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Based on observations during tour of the facility, it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility failed to maintain corridor doors to prevent impediments to closing to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings include:
On January 3, 2012 at 2:08 PM while on tour of the Shands at UF building with facility staff , the corridor door labeled SMKA0102063 failed to close completely and latch when released from the magnetic hold open devices.
On January 3, 2012 at 2:18 PM while on tour of the Shands at UF building with facility staff, the corridor door labeled SMKA0102021 failed to close completely and latch when released from the magnetic hold open devices due to a faulty door coordinator. Smoke doors are required to be free from impediments to closing. NFPA 101(2000) 8.3.4; 19.3.7.6

Based on observation, the facility failed to provide complete sprinkler coverage for the building as required by NFPA 101 and installed per NFPA 13.

Findings include:
On January 4, 2012, at 1:00 PM while on tour of the Shands Vista and Rehab Facility with facility staff, a canopy structure outside of the central supply receiving area/loading dock was observed. The canopy is attached to the structure, and extends approximately 14 to 30 feet from the structure. The canopy structure is of aluminum (non-combustible) construction. Failure to provide sprinkler coverage to these areas could result in the uncontrolled development of fire and the spread of fire to the host structure thereby endangering the occupants and rescue personnel. . " Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled. " NFPA 13 (1999) 5-13.8.2; NFPA 19.3.5

Based on a review of the facility records, interviews with the staff, it was determined that automatic sprinkler system was not maintained, inspected and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include;
On January 4, 2012 at 10:15 AM while on tour of the facility with facility staff, at the Cancer Hospital in room 1218 observed an incomplete installed drop ceiling with concealed sprinkler heads for protection of the space no heads located above the dropped ceiling grid. Failure to complete the dropped ceiling will allow for heated fire gases to bypass the heads delaying the reaction to control a fire endangering the patients, staff, and building occupants in violation of NFPA 13 (1999) 5-1.1(3), NFPA 25 (1998) 1-4.6, 2-2.1.1, NFPA 101 (2000) 9.7.1, 19.3.5.1.

Based on observations and interviews with facility staff, the facility failed to maintain a safe environment from the hazard potential from patients and staff that smoke on the facility property.

Findings include:

On January 3, 2012 at 3:32 PM while on tour of the facility with facility staff, at the Cancer Hospital on the Garden Service 3rd floor exterior patio posted non-tobacco use area observed (7) cigarette butts, (1) one cigar butt, and multiple cigarettes inside 3 of the 5 trash receptacles located on the patio which also showed staining from extinguishing of smoking materials on the rim. This could result in a fire endangering the patients, staff, and building occupants. NFPA 101 (2000) 19.7.4(4).

Based on observations and interviews with facility staff and records review, the facility failed to provide and install privacy curtains in resident rooms in accordance with NFPA standards.

Findings include:

On January 3-4, 2011 while on tour of the Shands at UF building with facility staff, the curtains in rooms 4520, 4524, and 2543 had no mesh top section and were hung from tracks mounted directly to the ceiling. This limited the sprinkler coverage in these areas to only one side of the curtained area. Newly introduced curtains shall comply with NFPA 101 (2000)10.3.1, 19.3.5.5, NFPA 13, and NFPA 701

Based on observation, the facility failed to maintain the features of life safety and to fully implement the interim life safety measures as identified in the facility guidlines and NFPA 101 during construction and renovation.

Findings include:

On January 3, 2012 at 12:00 PM while on tour of the Shands at UF building with facility staff in the Section 95 Ped's wing, a temporary partition was observed along one side of the corridor. The temporary partition partially obscured one exit sign and completely obscured a second at the corridor exit. Review of the interim life safety measures for the renovation indicated that all exit signs were to be maintained. "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place" NFPA 101 (2000) 4.6.10.1

Based on observation, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70.

Findings include;
On January 3, 2012 at 11:20 AM through 2:50 PM while on tour of the Cancer Hospital with facility staff, mobile push computer chart dollies observed with exposed internal electrical wiring at the base of the battery recharging cord were found on the 6th floor (3) three units, 5th floor (4) four units, and 4th floor (3) three units. This could result in shock, electrocution, or fire endangering patients, staff, and building occupants in violation of NFPA 70 (1999) Article 110-12(c), NFPA 101 9.1.2, 19.5.1.
On January 4, 2012 at 10:30 AM while on tour of the Cancer Hospital with facility staff, in the Cancer Center Kitchen observed the cord for the Ice Machine had separated from the plug head exposing the internal electrical wiring. This could result in shock, electrocution, or fire endangering patients, staff, and building occupants in violation of NFPA 70 (1999) Article 110-12(c), NFPA 101 9.1.2, 19.5.1.
On January 4, 2012 at 10:42 AM while on tour of the Cancer Hospital with facility staff, in Room G302 observed a refrigerator freezer plugged into a power-strip with multiple devices which was extended by an extension cord. This can result in overload or fire endangering the patients, staff, or building occupants in violation of NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 19.5.1, 9.1.2.
On January 5, 2012 at 9:38 AM while on tour of the Shands at UF building with facility staff, all pendant type nurse call devices throughout the Endoscopy and PACU wings observed were not listed for use by patients undergoing oxygen therapy in areas where oxygen is administered. "Appliances or part(s) of an appliances or system to be used in the site of intentional expulsion shall comply with... (1) Be listed for use in oxygen-enriched atmospheres" in violation of NFPA 70 (1999) 517-61(c), NFPA 99 (1999) 7-6.2.4.2, NFPA 101 (2000) 9.1.2, 21.5.1.

Based on observations during tour of the facility, it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility failed to maintain corridor doors to prevent impediments to closing to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings include:
On January 3, 2012 at 2:08 PM while on tour of the Shands at UF building with facility staff , the corridor door labeled SMKA0102063 failed to close completely and latch when released from the magnetic hold open devices.
On January 3, 2012 at 2:18 PM while on tour of the Shands at UF building with facility staff, the corridor door labeled SMKA0102021 failed to close completely and latch when released from the magnetic hold open devices due to a faulty door coordinator. Smoke doors are required to be free from impediments to closing. NFPA 101(2000) 8.3.4; 19.3.7.6

Based on observation, the facility failed to provide complete sprinkler coverage for the building as required by NFPA 101 and installed per NFPA 13.

Findings include:
On January 4, 2012, at 1:00 PM while on tour of the Shands Vista and Rehab Facility with facility staff, a canopy structure outside of the central supply receiving area/loading dock was observed. The canopy is attached to the structure, and extends approximately 14 to 30 feet from the structure. The canopy structure is of aluminum (non-combustible) construction. Failure to provide sprinkler coverage to these areas could result in the uncontrolled development of fire and the spread of fire to the host structure thereby endangering the occupants and rescue personnel. . " Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled. " NFPA 13 (1999) 5-13.8.2; NFPA 19.3.5

Based on a review of the facility records, interviews with the staff, it was determined that automatic sprinkler system was not maintained, inspected and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include;
On January 4, 2012 at 10:15 AM while on tour of the facility with facility staff, at the Cancer Hospital in room 1218 observed an incomplete installed drop ceiling with concealed sprinkler heads for protection of the space no heads located above the dropped ceiling grid. Failure to complete the dropped ceiling will allow for heated fire gases to bypass the heads delaying the reaction to control a fire endangering the patients, staff, and building occupants in violation of NFPA 13 (1999) 5-1.1(3), NFPA 25 (1998) 1-4.6, 2-2.1.1, NFPA 101 (2000) 9.7.1, 19.3.5.1.

Based on observations and interviews with facility staff, the facility failed to maintain a safe environment from the hazard potential from patients and staff that smoke on the facility property.

Findings include:

On January 3, 2012 at 3:32 PM while on tour of the facility with facility staff, at the Cancer Hospital on the Garden Service 3rd floor exterior patio posted non-tobacco use area observed (7) cigarette butts, (1) one cigar butt, and multiple cigarettes inside 3 of the 5 trash receptacles located on the patio which also showed staining from extinguishing of smoking materials on the rim. This could result in a fire endangering the patients, staff, and building occupants. NFPA 101 (2000) 19.7.4(4).

Based on observations and interviews with facility staff and records review, the facility failed to provide and install privacy curtains in resident rooms in accordance with NFPA standards.

Findings include:

On January 3-4, 2011 while on tour of the Shands at UF building with facility staff, the curtains in rooms 4520, 4524, and 2543 had no mesh top section and were hung from tracks mounted directly to the ceiling. This limited the sprinkler coverage in these areas to only one side of the curtained area. Newly introduced curtains shall comply with NFPA 101 (2000)10.3.1, 19.3.5.5, NFPA 13, and NFPA 701

Based on observation, the facility failed to maintain the features of life safety and to fully implement the interim life safety measures as identified in the facility guidlines and NFPA 101 during construction and renovation.

Findings include:

On January 3, 2012 at 12:00 PM while on tour of the Shands at UF building with facility staff in the Section 95 Ped's wing, a temporary partition was observed along one side of the corridor. The temporary partition partially obscured one exit sign and completely obscured a second at the corridor exit. Review of the interim life safety measures for the renovation indicated that all exit signs were to be maintained. "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place" NFPA 101 (2000) 4.6.10.1

Based on observation, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70.

Findings include;
On January 3, 2012 at 11:20 AM through 2:50 PM while on tour of the Cancer Hospital with facility staff, mobile push computer chart dollies observed with exposed internal electrical wiring at the base of the battery recharging cord were found on the 6th floor (3) three units, 5th floor (4) four units, and 4th floor (3) three units. This could result in shock, electrocution, or fire endangering patients, staff, and building occupants in violation of NFPA 70 (1999) Article 110-12(c), NFPA 101 9.1.2, 19.5.1.
On January 4, 2012 at 10:30 AM while on tour of the Cancer Hospital with facility staff, in the Cancer Center Kitchen observed the cord for the Ice Machine had separated from the plug head exposing the internal electrical wiring. This could result in shock, electrocution, or fire endangering patients, staff, and building occupants in violation of NFPA 70 (1999) Article 110-12(c), NFPA 101 9.1.2, 19.5.1.
On January 4, 2012 at 10:42 AM while on tour of the Cancer Hospital with facility staff, in Room G302 observed a refrigerator freezer plugged into a power-strip with multiple devices which was extended by an extension cord. This can result in overload or fire endangering the patients, staff, or building occupants in violation of NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 19.5.1, 9.1.2.
On January 5, 2012 at 9:38 AM while on tour of the Shands at UF building with facility staff, all pendant type nurse call devices throughout the Endoscopy and PACU wings observed were not listed for use by patients undergoing oxygen therapy in areas where oxygen is administered. "Appliances or part(s) of an appliances or system to be used in the site of intentional expulsion shall comply with... (1) Be listed for use in oxygen-enriched atmospheres" in violation of NFPA 70 (1999) 517-61(c), NFPA 99 (1999) 7-6.2.4.2, NFPA 101 (2000) 9.1.2, 21.5.1.