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Based on observation and interview, the facility did not provide a 'common separation wall' with 90 minute fire rated doors & closers on all doors in the separation wall from outside building to outside building. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 6 of the 39 staff that were working.

FINDINGS INCLUDE:
On May 10, 2012, at 11:20 am surveyor #18107 observed in the SC-20 smoke compartment on the 1st floor in the Corridor between Child & Adolescent Center (CBRF) and Existing (Vacated) Psych Hospital, that the separation wall was non-compliant because it was not built to a 2-hour fire assembly requirement where two different Occupancies occur per 19.1.2.3 and 19.1.1.4. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 10 of the 39 staff that were working.

FINDINGS INCLUDE:
On May 10, 2012, at 3:55 pm surveyor #18107 observed in the SC-15 smoke compartment on the Ground floor in the Data & Storage Rooms, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included multiple ceiling tile panels out exposing the floor deck above. Upon looking up into the intersitial space above the open ceiling, Surveyor #18107 noticed a hole in the floor above. Penetration's adversely affect the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide corridor separation doors with compliant corridor doors, and double doors with an astragal seal. This deficiency occurred in 6 of the 9 smoke compartments, and had the potential to affect 31 of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/10/2012 at 9:22 am surveyor #18107 observed in the SC-1, SC-3, SC-5, SC-7 & SC-9 smoke compartments on the Lower level, 1st & 2nd floors in the Inpatient Sleeping Rooms, that the corridor was not compliant. The sleeping room corridor doors at all levels of the new Inpateint Sleeping Building do not have the continuous smoke-tight gasketing along the entire upper door edge meeting the limited combustibility requirements. The doors are double swing for emergency access. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/10/2012 at 11:00 am surveyor #18107 observed in the SC-6 smoke compartment on the 1st floor in the Closet of the Experimental Therapy area, that the room had double corridor doors with a gap greater than 1/8 inch at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with and changes in egress direction marked with exit signs. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 15 of the 40 staff that were working.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:40 am surveyor #18107 observed in the SC-11 smoke compartment on the 3rd floor in the Outdoor Porch, that egress was not readily apparent and an exit sign was not provided when persons are present out on the porch. The porch that is used by staff and guests on nice Summer and Fall Days is missing a exit sign on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:57 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Suite, that the change in direction in the path of egress was not readily apparent and an exit sign was not provided. The Kitchen Suite was missing a Exit Sign out of the primary exit egress of the Kitchen. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 16 of the 39 staff that were working this day.

FINDINGS INCLUDE:
On May 10, 2012, at 3:27 pm surveyor #18107 observed in the SC-16 smoke compartment on the Ground floor in the New Resident Storage Suite, that the path of egress in the corridor was not readily apparent and an Exit Sign was not provided near the 2nd exit access out of the Resident Storage Suite. The size of this Suite was not able to be determined at time of survey. Two exit access signage is required when Suite is larger than 2,500 square feet per NFPA 101, Section 19.2.10. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with taped joints on rated walls . This deficiency occurred in 2 of the 9 smoke compartments, and had the potential to affect 8 of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/10/2012 at 9:30 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Corridor at smoke barrier, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This was discovered at wall above ceiling in corridor between SC-2 & SC-1. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 1 of the 21 staff that were working in this building that day.

FINDINGS INCLUDE:
On 05/10/2012 at 9:50 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Information Technology (IT) Room, that penetration(s) were not sealed according to an approved method. The deficiency included penetrations through wall by hot and cold pipe lines. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide enclosures around exit stairs with stairwell requirements, and rated wall construction. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 23 of the 39 staff that were working, including the CBRF residents and CBRF Staff not identified in this report.

FINDINGS INCLUDE:
1. On May 10, 2012 at 11:28 am surveyor #18107 observed in the SC-18 smoke compartment on the 1st floor in the Midway Stair, that the stairwell was not compliant. The wall with door access separating the Midway Stair from the 1st Floor corridor did not provide sufficient landing depth on the stair side per 2000 NFPA 101, 19.2.2.3, 7.2.2.2.1(b) & 7.2.1.3. During the multi-phased construction project currently under way, these Stairs along with the Mail Room Stairs and Annex Stairs are suppose to be 'removed' because they are non-compliant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On May 10, 2012, at 3:35 pm surveyor #18107 observed in the SC-17 & SC-15 smoke compartments between the Ground, 1st, 2nd & 3rd floors in the Annex Stair & Mailroom Stair, that the stairwells were not compliant. The Annex Stairwell did not have the correct riser and tread dimensions for an existing stairs per NFPA 101, Table 7.2.2.2.1(b) and landings did not meet the requirements for Section 7.2.2.3.2 since the egress width was reduced at the landings due to heating elements at exterior walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On May 10, 2012, at 3:00 pm surveyor #18107 observed in the SC-15 smoke compartment on the Ground floor in the Mailroom Stairs, that the exit enclosure wall was not constructed to the required fire-rating. Stairwell wall adjacent to Electrical Room was missing at bottom of existing stairs. Electrical Room had high voltage switchgear equipment within room. Stairwell walls were damaged at one location exposing the stair structure under the plaster. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 30 pounds of force. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 1 of the 21 staff that were working in this building the day of the survey.

FINDINGS INCLUDE:
On 05/10/2012 at 9:39 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Group Room, that the door in the path of egress would not open when a force of greater than 30 lbs. pressure was applied to the door to start it moving because the door was too tight when closed to the adjoining leaf and catching on the latching mechanism. 31 pounds pressure was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, Section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since existing CBRF patients may be incapable of self preservation and rely on a highly reliable fire alarm system to defend-in-place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This facility is 'in transition' as patients & CBRF residents leave the facility to new buildings being constructed. The facility did not provide a fire alarm system with smoke detectors properly placed at required locations. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 7 of the 39 staff that were working this day along with the Child & Adolescent Center (CBRF) residents within the building at 1st and 2nd Floors.

FINDINGS INCLUDE:
On May 10, 2012, at 11:35 am surveyor #18107 observed in the SC-18 smoke compartment on the 1st floor in the Physician Suite, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was observed 18 to 20 inches down on wall from the ceiling and should have been less than 12 inches but greater than 4 inches from ceiling but on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation, interview and a review of documents, the facility (Building No. 2) did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 35 of the 78 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/07/2012 at 1:28 pm surveyor #18107 observed in the Partial Day area - SC2 smoke compartment on the 2nd floor in the Electrical Closet #2521, that there was one or more unsealed holes near the ceiling. The hole(s) included several 1/2 inch and 1 inch conduit holes were penetrating the ceiling near the wall. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a ceiling system sealed above the sprinkler(s) to collect heat. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect 26 of the 39 staff that were working as well as the Child & Adolescent Center (CBRF) Residents present in the facility this day.

FINDINGS INCLUDE:
1. On May 10, 2012, at 3:20 pm surveyor #18107 observed in the SC-15 & SC-16 smoke compartment on the Ground floor in the Data + Communication Room & CBRF Resident Laundry Room, that there was one or more unsealed holes near the ceiling. The hole(s) included ceiling panels were open in these areas at Ground Floor, which is showing a pattern in less used spaces. Automatic Sprinklers were present in these Hazardous Spaces. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On May 10, 2012, at 3:30 pm surveyor #18107 observed in the SC-16 smoke compartment on the Ground floor in the Materials Management Storage Room, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles out. These holes would reduce the response time of the sprinkler(s) in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the residents that were in the facility the day of the survey (and licensed to serve), as well as 40 staff and an unidentified number of visitors.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:35 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Unisex Toilet, that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:25 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Family Triage Storage Closet #1093, that there was one unsealed hole near the ceiling. The hole included a 1 inch opening. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On 05/11/2012 at 10:30 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Large Intake Office, that there was one unsealed hole near the ceiling. The hole included a 1 inch opening. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

4. On 05/11/2012 at 10:43 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Cooler, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Item #1
NFPA 101, 2000 edition 38.3.4.1 " General. A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exist:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject1to 300 or more total occupants "
Section 9.6 states " ...9.6.1.9 For the purpose of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation The initiation function provides the input signal to the system.
(b) Notification The notification function is the means by which the system, advises that human action is required in response to a particular condition.
(c) Control The control function provides outputs to control building equipment to enhance protection of life.

Bases on observation, and staff interview (P and Q) the facility failed to provide a complete fire alarm system in accordance section 9.6.

FINDINGS INCLUDE
1) During of tour of the facility with staff P and Q on May 10, 2012, Surveyor 12187 observed: There are four occupied stores with a basement in the building with the first floor being the level of exit discharge. There are 3 pull stations and strobes and horns located at the 3 exit doors of the building. There are no other manual pull stations, horns or strobes in the lobby stair or in the ' business suite ' occupied by the provider. The horns and strobes by the 3 exits would not notify all persons in the ' suite ' . This is not a complete fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.
2) During a tour of the facility and review of the maintenance records, there was no record of testing of the fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.

Item #2
NPFA 101, 2000 edition 38.5.2 state " Heating, Ventilating and Air Conditioning. Heating, ventilating, and air conditioning equipment shall comply with the provisions of Section 9.2 "
Section 9.2.1 states " Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems ... "
NFPA 90A, 1999 edition 3-4.7 states " Maintenance. At least every 4 years fusible links (where applicable) shall be removed, all dampers shall be operated to verify that they fully close, the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. "

Based on observation, staff interview and record review, the facility failed to provide maintenance on the fire dampers in accordance with NFPA 90A.

FINDINGS INCLUDE
During the tour the facility with staff P, Q, and R on May 10, 2012 at 10:20 AM, staff R stated to Surveyor 12187 that there were no records of testing of the fire dampers. No records were produced. Staff R stated that no fire damper tests were done since his company owned the building and the previous owner did not leave any record of test of the fire dampers.


Item #3
NFPA 101, 2000 edition, 38.2.8 states " Illumination of Means of Egress. Means of Egress shall be illuminated in accordance with Section 7.8. Section 7.8.1.2 states " Illumination of the means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress shall be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria value herein specified.

Based on observation and record review and interviews, the facility failed to provide operating light and provide maintenance on the emergency lights in the path of egress.

FINDINGS INCLUDE
During the tour of the facility with staff P, Q, and R at 10:30 AM on May 10, 2012 it was observed that the emergency light near the nurse station did not light up when the test button was pushed by Surveyor 12187. Surveyor then asked for records of testing of the emergency lights. Staff P, Q, and R did not know of any testing that was done.


Item #4
NFPA 101, 2000 edition, 38.2.7 states " Discharge from Exits. Exit discharge shall comply with Section 7.7. Section 7.71 states, " Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be required width and size to provide all occupants with a safe access to a public way. "

Based on observation, and interviews the facility failed to provide a safe path to a public way out of the 2 stairs (exits) to the north of the building.

FINDING INCLUDE
During a tour of the facility with staff P, Q and R, at 10:40 AM , on May 10, 2012, it was observed that both stair exits to the north of the building went to a concrete pad, 8 feet by 8 feet. The nearest public way was approximately 100 feet to the north, Mineral Point Rd. The terrain would not allow a safe path to a public way since the surface is not an all weather hard surface.
When Surveyor 12187 asked if there was a path cleared of snow, staff R told Surveyor 12187 that no path to the north of building from the stairwells was cleared in the winter.


Item #5
NFPA 101, 2000 edition, 38.5.1 states " Utilities. Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 states " Electric. Electrical wire and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, 1999 edition, section 110-22 states " Identification of Disconnecting Means. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved .... "

Based on observation and staff interview, the facility failed to provide labeled circuit breakers in the electrical panel.

FINDING INCLUDE
During a tour of the facility with staff P, and Q, at 9:20 AM , on May 10, 2012, it was observed that the circuit breaker box in the I.T. Room did not have identification as to what circuits the circuit breakers served.

Item #6NFPA 101, 2000 edition, 38.3.6.1 states " Where access to exits is provided by corridors, such corridors shall be separated from use areas by halls having a fire resistance rating of not less than 1 hour in accordance with 8.2.3 ... ...
Exception No. 3: Within buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 " Section 9.7.1.1 states " Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. "

Based on observation and staff interview, the corridor walls are not built to a fire resistance of 1 hour because they are built out of glass. In addition, the facility failed to have a building that is fully sprinkled as noted with the findings.

FINDINGS INCLUDE:
During a tour of the facility with staff P, and Q, on May 10, 2012, it was observed that:
1) Full sprinkler coverage was not provided in the E.T. Consult room and Consult room #1 because a water shadow, where sprinkler coverage of the floor area did not happen, was formed by a wing wall blocking the spray pattern of the sprinkler. This was observed at 9:00 AM.
2) In the bottom of both stairs full sprinkler coverage was not provided because sprinkler coverage was not provided underneath the stairs. This was observed at 8:55 AM.

Item #7
NFPA 101, 2000 edition, 38.2.1.1 States " All means of egress shall be in accordance with Chapter 7 and this chapter. " Section 7.1.3.2.3 states " An exit enclosure shall not be used for any purpose that has the potential to interfere with it use as an exit and if so designated, an area of refuge.

Based on observation and staff interview, the exit stairs was used for other purposes other than exiting.

FINDINGS INCLUDE:
During a tour of the facility with staff P, Q and R on May 10, 2012 at 8:45 AM, it was observed that the west stair well had a bicycle being store in the stairwell at the main floor, which impeded the path of egress out of the stairs. In addition, the east stair well had a storage box containing an artificial Christmas tree stored underneath the stairs. Storage is not a purpose for the stairs.

Based on observation and interview, the facility (Building No. 2) did not provide a code compliant environment with and miscellaneous deficiencies. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect 102 of the 78 inpatients and 102 outpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/07/2012 at 1:06 pm surveyor #18107 observed in the Administration Area - SC1 smoke compartment on the 2nd floor in the Smoke Barrier (wall) between SC1 & SC2, that the smoke barrier (walls) were not all properly identified correctly. Above the ceiling, stenciling was missing for indicating what rating the wall assembly was, and that it was incorrectly identified on the life safety plans provided to the surveyors for there use during the tours. This caused confusion as to were the smoke barrier was coming from and where it was going to. This was confusing between SC1 & SC2 at several rooms. This observed situation was not compliant with NFPA 101 (2000 edition), 4.5.1 & 4.5.2 & 4.6.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

2. On 05/07/2012 at 2:33 pm surveyor #18107 observed in the Child & Adolescent Day Treatment - SC5 smoke compartment on the 1st floor in the Sally-Port & Garage, that The garage had latent exhaust fumes and gasoline smells upon entering, and observed there was no exhaust vent within the space. As the Health Care Surveyor who opened the 2008 Addition and approved it, I was told they would not be leaving vehicles running while within the garage. This is a 'changed condition' since the original opening of this garage, therefore an exhaust vent 'is required' per the building code to remove hazardous and noxious fumes from the space, caused by idling engines. This observed situation was not compliant with NFPA 101 (2000 edition), 4.5.1 & 4.5.2 & 4.6.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

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Based on observation and interview, the facility did not provide a code compliant environment under Miscellaneous Deficiencies. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 5 of the 21 staff that were working this day.

FINDINGS INCLUDE:
On 05/10/2012 at 10:58 am surveyor #18107 observed in the SC-6 smoke compartment on the 1st floor in the Corridor at smoke barrier, that the double doors separating the Experimental Therapy area from the Controlled Corridor in the Inpatient Sleeping area would not latch as originally designed. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.6. New Construction requirements. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a code compliant environment under the heading of Miscellaneous Deficiencies. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the 40 staff that were working in this building on the day of the survey.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:00 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Shell Space next to Plumbing Equipment Room, that this room was the old receiving dock and has been cut-off from the rest of the campus because of the new Tunnel and Corridor Link. The only entry is through another office. After review with the Owner no decision was made as to its future function, therefore it's to remain as 'shell space'. This space will need to be controlled and limited in access because storage materials could easily be placed within the room. No ventilation (fresh air) is currently supplied to this space. The Office adjacent this room appeared to be part of the old receiving dock and the air to this room was stagnant. This Office could not be verified with any air changes per hour, at time of survey, for a two person office. This is part of new construction and falls under Chapters 18.1.1.4.1 & 4.6.6. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 & 4.6.10.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:54 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that one of two eye solution bottles used in the event of a chemical spill within the eyes were missing in the Kitchen Production area. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 & 4.6.10.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a code compliant second exit access out of a Suite per Miscellaneous Deficiencies. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 3 of the 39 staff that were working this day.

FINDINGS INCLUDE:
On May 10, 2012, at 3:40 pm surveyor #18107 observed in the SC-17 smoke compartment on the Ground floor next to the New Inpatient Building Stair'A', that this New Stairway was suppose to be operational upon opening the New Inpatient Building (5/8/2012), based on the last construction inspection discussion on (4/28/2012), since the Annex Stairway was removed from service. If the Materials Management Suite is larger than 2,500 square feet, two (2) exits are required out of the Suite per 2000 NFPA 101, Section 19.2.5.3. This building is still considered a hospital after talking with the Chief Financial Officer and understanding the Building is holding Child and Adolescent Center (CAC) Programs at 2nd & 1st Floors of the South Wing within the Building and they plan to continue using a portion of the building for clinical and consultive care support to the patients in the future. This observed situation was not compliant with 3 of 39 staff persons present at the time of the finding. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with and electrical panels with complete directories. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the 40 staff that were working the day of the survey.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:12 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #C, #30 breaker was in an 'ON' position and not properly identified. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:49 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #K (R), breakers 6, 8, 10, 12, 35, 37, 39, & 41were not identified correctly. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On 05/11/2012 at 10:51 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #K(L), breakers 61, 65, 80, 82, 84 where in the 'ON' position, but noted as spares. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

4. On 05/11/2012 at 11:08 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Building Air Handling & ATS Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #A, breakers 17 & 22 were not identified correctly. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a 'common separation wall' with 90 minute fire rated doors & closers on all doors in the separation wall from outside building to outside building. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 6 of the 39 staff that were working.

FINDINGS INCLUDE:
On May 10, 2012, at 11:20 am surveyor #18107 observed in the SC-20 smoke compartment on the 1st floor in the Corridor between Child & Adolescent Center (CBRF) and Existing (Vacated) Psych Hospital, that the separation wall was non-compliant because it was not built to a 2-hour fire assembly requirement where two different Occupancies occur per 19.1.2.3 and 19.1.1.4. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 10 of the 39 staff that were working.

FINDINGS INCLUDE:
On May 10, 2012, at 3:55 pm surveyor #18107 observed in the SC-15 smoke compartment on the Ground floor in the Data & Storage Rooms, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included multiple ceiling tile panels out exposing the floor deck above. Upon looking up into the intersitial space above the open ceiling, Surveyor #18107 noticed a hole in the floor above. Penetration's adversely affect the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide corridor separation doors with compliant corridor doors, and double doors with an astragal seal. This deficiency occurred in 6 of the 9 smoke compartments, and had the potential to affect 31 of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/10/2012 at 9:22 am surveyor #18107 observed in the SC-1, SC-3, SC-5, SC-7 & SC-9 smoke compartments on the Lower level, 1st & 2nd floors in the Inpatient Sleeping Rooms, that the corridor was not compliant. The sleeping room corridor doors at all levels of the new Inpateint Sleeping Building do not have the continuous smoke-tight gasketing along the entire upper door edge meeting the limited combustibility requirements. The doors are double swing for emergency access. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/10/2012 at 11:00 am surveyor #18107 observed in the SC-6 smoke compartment on the 1st floor in the Closet of the Experimental Therapy area, that the room had double corridor doors with a gap greater than 1/8 inch at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with and changes in egress direction marked with exit signs. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 15 of the 40 staff that were working.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:40 am surveyor #18107 observed in the SC-11 smoke compartment on the 3rd floor in the Outdoor Porch, that egress was not readily apparent and an exit sign was not provided when persons are present out on the porch. The porch that is used by staff and guests on nice Summer and Fall Days is missing a exit sign on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:57 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Suite, that the change in direction in the path of egress was not readily apparent and an exit sign was not provided. The Kitchen Suite was missing a Exit Sign out of the primary exit egress of the Kitchen. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 16 of the 39 staff that were working this day.

FINDINGS INCLUDE:
On May 10, 2012, at 3:27 pm surveyor #18107 observed in the SC-16 smoke compartment on the Ground floor in the New Resident Storage Suite, that the path of egress in the corridor was not readily apparent and an Exit Sign was not provided near the 2nd exit access out of the Resident Storage Suite. The size of this Suite was not able to be determined at time of survey. Two exit access signage is required when Suite is larger than 2,500 square feet per NFPA 101, Section 19.2.10. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with taped joints on rated walls . This deficiency occurred in 2 of the 9 smoke compartments, and had the potential to affect 8 of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/10/2012 at 9:30 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Corridor at smoke barrier, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This was discovered at wall above ceiling in corridor between SC-2 & SC-1. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 1 of the 21 staff that were working in this building that day.

FINDINGS INCLUDE:
On 05/10/2012 at 9:50 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Information Technology (IT) Room, that penetration(s) were not sealed according to an approved method. The deficiency included penetrations through wall by hot and cold pipe lines. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide enclosures around exit stairs with stairwell requirements, and rated wall construction. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 23 of the 39 staff that were working, including the CBRF residents and CBRF Staff not identified in this report.

FINDINGS INCLUDE:
1. On May 10, 2012 at 11:28 am surveyor #18107 observed in the SC-18 smoke compartment on the 1st floor in the Midway Stair, that the stairwell was not compliant. The wall with door access separating the Midway Stair from the 1st Floor corridor did not provide sufficient landing depth on the stair side per 2000 NFPA 101, 19.2.2.3, 7.2.2.2.1(b) & 7.2.1.3. During the multi-phased construction project currently under way, these Stairs along with the Mail Room Stairs and Annex Stairs are suppose to be 'removed' because they are non-compliant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On May 10, 2012, at 3:35 pm surveyor #18107 observed in the SC-17 & SC-15 smoke compartments between the Ground, 1st, 2nd & 3rd floors in the Annex Stair & Mailroom Stair, that the stairwells were not compliant. The Annex Stairwell did not have the correct riser and tread dimensions for an existing stairs per NFPA 101, Table 7.2.2.2.1(b) and landings did not meet the requirements for Section 7.2.2.3.2 since the egress width was reduced at the landings due to heating elements at exterior walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On May 10, 2012, at 3:00 pm surveyor #18107 observed in the SC-15 smoke compartment on the Ground floor in the Mailroom Stairs, that the exit enclosure wall was not constructed to the required fire-rating. Stairwell wall adjacent to Electrical Room was missing at bottom of existing stairs. Electrical Room had high voltage switchgear equipment within room. Stairwell walls were damaged at one location exposing the stair structure under the plaster. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 30 pounds of force. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 1 of the 21 staff that were working in this building the day of the survey.

FINDINGS INCLUDE:
On 05/10/2012 at 9:39 am surveyor #18107 observed in the SC-2 smoke compartment on the 2nd floor in the Group Room, that the door in the path of egress would not open when a force of greater than 30 lbs. pressure was applied to the door to start it moving because the door was too tight when closed to the adjoining leaf and catching on the latching mechanism. 31 pounds pressure was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, Section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since existing CBRF patients may be incapable of self preservation and rely on a highly reliable fire alarm system to defend-in-place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This facility is 'in transition' as patients & CBRF residents leave the facility to new buildings being constructed. The facility did not provide a fire alarm system with smoke detectors properly placed at required locations. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 7 of the 39 staff that were working this day along with the Child & Adolescent Center (CBRF) residents within the building at 1st and 2nd Floors.

FINDINGS INCLUDE:
On May 10, 2012, at 11:35 am surveyor #18107 observed in the SC-18 smoke compartment on the 1st floor in the Physician Suite, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was observed 18 to 20 inches down on wall from the ceiling and should have been less than 12 inches but greater than 4 inches from ceiling but on the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation, interview and a review of documents, the facility (Building No. 2) did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 35 of the 78 inpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/07/2012 at 1:28 pm surveyor #18107 observed in the Partial Day area - SC2 smoke compartment on the 2nd floor in the Electrical Closet #2521, that there was one or more unsealed holes near the ceiling. The hole(s) included several 1/2 inch and 1 inch conduit holes were penetrating the ceiling near the wall. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a ceiling system sealed above the sprinkler(s) to collect heat. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect 26 of the 39 staff that were working as well as the Child & Adolescent Center (CBRF) Residents present in the facility this day.

FINDINGS INCLUDE:
1. On May 10, 2012, at 3:20 pm surveyor #18107 observed in the SC-15 & SC-16 smoke compartment on the Ground floor in the Data + Communication Room & CBRF Resident Laundry Room, that there was one or more unsealed holes near the ceiling. The hole(s) included ceiling panels were open in these areas at Ground Floor, which is showing a pattern in less used spaces. Automatic Sprinklers were present in these Hazardous Spaces. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On May 10, 2012, at 3:30 pm surveyor #18107 observed in the SC-16 smoke compartment on the Ground floor in the Materials Management Storage Room, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles out. These holes would reduce the response time of the sprinkler(s) in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the residents that were in the facility the day of the survey (and licensed to serve), as well as 40 staff and an unidentified number of visitors.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:35 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Unisex Toilet, that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:25 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Family Triage Storage Closet #1093, that there was one unsealed hole near the ceiling. The hole included a 1 inch opening. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On 05/11/2012 at 10:30 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Large Intake Office, that there was one unsealed hole near the ceiling. The hole included a 1 inch opening. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

4. On 05/11/2012 at 10:43 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Cooler, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Item #1
NFPA 101, 2000 edition 38.3.4.1 " General. A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exist:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject1to 300 or more total occupants "
Section 9.6 states " ...9.6.1.9 For the purpose of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following.
(a) Initiation The initiation function provides the input signal to the system.
(b) Notification The notification function is the means by which the system, advises that human action is required in response to a particular condition.
(c) Control The control function provides outputs to control building equipment to enhance protection of life.

Bases on observation, and staff interview (P and Q) the facility failed to provide a complete fire alarm system in accordance section 9.6.

FINDINGS INCLUDE
1) During of tour of the facility with staff P and Q on May 10, 2012, Surveyor 12187 observed: There are four occupied stores with a basement in the building with the first floor being the level of exit discharge. There are 3 pull stations and strobes and horns located at the 3 exit doors of the building. There are no other manual pull stations, horns or strobes in the lobby stair or in the ' business suite ' occupied by the provider. The horns and strobes by the 3 exits would not notify all persons in the ' suite ' . This is not a complete fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.
2) During a tour of the facility and review of the maintenance records, there was no record of testing of the fire alarm system. This was observed at 9:37 AM on May 10, 2012 with staff P and Q present.

Item #2
NPFA 101, 2000 edition 38.5.2 state " Heating, Ventilating and Air Conditioning. Heating, ventilating, and air conditioning equipment shall comply with the provisions of Section 9.2 "
Section 9.2.1 states " Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems ... "
NFPA 90A, 1999 edition 3-4.7 states " Maintenance. At least every 4 years fusible links (where applicable) shall be removed, all dampers shall be operated to verify that they fully close, the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. "

Based on observation, staff interview and record review, the facility failed to provide maintenance on the fire dampers in accordance with NFPA 90A.

FINDINGS INCLUDE
During the tour the facility with staff P, Q, and R on May 10, 2012 at 10:20 AM, staff R stated to Surveyor 12187 that there were no records of testing of the fire dampers. No records were produced. Staff R stated that no fire damper tests were done since his company owned the building and the previous owner did not leave any record of test of the fire dampers.


Item #3
NFPA 101, 2000 edition, 38.2.8 states " Illumination of Means of Egress. Means of Egress shall be illuminated in accordance with Section 7.8. Section 7.8.1.2 states " Illumination of the means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress shall be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria value herein specified.

Based on observation and record review and interviews, the facility failed to provide operating light and provide maintenance on the emergency lights in the path of egress.

FINDINGS INCLUDE
During the tour of the facility with staff P, Q, and R at 10:30 AM on May 10, 2012 it was observed that the emergency light near the nurse station did not light up when the test button was pushed by Surveyor 12187. Surveyor then asked for records of testing of the emergency lights. Staff P, Q, and R did not know of any testing that was done.


Item #4
NFPA 101, 2000 edition, 38.2.7 states " Discharge from Exits. Exit discharge shall comply with Section 7.7. Section 7.71 states, " Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be required width and size to provide all occupants with a safe access to a public way. "

Based on observation, and interviews the facility failed to provide a safe path to a public way out of the 2 stairs (exits) to the north of the building.

FINDING INCLUDE
During a tour of the facility with staff P, Q and R, at 10:40 AM , on May 10, 2012, it was observed that both stair exits to the north of the building went to a concrete pad, 8 feet by 8 feet. The nearest public way was approximately 100 feet to the north, Mineral Point Rd. The terrain would not allow a safe path to a public way since the surface is not an all weather hard surface.
When Surveyor 12187 asked if there was a path cleared of snow, staff R told Surveyor 12187 that no path to the north of building from the stairwells was cleared in the winter.


Item #5
NFPA 101, 2000 edition, 38.5.1 states " Utilities. Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 states " Electric. Electrical wire and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, 1999 edition, section 110-22 states " Identification of Disconnecting Means. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved .... "

Based on observation and staff interview, the facility failed to provide labeled circuit breakers in the electrical panel.

FINDING INCLUDE
During a tour of the facility with staff P, and Q, at 9:20 AM , on May 10, 2012, it was observed that the circuit breaker box in the I.T. Room did not have identification as to what circuits the circuit breakers served.

Item #6NFPA 101, 2000 edition, 38.3.6.1 states " Where access to exits is provided by corridors, such corridors shall be separated from use areas by halls having a fire resistance rating of not less than 1 hour in accordance with 8.2.3 ... ...
Exception No. 3: Within buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 " Section 9.7.1.1 states " Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. "

Based on observation and staff interview, the corridor walls are not built to a fire resistance of 1 hour because they are built out of glass. In addition, the facility failed to have a building that is fully sprinkled as noted with the findings.

FINDINGS INCLUDE:
During a tour of the facility with staff P, and Q, on May 10, 2012, it was observed that:
1) Full sprinkler coverage was not provided in the E.T. Consult room and Consult room #1 because a water shadow, where sprinkler coverage of the floor area did not happen, was formed by a wing wall blocking the spray pattern of the sprinkler. This was observed at 9:00 AM.
2) In the bottom of both stairs full sprinkler coverage was not provided because sprinkler coverage was not provided underneath the stairs. This was observed at 8:55 AM.

Item #7
NFPA 101, 2000 edition, 38.2.1.1 States " All means of egress shall be in accordance with Chapter 7 and this chapter. " Section 7.1.3.2.3 states " An exit enclosure shall not be used for any purpose that has the potential to interfere with it use as an exit and if so designated, an area of refuge.

Based on observation and staff interview, the exit stairs was used for other purposes other than exiting.

FINDINGS INCLUDE:
During a tour of the facility with staff P, Q and R on May 10, 2012 at 8:45 AM, it was observed that the west stair well had a bicycle being store in the stairwell at the main floor, which impeded the path of egress out of the stairs. In addition, the east stair well had a storage box containing an artificial Christmas tree stored underneath the stairs. Storage is not a purpose for the stairs.

Based on observation and interview, the facility (Building No. 2) did not provide a code compliant environment with and miscellaneous deficiencies. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect 102 of the 78 inpatients and 102 outpatients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/07/2012 at 1:06 pm surveyor #18107 observed in the Administration Area - SC1 smoke compartment on the 2nd floor in the Smoke Barrier (wall) between SC1 & SC2, that the smoke barrier (walls) were not all properly identified correctly. Above the ceiling, stenciling was missing for indicating what rating the wall assembly was, and that it was incorrectly identified on the life safety plans provided to the surveyors for there use during the tours. This caused confusion as to were the smoke barrier was coming from and where it was going to. This was confusing between SC1 & SC2 at several rooms. This observed situation was not compliant with NFPA 101 (2000 edition), 4.5.1 & 4.5.2 & 4.6.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

2. On 05/07/2012 at 2:33 pm surveyor #18107 observed in the Child & Adolescent Day Treatment - SC5 smoke compartment on the 1st floor in the Sally-Port & Garage, that The garage had latent exhaust fumes and gasoline smells upon entering, and observed there was no exhaust vent within the space. As the Health Care Surveyor who opened the 2008 Addition and approved it, I was told they would not be leaving vehicles running while within the garage. This is a 'changed condition' since the original opening of this garage, therefore an exhaust vent 'is required' per the building code to remove hazardous and noxious fumes from the space, caused by idling engines. This observed situation was not compliant with NFPA 101 (2000 edition), 4.5.1 & 4.5.2 & 4.6.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

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Based on observation and interview, the facility did not provide a code compliant environment under Miscellaneous Deficiencies. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect 5 of the 21 staff that were working this day.

FINDINGS INCLUDE:
On 05/10/2012 at 10:58 am surveyor #18107 observed in the SC-6 smoke compartment on the 1st floor in the Corridor at smoke barrier, that the double doors separating the Experimental Therapy area from the Controlled Corridor in the Inpatient Sleeping area would not latch as originally designed. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.6. New Construction requirements. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a code compliant environment under the heading of Miscellaneous Deficiencies. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the 40 staff that were working in this building on the day of the survey.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:00 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Shell Space next to Plumbing Equipment Room, that this room was the old receiving dock and has been cut-off from the rest of the campus because of the new Tunnel and Corridor Link. The only entry is through another office. After review with the Owner no decision was made as to its future function, therefore it's to remain as 'shell space'. This space will need to be controlled and limited in access because storage materials could easily be placed within the room. No ventilation (fresh air) is currently supplied to this space. The Office adjacent this room appeared to be part of the old receiving dock and the air to this room was stagnant. This Office could not be verified with any air changes per hour, at time of survey, for a two person office. This is part of new construction and falls under Chapters 18.1.1.4.1 & 4.6.6. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 & 4.6.10.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:54 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that one of two eye solution bottles used in the event of a chemical spill within the eyes were missing in the Kitchen Production area. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 & 4.6.10.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide a code compliant second exit access out of a Suite per Miscellaneous Deficiencies. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 3 of the 39 staff that were working this day.

FINDINGS INCLUDE:
On May 10, 2012, at 3:40 pm surveyor #18107 observed in the SC-17 smoke compartment on the Ground floor next to the New Inpatient Building Stair'A', that this New Stairway was suppose to be operational upon opening the New Inpatient Building (5/8/2012), based on the last construction inspection discussion on (4/28/2012), since the Annex Stairway was removed from service. If the Materials Management Suite is larger than 2,500 square feet, two (2) exits are required out of the Suite per 2000 NFPA 101, Section 19.2.5.3. This building is still considered a hospital after talking with the Chief Financial Officer and understanding the Building is holding Child and Adolescent Center (CAC) Programs at 2nd & 1st Floors of the South Wing within the Building and they plan to continue using a portion of the building for clinical and consultive care support to the patients in the future. This observed situation was not compliant with 3 of 39 staff persons present at the time of the finding. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with and electrical panels with complete directories. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect 21 of the 40 staff that were working the day of the survey.

FINDINGS INCLUDE:
1. On 05/11/2012 at 10:12 am surveyor #18107 observed in the SC-13 smoke compartment on the 1st floor in the Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #C, #30 breaker was in an 'ON' position and not properly identified. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

2. On 05/11/2012 at 10:49 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #K (R), breakers 6, 8, 10, 12, 35, 37, 39, & 41were not identified correctly. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

3. On 05/11/2012 at 10:51 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Kitchen Production area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #K(L), breakers 61, 65, 80, 82, 84 where in the 'ON' position, but noted as spares. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

4. On 05/11/2012 at 11:08 am surveyor #18107 observed in the SC-14 smoke compartment on the Ground floor in the Building Air Handling & ATS Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #A, breakers 17 & 22 were not identified correctly. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).

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