Northeast Florida State Hospital

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 14762 Based on observation, interview, and record review it was determined the hospital failed to ensure a nursing care plan was developed that reflected the nursing care provided related to a lapbelt restraint for 1 of 16 sampled patients. (Patient #5) Findings include: A tour of unit 32 was conducted on 3/10/25 at approximately 1:20 PM. During that tour, patient #5 was observed seated in a highback wheelchair in the main living area with a blue lapbelt across her waist and appeared to be sleeping. Hospital staff were observed coming in and out of the area. At 1:55 PM, patient #5 was observed yelling out and appeared agitated. No staff responded to the patient or assessed her in anyway. At 2:40 PM, patient #5 was observed in the same position. An interview with staff member D, a certified nursing assistant (CNA) was conducted at this time and asked about the process for the monitoring of patient #5. Staff member D indicated the patient was to be released from the lapbelt every 2 hours when toileted. Staff member D stated, “if she does not have a lapbelt then she will slide out and fall.” Staff member D was noted to be making entries on a flow record titled Critical Pathway which reflected 30 minute increments of time for staff to document when the patient was offered fluids, received range of motion, lapbelt to be checked if it was in the correct position, patient’s skin was warm and dry, position changed every 2 hours, and if patient had voided or had a bowel movement. The Critical Pathway was noted be signed by both registered nurses (RN) and CNAs. The Critical Pathway indicated the patient had received offering of fluids, range of motion, and had her skin assessed, however during the observation period from 1:20 PM till 2:40 PM, staff did not offer fluids, assess the patient, change her position or assess if the restraint was applied correctly. The Critical Pathway did reflect patient #5 had been toileted twice from 7:00 AM till 2:00 PM, at 7:00 AM and again at 12:00 PM, but not every 2 hours as described by staff member D as the process. (copy obtained) A continuous observation of patient #5 was conducted on 3/11/25 from 8:45 AM till 11:20 AM. Patient #5 was observed in a highback wheelchair in the main living area with a blue lapbelt across her waist and she appeared to be sleeping. A review of the Critical Pathway dated 3/11/25 revealed staff had documented patient #5 had been offered fluids, had her skin assessed as warm and dry, had been assessed that the restraint was correctly applied, been provided range of motion and position changes every 30 minutes during the continuous observation period, however those nursing interventions did not occur. (copy obtained) A review of the hospital’s Restraint policy and procedure dated January 2025 (OP16-01-02) revealed that direct care staff were to monitor the patient and document the safety checks every 30 minutes on the Critical Pathway for medical restraints for the offered activities of: skin integrity, circulation and general condition nutritional status and intake toileting or changing every 2 hours repositioning at least every 2 hours (copy obtained) A review of patient #5’s nursing care plan, last updated 9/17/24, revealed nursing diagnosis of fall risk/unsteady gate and muscle weakness. The care plan goal was listed as the patient would be free from falls and request assistance for support if needed. The nurse interventions were for nursing/staff will assist with transfers and activities of daily living (ADLs). The nursing care plan lacked any notations of the lapbelt restraint or justification for the restraint. (copy obtained) An interview was conducted with staff member B, unit 32 nursing supervisor, on 3/11/25 at approximately 10:45 AM. She was asked about the lack of a nursing care plan for the lapbelt restraint and the documentation concerns on the Critical Pathway. She stated, “we have been told we do not need a care plan for a medical restraint.” She had no explanation for the documentation concerns and observations related to the Critical Pathway. On 3/11/25 at approximately 3:30 PM, an interview was conducted with the interim Chief Nursing Officer, (CNO). He indicated the hospital did not have a specific policy and procedure for nursing care plans.”

“An unannounced Fire & Life Safety recertification survey was conducted March 10-12, 2025 at Northeast Florida State Hospital, 7487 S. State Road 121, a hospital in Mcclenny, Florida 32063. Northeast Florida State Hospital is in compliance with 42 CFR part 482 Subpart A-E and National Fire Protection Association (NFPA) 101 (2012 edition) and NFPA 99 (2012 edition), requirements for hospitals. Bldg. #12 Initial Plan Review: 1959 New or Existing: Existing NFPA 220 Construction Type: II (111) Square Footage: 49,682 Stories: 4 Fully Sprinkled Monitored Fire Alarm Generator: 100 kw Number of beds: 1038 Census: 605 Bldg. #13 Initial Plan Review: 1959 New or Existing: Existing NFPA 220 Construction Type: II (111) Square Footage: 60,556 Stories: 4 Fully Sprinkled Monitored Fire Alarm Generator: 100 kw Buildings 7, 8, 9, 10, 15, 17, 36A, 36B, and 36 D were of Type II (000) construction and were single story in height. Buildings 7, 8, 9,10, 15, 17, 36A, 36 B, and 36 D were provided with a monitored fire alarm system and smoke compartments. The following is a description of the noncompliance:”

“Means of Egress Capacity CFR(s): NFPA 101 Means of Egress Capacity The capacity of required means of egress is in accordance with 7.3. 18.2.3.1, 19.2.3.1 This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to remain in compliance with requirements for means of egress per NFPA 101 (2012). On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. During the tour of the facility with the Plant Operations Staff in the Dental area door #64, 65 revealed that main entrance door and the interior entrance door measured 28” which does not allow a non-ambulatory patient access to services or the ability to egress while sitting in a wheelchair. The Director of Maintenance observed the finding along with the Director of Nursing which agreed that patients cannot pass through each door for care. During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the egress capacity were not compliance and he had no comment. per: NFPA 101 (2012 Edition) 7.2, 7.2.1.1.1 These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to provide exit sign with proper directional indication to show the proper means to egress from the facility in accordance with NFPA 101 (2012). The findings include: On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12, Floor 3 while on tour with facility staff, it was observed near door 30, an EXIT sign on the wall over door 30 without directional indication of which way to EXIT. This EXIT sign gives the impression that door 30 might be an EXIT due to the appearance of the EXIT sign above the door. Egress shall be provided with directional signs which are continuously illuminated by the emergency lighting system in accordance with During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the exit sign directional indication was not visible and he stated that “the facility would correct it.” per: NFPA 101 (2012) 4.5.8, 4.6.13, 7.10.1, 7.10.2, 19.2.10, 19.7.6. These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 33962 Based on record review, observation and staff interview, the facility failed to maintain the kitchen hood fire suppression system as required by NFPA 17A (2009). The findings include: Dietary Bldg. #11 1) During record review with the Plant Operations Staff on 3/10/25 at 1:00 PM, the facility failed to produce documentation for the fire suppression hood semi-annual inspection, inspection for 3/24 was not produced. per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12. per: NFPA 17A (2009 Edition) 7.5.1. 2) During the facility tour with the Plant Operations Staff on 3/11/24 from 9:30 PM to 3:30 PM, in the kitchen, observed fire extinguishing system manual pull station was not secured, pin were broken. per: NFPA 101 (2012 Edition) 19.3.2.5., 9.2.3. per: NFPA 96 (2011 Edition) 10.5.2. 3) During the record review with the Plant Operations Staff on 3/10/25 at 1:10 PM, evidence of the 8 point monthly quick check inspection of the dietary kitchen could not be produced. per NFPA 101 (2012 Edition) 19.3.2.5.1., 9.2.3. per NFPA 96 (2011 Edition) 10.2.6.(4) per NFPA 17A (2009 Edition) 7.2.1, 7.2.2. 4) During the facility tour with the Plant Operations Staff on 3/11/24 from 9:30 PM to 3:30 PM, in the kitchen, observed the deep fryer were located less than 16” from the gas stove. per: NFPA 101 (2012 Edition) 19.3.2.5.1., 9.2.3. per: NFPA 96 (2011 Edition) 10.2.6.(4) per: NFPA 17A (2009 Edition) 7.2.1, 7.2.2. During an interview with the Plant Operations Staff on 3/11/25 at 10:05 AM, and he acknowledged the semi-annual inspection were not conducted and he stated, “I was not aware that the inspection were not completed.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to maintain the interior finishes (ceiling tiles) in the facility per NFPA 101 (2012 Edition). On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12 During the tour of the facility along with the Plant Operations Staff it was observed that the resident hall floor 3 had been painted which contributes for excessive fire load and changes the rating of the installed ceiling tiles. Ceiling finishes, including surfaces of the tiles have a flame spread rating of Class B. The addition of spray paint increases the flammability and could cause the sprinkler system to not function properly. During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the ceiling tiles were painted and he stated that “the facility were not aware of the painted tiles.” NFPA 101 (2012 Edition) 10.2., 19.3.3.1, 19.3.3.2., 4.6.12.1. These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to install fire alarm system components in accordance with NFPA 101 (2012). The findings include: On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed: 1) No heat / smoke detector was installed in the mechanical room in buildings 36-D, and 36-A. During an interview with the Plant Operations Staff on 3/10/25 at 3:30 PM, he acknowledged the smoke detector was not installed and he stated that “the facility would install it.” per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6, 9.6.1.8 per: NFPA 72 (2010 Edition) 17.5.3.1, 17.6.1.1, 17.6.2.1. These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 33962 Based on record review, observation and staff interview, the facility failed to maintain the fire alarm system in accordance with NFPA 101 (2012). The findings include: 1) During record review with the Plant Operations Staff on 3/10/25 at 10:30 AM, the facility failed to produce documentation for the fire alarm system smoke and duct detectors sensitivity testing. per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1. per: NFPA 72 (2010 Edition) Table 14.4.2.2.(14)(g)(1) 2) During record review with the Plant Operations Staff on 3/10/25 at 10:35 AM, the facility failed to produce documentation for the fire alarm system duct detectors differential pressure testing. per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1. per: NFPA 72 (2010 Edition) Table 14.4.2.2.(14)(g)(6) 3) During record review with the Plant Operations Staff on 3/10/25 at 10:40 AM, the facility failed to produce documentation of the semi-annual (visual) inspection of the fire alarm system. per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6.1. per: NFPA 72 (2010 Edition) Table 14.3.1. 4) On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed: A) Fire Alarm breakers, located in equipment rooms in buildings 36-A, 36-B, 36-D, 7, and 8 failed to have a red marking. B) Fire Alarm breakers in buildings 36-A, 36-B, 36-D, 7, and 8 failed to have a locking device installed to prevent breaker from being turned off. per: NFPA 101 (2012 Edition) 19.3.4.1, 9.6 per: NFPA 72 (2010 Edition) 10.6.5.2.3, 10.6.5.4 During an interview with the Plant Operations Staff on 3/11/25 at 3:00 PM, he acknowledged the fire alarm system inspection and testing was not completed and he stated that “the facility would schedule the inspections.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 33962 Based on record review, observation and staff interview, the facility failed to maintain required inspections of the automatic fire sprinkler system (AFSS) in accordance with NFPA 101 (2012). Failure to maintain or have inspected, the system could lead to an AFSS failure. The findings include: BLDG. #13 1) During record review with the Plant Operations Staff on 3/10/25 at 12:40 PM, the facility provided documentation that revealed the fire sprinkler system inspections were overdue, the last reports were dated 2023. per: NFPA 101 (2012 Edition) 19.3.5.1., 9.7.1.1. per: NFPA 25 (2011 Edition) 7.3.1. 2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12 between the hours of 1:00 p.m. and 4:00 p.m. during the facility tour with the Maintenance Director, it was found that the spare sprinkler cabinet located on the exterior of facility in fire riser room on the South East corner, failed to have an inventory list of the installed sprinklers and sprinkler wrench within the facility. per: NFPA 101 (2012 Edition) 19.3.5.1, 9.7, 9.7.1.1 per: NFPA 13 (2010 Edition) 6.2.9.7, 6.2.9.7.1.(1-4) During an interview with the Plant Operations Staff on 3/10/25 at 3:30 PM, he acknowledged the fire sprinkler system inspections were overdue and he stated that “the facility would schedule the inspections.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to maintain the fire extinguishers in the facility in accordance with NFPA 101 (2012). Failure to provide a clean agent fire extinguisher in the data and communication room could delay the extinguishment of a fire. The findings include: 1) On 3/10/2025 between the hours of 9:00 a.m. and 3:00 p.m. during the facility tour with the electrician, the following was observed: A) Fire Extinguisher, 1 of 1, located in equipment room 25 of building 36-D, failed to have monthly inspections performed and documented on inspection tag. The annual inspection was completed in December 2024. B) Fire Extinguisher, 1 of 1, located in equipment room 23 of building 7, failed to have the annual inspection completed. The last inspection was completed in June 2023. per: NFPA 101 (2012 Edition) 19.3.5.12 per: NFPA 10 (2010 Edition) 7.2.1.1, 7.2.1.2, 7.2.4.1.2, 7.2.4.1.4 2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the tour of the building 12 it was discovered that the fire Extinguisher’s located in maintenance room with generator has an expired portable fire extinguisher dated 2023 and not signed off monthly as required. Located in Building 12-3 room 120 fire extinguisher not signed off monthly as required and sitting on the floor. Located in room 123 CO2 fire extinguisher not signed off monthly as required. Located behind door 124 fire extinguisher expired 2023, not signed off monthly as required. Located in elevator roof maintenance area entry door fire extinguisher not signed off monthly as required. Located in elevator switch room fire extinguisher expired 2023, not signed off monthly as required. Located in beauty salon behind door 70 fire extinguisher expired 2023, not signed off monthly as required. per: NFPA 99 ( 2012 Edition) 16.9.1.3. During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the fire extinguishers annual and monthly inspection were not done and he stated that “the facility would do the inspections.” These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to properly maintain the required fire/smoke barriers penetrations, which have not been fire-stopped or smoke-sealed per the requirements of NFPA 101 (2012). The findings include: During the facility tour with the Plant Operations Staff on 3/10-12/25 from 9:00 AM to 3:30 PM, in Building 12-3, it was found that the smoke/fire walls were not properly protected with the required firestopping system in the following area(s): 1) Located on the first, second and third floors inside room 43 by hazardous room drywall has been removed from room 2) Located in room 46 open penetrations in the walls 3) Open wall behind washing machine machines has penetrations 4) Located in room 15 open hole penetrations in the ceiling During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the penetrations in the wall and he stated that “he would repair the penetration.” per: NFPA 101 (2012 Edition) 19.3.7.3., 8.5.6., 8.5.6.1. thru 8.5.6.6. These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 33962 Based on record review and staff interview, the facility failed to maintain fire/smoke dampers in the facility in accordance with NFPA 90A (2011). The findings include: Bldg. #12 & 13 During the record review with the Plant Operations Staff on 3/10/25 at 12:30 PM, the facility failed to produce documentation for fire/smoke dampers inspection. All dampers shall be operated to verify that they fully close, fusible links shall be removed at least every four years. During an interview with the Plant Operations Staff on 3/10/25 at 12:35 PM, he acknowledged the fire/smoke dampers inspection was not completed and he stated that “the facility would schedule the inspections.” per: NFPA 101 (2012 Edition) 19.5.2.1., 9.2.1. per: NFPA 90A (2011 Edition) 5.4.8.1. per: NFPA 80 (2010 Edition) 19.4.1.1., 19.4.9., 19.4.10. These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 33962 Based on record review and staff interview, the facility failed to maintain and inspect fire doors in accordance with NFPA 80 (2010). The findings include: Bldg. #13 1) During the record review with the Plant Operations Staff on 3/10/25 at 11:20 AM, it was found that the facility failed to produce documentation for fire doors inspection, the last inspection report was dated 2/17/22. per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12. per: NFPA 80 (2010 Edition) 5.2.4.1. 2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12-3. During the tour of the facility with the Plant Operations Staff in the main hallway between building 12 and 12-3 it was observed that a listed fire door number 7 is missing the lower half of the releasing hardware and has open penetrations at the panic hardware on each side of the door. per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12. per: NFPA 80 (2010 Edition) 5.2.4.1. During an interview with the Plant Operations Staff on 3/11/25 at 3:30 AM, he acknowledged the fire doors inspection was not completed and he stated that “he would complete the fire doors inspection immediately.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 33962 Based on record review and staff interview, the facility failed to maintain the emergency generators in accordance with NFPA 101 (2012). This in the event of a power failure could result in the generator malfunctioning with a resulting loss of power to the facility. The findings include: BLDG. #12 & 13 / Entire Facility Generator 1) During record review with the Plant Operations Staff on 3/10/25 at 10:50 AM, it was found that the annual Fuel Quality Testing was not completed. per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1. per: NFPA 110 (2010 Edition) 8.3.8. 2) During record review with the Plant Operations Staff on 3/10/25 at 10:55 AM, no evidence of annual 1.5 hour load testing was found. There was also no record of exceptions to testing as allowed by NFPA 110. per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1. per: NFPA 110 (2010 Edition) 8.4.2.3. 3) During record review with the Plant Operations Staff on 3/10/25 at 11:00 AM, it was found that the annual major PM service was not completed. per: NFPA 101 (2012 Edition) 19.5.1.1., 9.1.3.1. per: NFPA 110 (2010 Edition) 8.1.1. 4) During record review with the Plant Operations Staff on 3/10/25 at 11:05 AM, no records of main and feeder circuit breaker inspection and exercising was provided. per: NFPA 101 (2012 Edition) 19.7.6., 4.6.12. per: NFPA 99 (2012 Edition) 6.4.4.1.2.1. During an interview with the Plant Operations Staff on 3/10/25 at 11:10 AM, he acknowledged the emergency generator inspections was not completed and he stated that “he would call the vendor and complete the generator inspections immediately.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to prevent the improper use of power strips in accordance with NFPA 101 (2012). This failure could result in endangerment to the residents, staff and other building occupants. The findings include: On 10 - 12 March 2025 at Northeast Florida State Hospital, building 12 and 13 with the Plant Operations Staff it was found that the facility was improperly using extension cords, power strips and multi-port adapters. 1.) Main hallway room number 9 copier and microwave plugged into power strip 2.) Main hallway room number 6 refrigerator and microwave plugged into power strip 3.) Bldg. 12 room 100 office power strips being daisy chained. 4.) Bldg. 12 room 104 refrigerator and microwave plugged into power strip. 5.) Bldg. 12 multi-port adapter shows signs of being overheated. 6.) Bldg. 12 IT room has power strip used as permanent wiring for IT equipment in rack per: NFPA 99 (2012 Edition) 10.2.3.6, 10.2.4 per: NFPA 70 (2011 Edition) 400.8, 590.3(D) During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the power strips were used improperly and he stated that “he would remove them.” These findings were verified by the Plant Operations Staff at the times of record review and the Administration at the exit conference on 3/12/25 at 11:00 AM.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 33962 Based on observation and staff interview, the facility failed to maintain medical gas storage rooms in accordance with NFPA 99 (2012). This failure could result in endangerment to the residents, staff and other building occupants The findings include: 1) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the facility tour with the Plant Operations Staff, it was found on 3rd floor door 2, 74 & 98 oxygen storage room in the O2 storage room by the south nursing station that the facility failed to display the correct signage per NFPA 99 for storing oxidizing gases. per: NFPA 99 (2012 Edition) 11.3.2.3, 11.3.4.1, 11.3.4.2. 2) On 10 - 12 March 2025 at Northeast Florida State Hospital, Building 12. during the tour of the facility with the Plant Operations Staff in the Medical Triage area revealed that an E Oxygen cylinder was observed free standing without being secured in transport cart or secured to the wall as required. NFPA 99 (2012 Edition) 11.6.5.2, 11.6.5.3. During an interview with the Plant Operations Staff on 3/11/25 at 3:30 PM, he acknowledged the oxygen storage signage were not installed and he stated that “he would order the signs immediately.” These findings were verified by the Plant Operations Staff at the times of observations and the Administration at the exit conference on 3/12/25 at 11:00 AM.”