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Based on observation and interview, the facility did not provide wall construction to protect the corridor from non-corridor spaces with staff supervision or smoke detection with spaces that are open to the corridor. This deficiency occurred in 10 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/04/15 at 2:02 pm surveyor observed on the Tenth floor in the Video GG Monitoring Space, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101section 19.3.6.1.

2. On 05/05/15 at 2:35 pm surveyor observed on the Third floor in Waiting area 5, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

3. On 05/05/15 at 3:30 pm surveyor observed on the Second floor in lounge K2-L24-42, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

4. On 05/05/15 at 3:40 pm surveyor observed on the Second floor in dining N2-F2257, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

5. On 05/07/15 at 10:00 am surveyor observed on the 11th floor in patient lounge K-11-L11432, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and smoke detection in spaces that are open to the corridor. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 15 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 11:07 am it was observed in the 1NW smoke compartment on the 1st floor in the #1075 corridor, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included wall membrane that did not extend to the underside of the deck, unsealed joints and screws. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1.

2. On 5-5-2015 at 11:10 am it was observed in the 1NW smoke compartment on the 1st floor in the #1077 corridor, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included wall membrane that did not extend to the underside of the deck, unsealed joints and screws. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1.

3. On 5-6-2015 at 10:41 am it was observed in the 5CW smoke compartment on the 5th floor in the #5529 Pharmacy room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware and did not provide doors suitable to resist the passage of smoke. This deficiency occurred in 8 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/04/15 at 1:50 pm, surveyor observed on the 11th floor, in Patient room L11424, that the corridor door would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

2. On 05/04/15 at 2:35 pm, surveyor observed on the 6th floor, that the corridor door K6-02-F1 would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

3. On 05/06/15 at 1:30 pm, surveyor observed on the 1st Floor NICU the double corridor doors K-1-L1400A defining the suite had a ¼ inch gap between the door leaves. Per NFPA 101 section 19.3.6.3.1, the facility must ensure all doors protecting the corridors are suitable for resisting the passage of smoke. Per CMS memorandum S&C 07-18, the gap is permitted to exceed 1/8-inch provided that the meeting edges of the leaves are equipped with an astragal, rabbet, or a bevel.

4. On 05/07/15 at 11:00 am, surveyor observed on the 8th floor, that the corridor doors T8113 would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide compliant corridor separation doors. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 30 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 5-5-2015 at 2:02 pm it was observed in the 2S smoke compartment on the 2nd floor in the #3101 Storage room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2.

2. On 5-5-2015 at 11:07 am it was observed in the 1NW smoke compartment on the 1st floor in the #1075 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

3. On 5-5-2015 at 11:10 am it was observed in the 1NW smoke compartment on the 1st floor in the #1077 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Asst).

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Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 10:36 am surveyor observed on the Second floor in the North Suite Entrance, that the door to the corridor was held open with a wood chuck at the suite door. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with and doors with positive-latching hardware. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 30 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 3:35 pm, it was observed in the 3NE smoke compartment on the 3rd floor in the Stair #13, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The pair of doors were misaligned to effectively latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

2. On 5-5-2015 at 2:33 pm, it was observed in the 3SE smoke compartment on the 3rd floor in the Stair #4, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The strike of the door frame was covered with tape to prevent the latch from engaging. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), and staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Assit).


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Based on observation and interview, the facility did not ensure that 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 2 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/04/15 at 3:35 pm, surveyor observed on the 3rd floor smoke between smoke compartment 1 and 2, that the path of egress in the corridor was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 section 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with and sealed wall penetrations. This deficiency occurred in 4 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 8:32 am surveyor observed on the Basement floor in the LL-FD 035, that penetration(s) were not sealed according to according to an approved method. The deficiency included a hole in wall where a clock was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC) and staff VVV (Supervisor Facilities ASLSS).

2. On 05/05/2015 at 8:50 am surveyor observed on the Basement floor in the Credential Records Room, that penetration(s) were not sealed according to according to an approved method. The deficiency included 2" x 2" hole in the ceiling tile. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

3. On 05/05/2015 at 11:29 am surveyo observed on the Basement floor in the Nursing Education Classroom, that penetration(s) were not sealed according to according to an approved method. The deficiency included a clock on wall that does not cover the wall opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

4. On 05/05/2015 at 2:58 pm surveyor observed on the First floor in the SD-TC Office, that penetration(s) were not sealed according to according to an approved method. The deficiency included a hole in wall where a clock was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke barrier doors within clearances for proper operation. This deficiency occurred in 2 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/15 at 2:00 pm the surveyor observed on the 3rd floor in the Corridor at Smoke Barrier Doors C3-06-S1, that the pair of cross-corridor smoke barrier doors had a meeting edge clearance greater than 1/8" as defined for proper clearance and operation of smoke barrier doors. The doors were fire rated with an approximate clearance of 1/4" gap clearance between the meeting edges of the two smoke barrier doors. This observed situation was not compliant with NFPA 101 sections 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with and self closing hardware. This deficiency occurred in 2 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 8:20 am surveyor observed on the Basement floor in the LL-FD 010, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors does not work. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

2. On 05/05/2015 at 2:05 pm surveyor observed on the First floor in the IF-FD 015, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors did not allow the doors to close. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and staff interview, the facility did not provide the required separation of hazards from other use areas. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

Findings include:

1. On 05/04/15 at 2:43 pm, surveyor observed that a room was used for combustible storage and the access door C6-H6361 did not have an automatic door closer installed. The combustibles included personnel lockers and facility storage materials of a combustible nature. Per NFPA 101 Section 19.3.2.1, the facility must ensure all rooms or spaces greater than 50 square feet used for storage of combustible supplies and equipment deemed hazardous by the authority having jurisdiction mush be separated from other use areas. All doors to hazards areas must automatically close and latch when released. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency occurred in 11 of the 42 smoke compartments, and had the potential to affect 80 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-6-2015 at 9:42 am it was observed in the 4NE smoke compartment on the 4th floor in the #4634 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was used for storing approximately (75) seventy five cardboard file boxes. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

2. On 5-6-2015 at 9:54 am it was observed in the 4SE smoke compartment on the 4th floor in the #4617 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

3. On 5-6-2015 at 9:58 am it was observed in the 4C smoke compartment on the 4th floor in the #4116 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

4. On 5-6-2015 at 10:49 am it was observed in the 5C smoke compartment on the 5th floor in the #5506 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

5. On 5-6-2015 at 10:52 am it was observed in the 5CW smoke compartment on the 5th floor in the #5507 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was used for storing stacks of folded down cardboard boxes and a large quantity of foam packing material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

6. On 5-6-2015 at 8:30 am it was observed in the 4SW smoke compartment on the 4th floor in the #4324 Storage room, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The door had a 1 1/2" hole where the lockset had been removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

7. On 5-5-2015 at 8:35 am it was observed in the BSW smoke compartment on the Basement floor in the #0907 Environmental Services, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (2) 1" diameter holes with conduit and a 2" fire protection system pipe penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

8. On 5-5-2015 at 8:39 am it was observed in the BSW smoke compartment on the Basement floor in the #0905 Office, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration and a 10" x 20" duct penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

9. On 5-5-2015 at 8:45 am it was observed in the BSW smoke compartment on the Basement floor in the #0902 Male Locker room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration and (1) 2" pipe penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

10. On 5-5-2015 at 8:52 am it was observed in the BNE smoke compartment on the Basement floor in the #8803 Central Supply room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included multiple pipe penetrations, structural penetrations and unfinished joints. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

11. On 5-5-2015 at 9:02 am it was observed in the BNE smoke compartment on the Basement floor in the #0800 Central Supply room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included multiple pipe penetrations, structural penetrations and unfinished joints. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

12. On 5-5-2015 at 9:16 am it was observed in the BNE smoke compartment on the Basement floor in the #0804 Elevator Equipment room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included 2" x 4" hole and (2) 1" conduit penetrations. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

13. On 5-5-2015 at 9:51 am it was observed in the BPOB smoke compartment on the Basement floor in the #C010 electrical vault, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1" conduit penetration and (1) 2" diameter hole in the CMU wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

14. On 5-5-2015 at 10:10 am it was observed in the 1S smoke compartment on the 1st floor in the Stair #12, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration, (2) 1" conduit penetrations and joints not sealed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

15. On 5-4-2015 at 3:45 pm it was observed in the BNW smoke compartment on the Basement floor in the #0919 electrical room, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. The walls were labeld as 1-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3.

16. On 5-5-2015 at 9:55 am it was observed in the BPOB smoke compartment on the Basement floor in the #C010 electrical vault, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. The walls were labeld as 1-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Asst).


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Based on observation and interview, the facility did not provide two exits for each floor or fire section. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 11:30 am, observation revealed on the 8th floor in the healing garden exit into corridor S8502, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt thumb turns on each leaf of this required exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and staff interview, the facility did not ensure that exit access doors remain identifiable as readily open-able from the inside, from which egress is to be made, at all times as required per NFPA 101 Life Safety Code sections 19.2. This deficiency occurred in 4 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

Findings include:

1. On 05/05/15 at 1:50 pm, surveyor observed within the SICU Unit on the third floor, that the double set of exit access doors in the corridor, were equipped with 15-second "delayed exit" magnetic locking devices. One of the two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

2. On 05/05/15 at 3:30 pm, surveyor observed within the NICU Unit on 2L Knisely second floor, that the double set of exit access doors in the corridor, are equipped with 15-second "delayed exit" magnetic locking devices. One of the two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

3. On 05/05/15 at 4:10 pm, surveyor observed within wing 2C on the second floor, that the double set of exit access doors in the corridor, are equipped with 15-second "delayed exit" magnetic locking devices. Two of two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

4. On 05/05/15 at 3:05 pm, surveyor observed within the emergency department on the second floor, that door OP2-25A was marked as an Exit yet was not readily accessible. The door was equipped with a magnetic locking device that did not meet any of the three exceptions for locking arrangements of NFPA 101 section 19.2.2.2.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures and properly instructed. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/06/15 at 9:35 am, surveyor observed during a review of facility fire drill reports for the prior 12 months that fire drills did not include participation by all applicable facility personnel. Selective facility staff were substantiated to have participated via facility documented fire reporting documents and was not in compliance with NFPA 101 section 19.7.2.1 which requires drills to be conducted quarterly on each shift to familiarize facility personnel ( nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. Selective facility staff documentation was also not in compliance with NFPA 101 section 19.7.2.3 which requires " All " health care occupancy personnel to be instructed in the use and response of fire alarms. This observed situation was not compliant with NFPA 101 section 19.7. The condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

Based on a review of hospital records, fire drills were not conducted quarterly on each shift. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/2015 at 2:34 pm surveyor observed that during a review of facility documents the fire drill reports showed that fire drills were not conducted quarterly on every shift. Fire drills were not documented for the third shift, second quarter or for the second shift, fourth quarter. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency occurred in 25 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/06/15 at 11:37 am, surveyor observed on the Basement floor in a fire alarm panel room, that a smoke detector was not located in accordance with NFPA 72 requirements. The room was not normally occupied and confirmed to contain a fire alarm control unit, yet no smoke detector located in the room as required according to NFPA 72 - 1999 edition Section 1-5.6. This observed situation was not compliant with NFPA 101 section 9.6.1.4 and NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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 deficiency occurred in 30 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

Findings include:

1. On 05/06/15 at 11:30 am, survey observed on the basement floor, that elevator machine room NB-65-F1 was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The machine room contained combustible hydraulic fluid and did not meet an exception for sprinkler protection. This condition was applicable to additional elevator machine rooms.

2. On 05/06/15 at 2:40 pm, survey observed on the basement floor, that service elevators 17, 18, and 19 were not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pits were directly observed to contain a hydraulic fluid delivery system and did not meet the sprinkler requirement of NFPA 13 section 5-13.6.1. Contracted elevator personnel from Schindler substantiated the top of the shafts were also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. This condition was applicable to additional existing elevators within the facility. The facility could not substantiate the car enclosure non-combustibility to American Society of Mechanical Engineering (ASME) - 17.1, nor that the hydraulic fluid was non-combustible.

3. On 05/06/15 at 2:30 pm, survey observed on the basement floor, that service elevator P for Central Storage transport was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pit was directly observed to not be sprinkler protected. Contracted elevator personnel from Schindler substantiated the top of the shaft was also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. The facility could not substantiate the car enclosure non-combustibility to ASME - 17.1.

4. On 05/06/15 at 11:10 am, survey observed on the basement floor, that the loading dock, trash compactor, and cardboard recycling compactor space were not sprinkler protected. This space is enclosed on three sides, is approximately 50 ft. wide and 100 ft. in depth, and is located under a fully sprinkler protected receiving department located on the first level directly above this loading dock / compactor space. Combustibles present at the time of survey were 2 - 25 cubic yard trash compactors, 1 - 30 cubic yard cardboard compactor, and 1 pick-up truck. The two bay semi-trailer loading dock was not observed to have any vehicles at the time of the survey, yet is actively used for hospital purposes. Per NFPA 13 - 1999 section 5-13.8, sprinklers shall be installed under exterior roofs and canopies greater than 4 foot wide attached to sprinkler protected structures containing combustible storage.

5. On 05/06/15 at 3:05 pm, survey observed on the sub-basement floor, that bottom of Stair L was not sprinkler protected per NFPA 13 section 5-13.3.2.

6. On 05/07/15 at 11:45 am, surveyor observed that a dedicated electrical room TM-16-F2 for UPS 5 on 6th floor was being used for combustible storage and was not sprinkler protected. The combustibles included a craftsman constructed four section wood ramp of common 2 x 6 dimensional lumber. The combustibles identified nullified the exception for sprinkler protection per NFPA 13 section 5-13.11.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers at required exterior locations, sprinklers that were too far from the ceiling, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 9 of the 42 smoke compartments, and had the potential to affect all of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 10:07 am it was observed in the 1S smoke compartment on the 1st floor in the Loading Dock, that sprinkler protection was not provided at the loading dock roofed area. The roofed area is subject to protection based on NFPA 13-1999 s. 5-13.7 This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.7.

2. On 5-5-2015 at 3:02 pm it was observed in the 3NE smoke compartment on the 3rd floor in the #3066 Electrical closet, that the sprinkler was placed farther than 22" below the ceiling. The pendant fire protection sprinkler head was (7') seven feet below the ceiling deck. This situation would delay release of water and does not satisfy listing. Requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1.

3. On 5-4-2015 at 3:35 pm it was observed in the BSW smoke compartment on the Basement floor in the #0932 kosher kitchen room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included several cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

4. On 5-5-2015 at 9:31 am it was observed in the BC smoke compartment on the Basement floor in the #0401 closet, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

5. On 5-5-2015 at 9:39 am it was observed in the BC smoke compartment on the Basement floor in the #0412 Information Services room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

6. On 5-5-2015 at 1:24 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2721 Electrical room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

7. On 5-6-2015 at 10:15 am it was observed in the 4SW smoke compartment on the 4th floor in the #4500 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

8. On 5-6-2015 at 10:25 am it was observed in the 5C smoke compartment on the 5th floor in the #5503 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

9. On 5-6-2015 at 10:31 am it was observed in the 5S smoke compartment on the 5th floor in the #5301 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

10. On 5-6-2015 at 9:34 am it was observed in the 4NE smoke compartment on the 4th floor in the #4126 Electrical Vault, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling, and unobstructed water distribution. This deficiency occurred in 3 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 9:44 am surveyor observed on the Basement floor in the LL Fitness Room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The area above the Fitness Room ceiling is open to a hazardous area and is not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

2. On 05/05/2015 at 1:13 pm surveyor observed on the First floor in the Day Surgery Room 8, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

3. On 05/05/2015 at 3:12 pm surveyor observed on the First floor in the Gift Shop Storage, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included items stored within 18" of the sprinkler. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation, interview, and record review the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection and testing program as required by NFPA 101 section 9.7.5 for NFPA 13 - 1999 Edition systems to NFPA 25 - 1998 Edition standards. The sprinkler systems had a water storage tank that was not tested, sprinklers without properly installed escutcheon rings, and sprinklers were not free of foreign material. This deficiency occurred in 100 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/07/15 at 10:30 am, the surveyor observed during a review of facility documents that the hyperbaric chamber fire suppression system tanks was not tested and was not documented per NFPA 25 Chapter 6, NFPA 99 (1999 Edition) section 19-2.1.2 and NFPA 101 section 9.7.5. The interior of the tanks were not inspected in the last five years per NFPA 25 sections 6-2.4, 6-3.7. The level indicators were not tested in the last five years for accuracy and freedom of movement per NFPA 25 section 6-3.1. The pressure gauges were not tested in the last five years with a calibrated gauge in accordance with the manufacturer ' s instructions. Gauges also were not tested to verify accuracy within 3 percent of the scale to substantiation recalibration or replaced per NFPA 25 section 6-3.6. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

2. On 05/07/15 at 2:30 pm, the surveyor observed during a review of facility documents that sprinkler gauges and pipe obstruction investigations were not tested in accordance with NFPA 25. Gauges were not replaced and were not tested in the last five years per NFPA 25 section 2-3.2. Pipe obstruction investigations were not conducted in the last five years per NFPA 25 Table 2-1 and section 10-2.2. Facility recorded indicated the last year for these events occurred in 2009. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, and staff QQQ.

3. On 05/06/15 at 10:46 am, the surveyor observed in the Basement floor in corridor east of Room 222, that a row of sidewall sprinklers had dirt and lint accumulation on their fusible links. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, staff QQQ, and staff RRR.

4. On 05/06/15 at 10:40 am, the surveyor observed in the Basement floor in Room 222, that two freezer sprinklers had displaced or improperly installed escutcheon rings. Freezer N-FRZ-905 had condensation dripping through and freezing on the sprinklers. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, staff QQQ, and staff RRR.

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, sprinklers free of lint, the appropriate quantity of spare sprinklers, and a wrench in the spare sprinkler cabinet. This deficiency occurred in 6 of the 42 smoke compartments, and had the potential to affect all of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-4-2015 at 3:19 pm it was observed in the BSW smoke compartment on the Basement floor in the #0938 dish wash room, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1.

2. On 5-5-2015 at 9:33 am it was observed in the BC smoke compartment on the Basement floor in the #0401 corridor, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1.

3. On 5-5-2015 at 9:41 am it was observed in the BC smoke compartment on the Basement floor in the #0416 Telecommunications room, that there was one or more unsealed holes near the ceiling. The hole(s) included (4) 6" x 6", (1) 6" x 12" and (2) 6" x 10" holes. 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.

4. On 5-5-2015 at 11:21 am it was observed in the 1CW smoke compartment on the 1st floor in the #1730 Emergency Entrance vestibule, that there was one or more unsealed holes near the ceiling. The hole(s) included a 24" x 24" ceiling tile. 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.

5. On 5-5-2015 at 9:37 am it was observed in the BC smoke compartment on the Basement floor in the #0412 Information Services room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12" x 12", a 24" x 48" and 24" x 24" 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.

6. On 5-5-2015 at 1:14 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2702 Staff room, 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.

7. On 5-5-2015 at 1:16 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2738 Housekeeping room, 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.

8. On 5-5-2015 at 9:25 am it was observed in the BNW smoke compartment on the Basement floor in the #0942 Sprinkler Riser room, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for recessed fire protection sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4.

9. On 5-5-2015 at 9:25 am it was observed in the BNW smoke compartment on the Basement floor in the #0942 Sprinkler Riser room, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


______________________________________

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, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 12 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 1:05 pm surveyor observed on the First floor in the Day Surgery Soiled Utility, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

2. On 05/06/2015 at 9:42 am surveyor observed on the First floor in the ICU Locker, that the escutcheon ring on the sprinkler was ceiling open at the sprinkler head. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

3. On 05/05/2015 at 8:34 am surveyor observed on the Basement floor in the Autopsy Parts Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tiles that were out of the grid. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC) and staff VVV (Supervisor Facilities ASLSS).

4. On 05/05/2015 at 8:48 am surveyor observed on the Basement floor in the Credential Records Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 2" hole in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

5. On 05/05/2015 at 9:55 am surveyor observed on the Basement floor in the Containment LL-FD 035, that there was one or more unsealed holes near the ceiling. The hole(s) included 13 pipes through the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

6. On 05/05/2015 at 11:05 am surveyor observed on the Basement floor in the Telephone Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 12 holes in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

7. On 05/05/2015 at 11:31 am surveyor observed on the Basement floor in the Chief Nursing Officer Office, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tiles that were out of the grid. These openings 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

8. On 05/05/2015 at 1:06 pm surveyor observed on the First floor in the Electrical Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile was missing. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

9. On 05/05/2015 at 4:00 pm surveyor observed on the First floor in the Lab Dish Room, that there was one or more unsealed holes near the ceiling. The hole(s) included ceiling tiles out of grid and openings where pipes penetrate ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

10. On 05/05/2015 at 4:02 pm surveyor observed on the First floor in the Lab Back Storage, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 2 tile out of the grid. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

11. On 05/06/2015 at 9:20 am surveyor observed on the First floor in the Angeo Equipment Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 4" wide gap in the ceiling tile for the length of the room. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

12. On 05/06/2015 at 9:33 am surveyor observed on the First floor in the ICU Nurse Call Closet, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile that was out of the grid and openings in the ceiling tiles. These openings 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

13. On 05/06/2015 at 10:43 am surveyor observed on the Second floor in the Film Processing, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3" hole in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

14. On 05/06/2015 at 10:50 am surveyor observed on the Second floor in the Medical Records, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile out of place. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

15. On 05/05/2015 at 10:01 am surveyor observed on the Basement floor in the Central Supply - Soiled room, that there were 4 sprinkler heads painted. These painted heads 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), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

16. On 05/05/2015 at 10:04 am surveyor observed on the Basement floor in the Central Supply - Clean room, that there were 3 sprinkler heads painted. These painted heads 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), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

17. On 05/06/2015 at 11:09 am surveyor observed on the Second floor in the Utility Storage Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 4 ceiling tile missing. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

18. On 05/06/2015 at 1:06 pm surveyor observed on the First floor in the Housekeeping CLoset, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile that is out of the grid. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

19. On 05/06/2015 at 2:02 pm surveyor observed on the Fourth floor in the 4 North Laundry, that there was lint on the sprinkler head. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

20. On 05/05/2015 at 1:19 pm surveyor observed on the First floor in the Day Surgery Resource Room, that there was lint on the sprinkler head. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 9:45 am surveyor observed on the First floor in the ICU PCM Office, that a fire extinguisher was not accessible for immediate use because a cart was in front of the electrical panel. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 5-5-2015 at 10:48 am it was observed in the 1NE smoke compartment on the 1st floor in the #1822 Clean Utility room, that the clear and unobstructed width of the corridor was blocked with a number of cardboard boxes and stored wheelchairs. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.10.
The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 8:21 am surveyor observed on the First floor in the Corridor of the Surgical Suite, that the clear and unobstructed width of the corridor was obstructed by twelve large pieces of equipment that were stored in the exit corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).
2. On 05/05/2015 at 10:40 am surveyor observed on the Basement floor in the Stair E-2 First Floor, that the travel out of the stairwell was interrupted to prevent travel to the building discharge. A wheelchair was blocking a stair exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with verification of rated hanging materials. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 11:10 am surveyor observed on the Second floor in the All Clinic Rooms, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. The cubicle curtains do not have a flame resistant tag. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.1 and 10.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview the facility did not maintain a patient medical air alarm panel in a reliable operating condition nor was the panel removed per NFPA 101 sections 19.3.2.4, 4.6.12.2 and NFPA 99. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/15 at 2:15 am, surveyor observed on the 3rd Floor in the operating room control room that a medical air alarm panel was nonfunctional nor maintained in a reliable operating condition. The medical air alarm panel was clearly observable by the facility staff, and in the event of an emergency; fire department personnel. The medical air alarm panel did not display any information and facility staff confirmed the panel was non-functional. This observed situation was not compliant with NFPA 101 section 4.6.12.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Item 1:
Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, sections 4.6.12.2 and 9.7.1.1. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients rely on a highly reliable sprinkler system for safety. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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 deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 8:41 am, surveyor observed on the 2nd floor in the pharmacy room, that a sprinkler head was located approximately four feet from another sprinkler head. Sprinklers cannot be closer to each other than the minimum required separation distance of 6'-0". This observed situation was not compliant with NFPA 13 (1999 edition), section 5-6.3. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 2:
Based on observation and interview, the facility did not ensure that the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent as required by NFPA 101 sections 39.2.10 and 7.10.1.2. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 9:05 am, surveyor observed on the 1st floor inside the central exit stair, that an occupant could continue beyond the intended 1st floor exit discharge level and proceed to the basement level. Similarly, occupants from the basement level are required to access this central stair, when proceeding upward to the intended 1st floor exit discharge level may proceed up to the second level. The 1st floor exit discharge level is not obvious, nor clearly identified within the central exit stair. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 3:
Based on observation and interview, the facility did not ensure that the means of egress was arranged that exits are readily accessible at all time as required by NFPA 101 sections 39.2.1.1 and 7.1. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 8:40 am, surveyor observed at the 1st floor entry vestibule, was a required exit yet had a storefront bi-parting sliding door system with a dead-bolt latching device. The dead-bolt latch was tested and it positively latched into the adjoining sliding door panel and would prohibit access to the required exterior exit discharge. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 4:
Based on observation and interview, the facility did not ensure that the means of egress was provided with a reliable means of illumination as required by NFPA 101 sections 39.2.8 and 7.8. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 9:40 am, surveyor observed at the basement floor North central exit that the failure of any single lighting fixture will leave the required exit discharge in darkness. The fixture did not contain a redundant light fixture. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Based on observation and interview, the facility did not keep records indicating that, when tested, the time for the emergency powers transfers, required to be in 10 seconds or less, was not documented. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/2015 at 2:36 pm surveyor observed that during a review of facility documents, the time for the generator to start could not be verified as being within the 10 second maximum. no records were found to confirm that the auto transfer switch transferred power in less than 10 seconds This observed situation was not compliant with NFPA 110 (1999 edition), 3-4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and staff interview, the facility did not provide electrical wiring that complies with NFPA 70, Article 305-3(a), 305(6)(b) and UL 1363, because six plug power strips or relocatable power taps (RPT) are used to supply power to non-computer related devices. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/15 at 1:45 pm, surveyor observed on the 1st Floor ACL Main Lab had two six plug power strips or relocatable power taps (RPT ' s) supplying power to five to six commercial grade laboratory testing pieces of equipment. The RPTs ' present can only be used to supply power to computers and computer peripherals per NFPA 70 and UL 1363. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Underwriters Laboratory (UL)

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with non-compliance, working clearances at electrical panels, fixed wiring rather than extension cords, and closed electrical raceways. This deficiency occurred in 7 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 4:10 pm surveyor observed on the First floor in the General Lab, that the electrical code was not followed. 2 outlets behind a sink are not GFI outlets. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

2. On 05/05/2015 at 10:10 am surveyor observed on the Basement floor in the Kitchen PNL BL-7, that access to electrical panel was less than 3'-0" clearance. A food cart in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

3. On 05/06/2015 at 11:07 am surveyor observed on the Second floor in the Storage Room, that access to electrical panel was less than 3'-0" clearance. 2 bins and 1 garbage cart were in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

4. On 05/05/2015 at 10:32 am surveyor observed on the Basement floor in the Employee Health, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave and a pencil sharpener. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

5. On 05/06/2015 at 8:48 am surveyor observed on the First floor in the Pac U Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to 2 power strips that were used for a refrigerator and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

6. On 05/06/2015 at 1:24 pm surveyor observed on the Third floor in the Patient Care Manager Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a refrigerator, coffee maker, microwave, and a clock. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

7. On 05/06/2015 at 2:09 pm surveyor observed on the Fourth floor in the Case Management #1, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power a fan, a coffee maker, and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

8. On 05/06/2015 at 2:10 pm surveyor observed on the Fourth floor in the Case Management #2, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to 2 power strips that were used to power a lamp, fan, radio, toaster, and a coffee maker. 5 power strips were found in the room. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

9. On 05/06/2015 at 2:30 pm surveyor observed on the Fourth floor in the 4 North Report Room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave and a coffee maker. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

10. On 05/05/2015 at 10:19 am surveyor observed on the Basement floor in the Clinical Information Office, that a exposed outlet box electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic sprinkler system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 2:15 pm, during a review of facility documents, the facility interim life safety Policy SAF 018 did not reliable describe the actions to be taken if the automatic sprinkler systems were out-of-service for more than 4 hours in a 24-hour period. The steps outlined in the procedure failed to specifically outline how fire notification would be initiated or site specify for the various buildings, sites, or campus configurations. The procedure also specified an appropriate 30 minute window between subsequent fire watch rounds yet a recently completed fire watch for a construction project performed its rounds in 60 minute intervals, in direct conflict with the facility ' s procedure. Reliable fire watch procedures are required for NFPA 13 sprinkler protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.7.6.1. This situation was not compliant with NFPA 101 section 9.7.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic fire alarm system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 2:30 pm, during a review of facility documents, the facility interim life safety Policy SAF 018 did not reliable describe the actions to be taken if the automatic fire alarm system is out-of-service for more than 4 hours in a 24-hour period. The steps outlined in the procedure failed to specifically outline how fire notification would be initiated or site specify for the various buildings, sites, or campus configurations. The procedure also specified an appropriate 30 minute window between subsequent fire watch rounds yet a recently completed fire watch for a construction project performed its rounds in 60 minute intervals, in direct conflict with the facility ' s procedure. Reliable fire watch procedures are required for NFPA 72 fire alarm protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.6.1.8. This situation was not compliant with NFPA 101 section 9.6.1.8 The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

Based on observation and interview, the facility did not provide alcohol based hand rub dispensers that were installed and located as permitted by the code with compliant installation. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 2:25 pm surveyor observed on the Fourth floor in the 4 North Nurse Station Med Room, that ABHR dispenser installed directly over a light switch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.7 and 42 CFR 403.744. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide wall construction to protect the corridor from non-corridor spaces with staff supervision or smoke detection with spaces that are open to the corridor. This deficiency occurred in 10 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/04/15 at 2:02 pm surveyor observed on the Tenth floor in the Video GG Monitoring Space, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101section 19.3.6.1.

2. On 05/05/15 at 2:35 pm surveyor observed on the Third floor in Waiting area 5, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

3. On 05/05/15 at 3:30 pm surveyor observed on the Second floor in lounge K2-L24-42, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

4. On 05/05/15 at 3:40 pm surveyor observed on the Second floor in dining N2-F2257, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

5. On 05/07/15 at 10:00 am surveyor observed on the 11th floor in patient lounge K-11-L11432, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in the same smoke compartment did not have smoke detection nor did it have direct staff supervision. The space is open to the corridor. This observed situation was not compliant with NFPA 101 section 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and smoke detection in spaces that are open to the corridor. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 15 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 11:07 am it was observed in the 1NW smoke compartment on the 1st floor in the #1075 corridor, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included wall membrane that did not extend to the underside of the deck, unsealed joints and screws. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1.

2. On 5-5-2015 at 11:10 am it was observed in the 1NW smoke compartment on the 1st floor in the #1077 corridor, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included wall membrane that did not extend to the underside of the deck, unsealed joints and screws. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1.

3. On 5-6-2015 at 10:41 am it was observed in the 5CW smoke compartment on the 5th floor in the #5529 Pharmacy room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware and did not provide doors suitable to resist the passage of smoke. This deficiency occurred in 8 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/04/15 at 1:50 pm, surveyor observed on the 11th floor, in Patient room L11424, that the corridor door would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

2. On 05/04/15 at 2:35 pm, surveyor observed on the 6th floor, that the corridor door K6-02-F1 would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

3. On 05/06/15 at 1:30 pm, surveyor observed on the 1st Floor NICU the double corridor doors K-1-L1400A defining the suite had a ¼ inch gap between the door leaves. Per NFPA 101 section 19.3.6.3.1, the facility must ensure all doors protecting the corridors are suitable for resisting the passage of smoke. Per CMS memorandum S&C 07-18, the gap is permitted to exceed 1/8-inch provided that the meeting edges of the leaves are equipped with an astragal, rabbet, or a bevel.

4. On 05/07/15 at 11:00 am, surveyor observed on the 8th floor, that the corridor doors T8113 would not positively self-latch. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide compliant corridor separation doors. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 30 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 5-5-2015 at 2:02 pm it was observed in the 2S smoke compartment on the 2nd floor in the #3101 Storage room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2.

2. On 5-5-2015 at 11:07 am it was observed in the 1NW smoke compartment on the 1st floor in the #1075 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

3. On 5-5-2015 at 11:10 am it was observed in the 1NW smoke compartment on the 1st floor in the #1077 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Asst).

______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 10:36 am surveyor observed on the Second floor in the North Suite Entrance, that the door to the corridor was held open with a wood chuck at the suite door. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with and doors with positive-latching hardware. This deficiency occurred in 2 of the 42 smoke compartments, and had the potential to affect 30 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 3:35 pm, it was observed in the 3NE smoke compartment on the 3rd floor in the Stair #13, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The pair of doors were misaligned to effectively latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

2. On 5-5-2015 at 2:33 pm, it was observed in the 3SE smoke compartment on the 3rd floor in the Stair #4, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The strike of the door frame was covered with tape to prevent the latch from engaging. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), and staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Assit).


______________________________________

Based on observation and interview, the facility did not ensure that 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 2 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/04/15 at 3:35 pm, surveyor observed on the 3rd floor smoke between smoke compartment 1 and 2, that the path of egress in the corridor was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 section 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with and sealed wall penetrations. This deficiency occurred in 4 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 8:32 am surveyor observed on the Basement floor in the LL-FD 035, that penetration(s) were not sealed according to according to an approved method. The deficiency included a hole in wall where a clock was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC) and staff VVV (Supervisor Facilities ASLSS).

2. On 05/05/2015 at 8:50 am surveyor observed on the Basement floor in the Credential Records Room, that penetration(s) were not sealed according to according to an approved method. The deficiency included 2" x 2" hole in the ceiling tile. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

3. On 05/05/2015 at 11:29 am surveyo observed on the Basement floor in the Nursing Education Classroom, that penetration(s) were not sealed according to according to an approved method. The deficiency included a clock on wall that does not cover the wall opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

4. On 05/05/2015 at 2:58 pm surveyor observed on the First floor in the SD-TC Office, that penetration(s) were not sealed according to according to an approved method. The deficiency included a hole in wall where a clock was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke barrier doors within clearances for proper operation. This deficiency occurred in 2 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/15 at 2:00 pm the surveyor observed on the 3rd floor in the Corridor at Smoke Barrier Doors C3-06-S1, that the pair of cross-corridor smoke barrier doors had a meeting edge clearance greater than 1/8" as defined for proper clearance and operation of smoke barrier doors. The doors were fire rated with an approximate clearance of 1/4" gap clearance between the meeting edges of the two smoke barrier doors. This observed situation was not compliant with NFPA 101 sections 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with and self closing hardware. This deficiency occurred in 2 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 8:20 am surveyor observed on the Basement floor in the LL-FD 010, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors does not work. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

2. On 05/05/2015 at 2:05 pm surveyor observed on the First floor in the IF-FD 015, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors did not allow the doors to close. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and staff interview, the facility did not provide the required separation of hazards from other use areas. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

Findings include:

1. On 05/04/15 at 2:43 pm, surveyor observed that a room was used for combustible storage and the access door C6-H6361 did not have an automatic door closer installed. The combustibles included personnel lockers and facility storage materials of a combustible nature. Per NFPA 101 Section 19.3.2.1, the facility must ensure all rooms or spaces greater than 50 square feet used for storage of combustible supplies and equipment deemed hazardous by the authority having jurisdiction mush be separated from other use areas. All doors to hazards areas must automatically close and latch when released. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency occurred in 11 of the 42 smoke compartments, and had the potential to affect 80 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-6-2015 at 9:42 am it was observed in the 4NE smoke compartment on the 4th floor in the #4634 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was used for storing approximately (75) seventy five cardboard file boxes. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

2. On 5-6-2015 at 9:54 am it was observed in the 4SE smoke compartment on the 4th floor in the #4617 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

3. On 5-6-2015 at 9:58 am it was observed in the 4C smoke compartment on the 4th floor in the #4116 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

4. On 5-6-2015 at 10:49 am it was observed in the 5C smoke compartment on the 5th floor in the #5506 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

5. On 5-6-2015 at 10:52 am it was observed in the 5CW smoke compartment on the 5th floor in the #5507 Office used as Storage room, that the door would not self-close because the door did not have an automatic closing device installed. The room was used for storing stacks of folded down cardboard boxes and a large quantity of foam packing material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1.

6. On 5-6-2015 at 8:30 am it was observed in the 4SW smoke compartment on the 4th floor in the #4324 Storage room, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The door had a 1 1/2" hole where the lockset had been removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

7. On 5-5-2015 at 8:35 am it was observed in the BSW smoke compartment on the Basement floor in the #0907 Environmental Services, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (2) 1" diameter holes with conduit and a 2" fire protection system pipe penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

8. On 5-5-2015 at 8:39 am it was observed in the BSW smoke compartment on the Basement floor in the #0905 Office, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration and a 10" x 20" duct penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

9. On 5-5-2015 at 8:45 am it was observed in the BSW smoke compartment on the Basement floor in the #0902 Male Locker room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration and (1) 2" pipe penetration. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

10. On 5-5-2015 at 8:52 am it was observed in the BNE smoke compartment on the Basement floor in the #8803 Central Supply room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included multiple pipe penetrations, structural penetrations and unfinished joints. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

11. On 5-5-2015 at 9:02 am it was observed in the BNE smoke compartment on the Basement floor in the #0800 Central Supply room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included multiple pipe penetrations, structural penetrations and unfinished joints. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

12. On 5-5-2015 at 9:16 am it was observed in the BNE smoke compartment on the Basement floor in the #0804 Elevator Equipment room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included 2" x 4" hole and (2) 1" conduit penetrations. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

13. On 5-5-2015 at 9:51 am it was observed in the BPOB smoke compartment on the Basement floor in the #C010 electrical vault, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1" conduit penetration and (1) 2" diameter hole in the CMU wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

14. On 5-5-2015 at 10:10 am it was observed in the 1S smoke compartment on the 1st floor in the Stair #12, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included (1) 1 1/2" pipe penetration, (2) 1" conduit penetrations and joints not sealed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1.

15. On 5-4-2015 at 3:45 pm it was observed in the BNW smoke compartment on the Basement floor in the #0919 electrical room, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. The walls were labeld as 1-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3.

16. On 5-5-2015 at 9:55 am it was observed in the BPOB smoke compartment on the Basement floor in the #C010 electrical vault, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. The walls were labeld as 1-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and EEEE (Fac Op Admin Asst).


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Based on observation and interview, the facility did not provide two exits for each floor or fire section. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 11:30 am, observation revealed on the 8th floor in the healing garden exit into corridor S8502, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt thumb turns on each leaf of this required exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and staff interview, the facility did not ensure that exit access doors remain identifiable as readily open-able from the inside, from which egress is to be made, at all times as required per NFPA 101 Life Safety Code sections 19.2. This deficiency occurred in 4 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

Findings include:

1. On 05/05/15 at 1:50 pm, surveyor observed within the SICU Unit on the third floor, that the double set of exit access doors in the corridor, were equipped with 15-second "delayed exit" magnetic locking devices. One of the two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

2. On 05/05/15 at 3:30 pm, surveyor observed within the NICU Unit on 2L Knisely second floor, that the double set of exit access doors in the corridor, are equipped with 15-second "delayed exit" magnetic locking devices. One of the two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

3. On 05/05/15 at 4:10 pm, surveyor observed within wing 2C on the second floor, that the double set of exit access doors in the corridor, are equipped with 15-second "delayed exit" magnetic locking devices. Two of two doors did not have the required "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" sign. This observed situation was not compliance with NFPA 101 sections 19.2.2 and 7.2.1.6.1.

4. On 05/05/15 at 3:05 pm, surveyor observed within the emergency department on the second floor, that door OP2-25A was marked as an Exit yet was not readily accessible. The door was equipped with a magnetic locking device that did not meet any of the three exceptions for locking arrangements of NFPA 101 section 19.2.2.2.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures and properly instructed. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/06/15 at 9:35 am, surveyor observed during a review of facility fire drill reports for the prior 12 months that fire drills did not include participation by all applicable facility personnel. Selective facility staff were substantiated to have participated via facility documented fire reporting documents and was not in compliance with NFPA 101 section 19.7.2.1 which requires drills to be conducted quarterly on each shift to familiarize facility personnel ( nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. Selective facility staff documentation was also not in compliance with NFPA 101 section 19.7.2.3 which requires " All " health care occupancy personnel to be instructed in the use and response of fire alarms. This observed situation was not compliant with NFPA 101 section 19.7. The condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

Based on a review of hospital records, fire drills were not conducted quarterly on each shift. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/2015 at 2:34 pm surveyor observed that during a review of facility documents the fire drill reports showed that fire drills were not conducted quarterly on every shift. Fire drills were not documented for the third shift, second quarter or for the second shift, fourth quarter. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency occurred in 25 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/06/15 at 11:37 am, surveyor observed on the Basement floor in a fire alarm panel room, that a smoke detector was not located in accordance with NFPA 72 requirements. The room was not normally occupied and confirmed to contain a fire alarm control unit, yet no smoke detector located in the room as required according to NFPA 72 - 1999 edition Section 1-5.6. This observed situation was not compliant with NFPA 101 section 9.6.1.4 and NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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 deficiency occurred in 30 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

Findings include:

1. On 05/06/15 at 11:30 am, survey observed on the basement floor, that elevator machine room NB-65-F1 was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The machine room contained combustible hydraulic fluid and did not meet an exception for sprinkler protection. This condition was applicable to additional elevator machine rooms.

2. On 05/06/15 at 2:40 pm, survey observed on the basement floor, that service elevators 17, 18, and 19 were not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pits were directly observed to contain a hydraulic fluid delivery system and did not meet the sprinkler requirement of NFPA 13 section 5-13.6.1. Contracted elevator personnel from Schindler substantiated the top of the shafts were also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. This condition was applicable to additional existing elevators within the facility. The facility could not substantiate the car enclosure non-combustibility to American Society of Mechanical Engineering (ASME) - 17.1, nor that the hydraulic fluid was non-combustible.

3. On 05/06/15 at 2:30 pm, survey observed on the basement floor, that service elevator P for Central Storage transport was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pit was directly observed to not be sprinkler protected. Contracted elevator personnel from Schindler substantiated the top of the shaft was also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. The facility could not substantiate the car enclosure non-combustibility to ASME - 17.1.

4. On 05/06/15 at 11:10 am, survey observed on the basement floor, that the loading dock, trash compactor, and cardboard recycling compactor space were not sprinkler protected. This space is enclosed on three sides, is approximately 50 ft. wide and 100 ft. in depth, and is located under a fully sprinkler protected receiving department located on the first level directly above this loading dock / compactor space. Combustibles present at the time of survey were 2 - 25 cubic yard trash compactors, 1 - 30 cubic yard cardboard compactor, and 1 pick-up truck. The two bay semi-trailer loading dock was not observed to have any vehicles at the time of the survey, yet is actively used for hospital purposes. Per NFPA 13 - 1999 section 5-13.8, sprinklers shall be installed under exterior roofs and canopies greater than 4 foot wide attached to sprinkler protected structures containing combustible storage.

5. On 05/06/15 at 3:05 pm, survey observed on the sub-basement floor, that bottom of Stair L was not sprinkler protected per NFPA 13 section 5-13.3.2.

6. On 05/07/15 at 11:45 am, surveyor observed that a dedicated electrical room TM-16-F2 for UPS 5 on 6th floor was being used for combustible storage and was not sprinkler protected. The combustibles included a craftsman constructed four section wood ramp of common 2 x 6 dimensional lumber. The combustibles identified nullified the exception for sprinkler protection per NFPA 13 section 5-13.11.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers at required exterior locations, sprinklers that were too far from the ceiling, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 9 of the 42 smoke compartments, and had the potential to affect all of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-5-2015 at 10:07 am it was observed in the 1S smoke compartment on the 1st floor in the Loading Dock, that sprinkler protection was not provided at the loading dock roofed area. The roofed area is subject to protection based on NFPA 13-1999 s. 5-13.7 This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.7.

2. On 5-5-2015 at 3:02 pm it was observed in the 3NE smoke compartment on the 3rd floor in the #3066 Electrical closet, that the sprinkler was placed farther than 22" below the ceiling. The pendant fire protection sprinkler head was (7') seven feet below the ceiling deck. This situation would delay release of water and does not satisfy listing. Requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1.

3. On 5-4-2015 at 3:35 pm it was observed in the BSW smoke compartment on the Basement floor in the #0932 kosher kitchen room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included several cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

4. On 5-5-2015 at 9:31 am it was observed in the BC smoke compartment on the Basement floor in the #0401 closet, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

5. On 5-5-2015 at 9:39 am it was observed in the BC smoke compartment on the Basement floor in the #0412 Information Services room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple cardboard boxes. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

6. On 5-5-2015 at 1:24 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2721 Electrical room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

7. On 5-6-2015 at 10:15 am it was observed in the 4SW smoke compartment on the 4th floor in the #4500 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

8. On 5-6-2015 at 10:25 am it was observed in the 5C smoke compartment on the 5th floor in the #5503 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

9. On 5-6-2015 at 10:31 am it was observed in the 5S smoke compartment on the 5th floor in the #5301 Electrical closet, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

10. On 5-6-2015 at 9:34 am it was observed in the 4NE smoke compartment on the 4th floor in the #4126 Electrical Vault, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


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Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling, and unobstructed water distribution. This deficiency occurred in 3 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 9:44 am surveyor observed on the Basement floor in the LL Fitness Room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The area above the Fitness Room ceiling is open to a hazardous area and is not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

2. On 05/05/2015 at 1:13 pm surveyor observed on the First floor in the Day Surgery Room 8, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

3. On 05/05/2015 at 3:12 pm surveyor observed on the First floor in the Gift Shop Storage, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included items stored within 18" of the sprinkler. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation, interview, and record review the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection and testing program as required by NFPA 101 section 9.7.5 for NFPA 13 - 1999 Edition systems to NFPA 25 - 1998 Edition standards. The sprinkler systems had a water storage tank that was not tested, sprinklers without properly installed escutcheon rings, and sprinklers were not free of foreign material. This deficiency occurred in 100 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 05/07/15 at 10:30 am, the surveyor observed during a review of facility documents that the hyperbaric chamber fire suppression system tanks was not tested and was not documented per NFPA 25 Chapter 6, NFPA 99 (1999 Edition) section 19-2.1.2 and NFPA 101 section 9.7.5. The interior of the tanks were not inspected in the last five years per NFPA 25 sections 6-2.4, 6-3.7. The level indicators were not tested in the last five years for accuracy and freedom of movement per NFPA 25 section 6-3.1. The pressure gauges were not tested in the last five years with a calibrated gauge in accordance with the manufacturer ' s instructions. Gauges also were not tested to verify accuracy within 3 percent of the scale to substantiation recalibration or replaced per NFPA 25 section 6-3.6. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

2. On 05/07/15 at 2:30 pm, the surveyor observed during a review of facility documents that sprinkler gauges and pipe obstruction investigations were not tested in accordance with NFPA 25. Gauges were not replaced and were not tested in the last five years per NFPA 25 section 2-3.2. Pipe obstruction investigations were not conducted in the last five years per NFPA 25 Table 2-1 and section 10-2.2. Facility recorded indicated the last year for these events occurred in 2009. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, and staff QQQ.

3. On 05/06/15 at 10:46 am, the surveyor observed in the Basement floor in corridor east of Room 222, that a row of sidewall sprinklers had dirt and lint accumulation on their fusible links. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, staff QQQ, and staff RRR.

4. On 05/06/15 at 10:40 am, the surveyor observed in the Basement floor in Room 222, that two freezer sprinklers had displaced or improperly installed escutcheon rings. Freezer N-FRZ-905 had condensation dripping through and freezing on the sprinklers. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, staff QQQ, and staff RRR.

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, sprinklers free of lint, the appropriate quantity of spare sprinklers, and a wrench in the spare sprinkler cabinet. This deficiency occurred in 6 of the 42 smoke compartments, and had the potential to affect all of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5-4-2015 at 3:19 pm it was observed in the BSW smoke compartment on the Basement floor in the #0938 dish wash room, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1.

2. On 5-5-2015 at 9:33 am it was observed in the BC smoke compartment on the Basement floor in the #0401 corridor, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1.

3. On 5-5-2015 at 9:41 am it was observed in the BC smoke compartment on the Basement floor in the #0416 Telecommunications room, that there was one or more unsealed holes near the ceiling. The hole(s) included (4) 6" x 6", (1) 6" x 12" and (2) 6" x 10" holes. 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.

4. On 5-5-2015 at 11:21 am it was observed in the 1CW smoke compartment on the 1st floor in the #1730 Emergency Entrance vestibule, that there was one or more unsealed holes near the ceiling. The hole(s) included a 24" x 24" ceiling tile. 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.

5. On 5-5-2015 at 9:37 am it was observed in the BC smoke compartment on the Basement floor in the #0412 Information Services room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12" x 12", a 24" x 48" and 24" x 24" 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.

6. On 5-5-2015 at 1:14 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2702 Staff room, 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.

7. On 5-5-2015 at 1:16 pm it was observed in the 2CW smoke compartment on the 2nd floor in the #2738 Housekeeping room, 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.

8. On 5-5-2015 at 9:25 am it was observed in the BNW smoke compartment on the Basement floor in the #0942 Sprinkler Riser room, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for recessed fire protection sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4.

9. On 5-5-2015 at 9:25 am it was observed in the BNW smoke compartment on the Basement floor in the #0942 Sprinkler Riser room, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).


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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, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 12 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 1:05 pm surveyor observed on the First floor in the Day Surgery Soiled Utility, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

2. On 05/06/2015 at 9:42 am surveyor observed on the First floor in the ICU Locker, that the escutcheon ring on the sprinkler was ceiling open at the sprinkler head. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

3. On 05/05/2015 at 8:34 am surveyor observed on the Basement floor in the Autopsy Parts Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tiles that were out of the grid. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC) and staff VVV (Supervisor Facilities ASLSS).

4. On 05/05/2015 at 8:48 am surveyor observed on the Basement floor in the Credential Records Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 2" hole in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

5. On 05/05/2015 at 9:55 am surveyor observed on the Basement floor in the Containment LL-FD 035, that there was one or more unsealed holes near the ceiling. The hole(s) included 13 pipes through the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

6. On 05/05/2015 at 11:05 am surveyor observed on the Basement floor in the Telephone Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 12 holes in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

7. On 05/05/2015 at 11:31 am surveyor observed on the Basement floor in the Chief Nursing Officer Office, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tiles that were out of the grid. These openings 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

8. On 05/05/2015 at 1:06 pm surveyor observed on the First floor in the Electrical Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile was missing. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

9. On 05/05/2015 at 4:00 pm surveyor observed on the First floor in the Lab Dish Room, that there was one or more unsealed holes near the ceiling. The hole(s) included ceiling tiles out of grid and openings where pipes penetrate ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

10. On 05/05/2015 at 4:02 pm surveyor observed on the First floor in the Lab Back Storage, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 2 tile out of the grid. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

11. On 05/06/2015 at 9:20 am surveyor observed on the First floor in the Angeo Equipment Room, that there was one or more unsealed holes near the ceiling. The hole(s) included 4" wide gap in the ceiling tile for the length of the room. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

12. On 05/06/2015 at 9:33 am surveyor observed on the First floor in the ICU Nurse Call Closet, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile that was out of the grid and openings in the ceiling tiles. These openings 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

13. On 05/06/2015 at 10:43 am surveyor observed on the Second floor in the Film Processing, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3" hole in the ceiling tile. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

14. On 05/06/2015 at 10:50 am surveyor observed on the Second floor in the Medical Records, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile out of place. 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 SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

15. On 05/05/2015 at 10:01 am surveyor observed on the Basement floor in the Central Supply - Soiled room, that there were 4 sprinkler heads painted. These painted heads 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), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

16. On 05/05/2015 at 10:04 am surveyor observed on the Basement floor in the Central Supply - Clean room, that there were 3 sprinkler heads painted. These painted heads 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), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

17. On 05/06/2015 at 11:09 am surveyor observed on the Second floor in the Utility Storage Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 4 ceiling tile missing. 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

18. On 05/06/2015 at 1:06 pm surveyor observed on the First floor in the Housekeeping CLoset, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling tile that is out of the grid. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

19. On 05/06/2015 at 2:02 pm surveyor observed on the Fourth floor in the 4 North Laundry, that there was lint on the sprinkler head. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

20. On 05/05/2015 at 1:19 pm surveyor observed on the First floor in the Day Surgery Resource Room, that there was lint on the sprinkler head. This 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 SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 9:45 am surveyor observed on the First floor in the ICU PCM Office, that a fire extinguisher was not accessible for immediate use because a cart was in front of the electrical panel. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 5-5-2015 at 10:48 am it was observed in the 1NE smoke compartment on the 1st floor in the #1822 Clean Utility room, that the clear and unobstructed width of the corridor was blocked with a number of cardboard boxes and stored wheelchairs. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.10.
The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ZZZ (Const Project Mngr), staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) and staff EEEE (Fac Op Admin Asst).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 8:21 am surveyor observed on the First floor in the Corridor of the Surgical Suite, that the clear and unobstructed width of the corridor was obstructed by twelve large pieces of equipment that were stored in the exit corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).
2. On 05/05/2015 at 10:40 am surveyor observed on the Basement floor in the Stair E-2 First Floor, that the travel out of the stairwell was interrupted to prevent travel to the building discharge. A wheelchair was blocking a stair exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with verification of rated hanging materials. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/2015 at 11:10 am surveyor observed on the Second floor in the All Clinic Rooms, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. The cubicle curtains do not have a flame resistant tag. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.1 and 10.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview the facility did not maintain a patient medical air alarm panel in a reliable operating condition nor was the panel removed per NFPA 101 sections 19.3.2.4, 4.6.12.2 and NFPA 99. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/15 at 2:15 am, surveyor observed on the 3rd Floor in the operating room control room that a medical air alarm panel was nonfunctional nor maintained in a reliable operating condition. The medical air alarm panel was clearly observable by the facility staff, and in the event of an emergency; fire department personnel. The medical air alarm panel did not display any information and facility staff confirmed the panel was non-functional. This observed situation was not compliant with NFPA 101 section 4.6.12.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Item 1:
Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, sections 4.6.12.2 and 9.7.1.1. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients rely on a highly reliable sprinkler system for safety. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 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 deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 8:41 am, surveyor observed on the 2nd floor in the pharmacy room, that a sprinkler head was located approximately four feet from another sprinkler head. Sprinklers cannot be closer to each other than the minimum required separation distance of 6'-0". This observed situation was not compliant with NFPA 13 (1999 edition), section 5-6.3. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 2:
Based on observation and interview, the facility did not ensure that the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent as required by NFPA 101 sections 39.2.10 and 7.10.1.2. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 9:05 am, surveyor observed on the 1st floor inside the central exit stair, that an occupant could continue beyond the intended 1st floor exit discharge level and proceed to the basement level. Similarly, occupants from the basement level are required to access this central stair, when proceeding upward to the intended 1st floor exit discharge level may proceed up to the second level. The 1st floor exit discharge level is not obvious, nor clearly identified within the central exit stair. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 3:
Based on observation and interview, the facility did not ensure that the means of egress was arranged that exits are readily accessible at all time as required by NFPA 101 sections 39.2.1.1 and 7.1. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 8:40 am, surveyor observed at the 1st floor entry vestibule, was a required exit yet had a storefront bi-parting sliding door system with a dead-bolt latching device. The dead-bolt latch was tested and it positively latched into the adjoining sliding door panel and would prohibit access to the required exterior exit discharge. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Item 4:
Based on observation and interview, the facility did not ensure that the means of egress was provided with a reliable means of illumination as required by NFPA 101 sections 39.2.8 and 7.8. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 05/07/15 at 9:40 am, surveyor observed at the basement floor North central exit that the failure of any single lighting fixture will leave the required exit discharge in darkness. The fixture did not contain a redundant light fixture. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff BBBB (Regional Dir, Facility Op) and staff VVV (Manager, Facility Op).

Based on observation and interview, the facility did not keep records indicating that, when tested, the time for the emergency powers transfers, required to be in 10 seconds or less, was not documented. This deficiency occurred in all of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/05/2015 at 2:36 pm surveyor observed that during a review of facility documents, the time for the generator to start could not be verified as being within the 10 second maximum. no records were found to confirm that the auto transfer switch transferred power in less than 10 seconds This observed situation was not compliant with NFPA 110 (1999 edition), 3-4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

Based on observation and staff interview, the facility did not provide electrical wiring that complies with NFPA 70, Article 305-3(a), 305(6)(b) and UL 1363, because six plug power strips or relocatable power taps (RPT) are used to supply power to non-computer related devices. This deficiency occurred in 1 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/06/15 at 1:45 pm, surveyor observed on the 1st Floor ACL Main Lab had two six plug power strips or relocatable power taps (RPT ' s) supplying power to five to six commercial grade laboratory testing pieces of equipment. The RPTs ' present can only be used to supply power to computers and computer peripherals per NFPA 70 and UL 1363. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), staff QQQ (Coordinator, QI), and staff RRR (Maintenance Tech Senior).

Underwriters Laboratory (UL)

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with non-compliance, working clearances at electrical panels, fixed wiring rather than extension cords, and closed electrical raceways. This deficiency occurred in 7 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 05/05/2015 at 4:10 pm surveyor observed on the First floor in the General Lab, that the electrical code was not followed. 2 outlets behind a sink are not GFI outlets. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

2. On 05/05/2015 at 10:10 am surveyor observed on the Basement floor in the Kitchen PNL BL-7, that access to electrical panel was less than 3'-0" clearance. A food cart in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

3. On 05/06/2015 at 11:07 am surveyor observed on the Second floor in the Storage Room, that access to electrical panel was less than 3'-0" clearance. 2 bins and 1 garbage cart were in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

4. On 05/05/2015 at 10:32 am surveyor observed on the Basement floor in the Employee Health, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave and a pencil sharpener. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff UUU (Construction Project Manager Sr. Aurora).

5. On 05/06/2015 at 8:48 am surveyor observed on the First floor in the Pac U Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to 2 power strips that were used for a refrigerator and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

6. On 05/06/2015 at 1:24 pm surveyor observed on the Third floor in the Patient Care Manager Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a refrigerator, coffee maker, microwave, and a clock. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

7. On 05/06/2015 at 2:09 pm surveyor observed on the Fourth floor in the Case Management #1, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power a fan, a coffee maker, and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

8. On 05/06/2015 at 2:10 pm surveyor observed on the Fourth floor in the Case Management #2, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to 2 power strips that were used to power a lamp, fan, radio, toaster, and a coffee maker. 5 power strips were found in the room. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

9. On 05/06/2015 at 2:30 pm surveyor observed on the Fourth floor in the 4 North Report Room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave and a coffee maker. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), staff YYY (Stationary Engineer), and staff WWW (QM Data Support Specialist ASLSS).

10. On 05/05/2015 at 10:19 am surveyor observed on the Basement floor in the Clinical Information Office, that a exposed outlet box electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff SSS (Director Facilities Operations ASLMC), staff TTT (Manager Facilities Operations ASLMC), staff VVV (Supervisor Facilities ASLSS), and staff WWW (QM Data Support Specialist ASLSS).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic sprinkler system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 2:15 pm, during a review of facility documents, the facility interim life safety Policy SAF 018 did not reliable describe the actions to be taken if the automatic sprinkler systems were out-of-service for more than 4 hours in a 24-hour period. The steps outlined in the procedure failed to specifically outline how fire notification would be initiated or site specify for the various buildings, sites, or campus configurations. The procedure also specified an appropriate 30 minute window between subsequent fire watch rounds yet a recently completed fire watch for a construction project performed its rounds in 60 minute intervals, in direct conflict with the facility ' s procedure. Reliable fire watch procedures are required for NFPA 13 sprinkler protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.7.6.1. This situation was not compliant with NFPA 101 section 9.7.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic fire alarm system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 05/07/2015 at 2:30 pm, during a review of facility documents, the facility interim life safety Policy SAF 018 did not reliable describe the actions to be taken if the automatic fire alarm system is out-of-service for more than 4 hours in a 24-hour period. The steps outlined in the procedure failed to specifically outline how fire notification would be initiated or site specify for the various buildings, sites, or campus configurations. The procedure also specified an appropriate 30 minute window between subsequent fire watch rounds yet a recently completed fire watch for a construction project performed its rounds in 60 minute intervals, in direct conflict with the facility ' s procedure. Reliable fire watch procedures are required for NFPA 72 fire alarm protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.6.1.8. This situation was not compliant with NFPA 101 section 9.6.1.8 The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), staff NNN (Manager, Facilities Safety), staff OOO (Spvr Facilities Electrical), staff PPP (Manager, Construction), and staff QQQ (Coordinator, QI).