 2nd Floor at the Center Nurse Station, in use was a multi-plug relocatable powertap device powering multiple electrical devices, while also powering another multi-plug relocatable powertap device powering multiple electrical devices, while also powering another multi-plug relocatable powertap device powering multiple electrical devices, while also powering another multi-plug relocatable powertap device powering multiple electrical devices in lieu of properly provided power receptacles. The Operations Manager acknowledged the use of the multi-plug relocatable power tap devices, one off another, loaded with multiple electrical devices at time of finding, which can result in overloading of the electrical system. Multi-plug relocatable powertap adapters shall not be utilized in lieu of permanent household power or in series one of another in accordance with NFPA 70 (1999) Article 400-4, 400-7(b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


6. On July 12, 2016 at 3:31 PM while on tour, it was observed on the 1st Floor at the Emergency Department Nurse Station, in use was a multi-plug relocatable powertap device powering multiple electrical devices, while also powering another multi-plug relocatable powertap device powering multiple electrical devices, in lieu of properly provided power receptacles. The Operations Manager acknowledged the use of the multi-plug relocatable power tap devices, one off another, loaded with multiple electrical devices at time of finding, which can result in overloading of the electrical system. Multi-plug relocatable powertap adapters shall not be utilized in lieu of permanent household power or in series one of another in accordance with NFPA 70 (1999) Article 400-4, 400-7(b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


These findings were confirmed with the Chief Operating Officer, Operations Director, and Engineer Director during the exit conference on July 12, 2016 at 4:45 PM.