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Based on observation and interview, the facility did not provide and maintain the required building construction type that had support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 15 of the 96 inpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On June 29, 2010 at 11:30 am Surveyor #18107 observed in the 42-B (0-IP) smoke compartment on the 2nd floor, in the Maintenance Area, fire proofing was missing from the structural steel at the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mechanical Utility Engineer), Staff DD (Operations& Maintenance Supervisor).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching dutch doors, doors with positive-latching hardware, and doors that would close when pushed or pulled. This deficiency occurred in 4 of the 36 smoke compartments, and would affect 0 of the 96 inpatients and 56 of the 56 outpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On June 29, 2010 at 8:45 am surveyor #18107 observed in the 52-A1 (0-IP) smoke compartment on the 2nd floor that in the #2329-Dishwashing Room the corridor door would not remain fully-closed if a force of 5 lbs were applied to the latch edge of the door. Large food carts were blocking the door from closing. The astragal was still damaged and waiting for door hardware to arrive. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir.-Operations).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations and rated wall construction. This deficiency occurred in 5 of the 36 smoke compartments, and would affect 28 of the 96 inpatients and 56 outpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:

1. On June 29, 2010 at 10:45 am surveyor #18107 was told the 42-B (0-IP) smoke compartment on the 2nd floor, in the Room #2220 at Corridor by Smoke Barrier duct penetration(s) were not sealed according to approved UL designs. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

2. On June 29, 2010 at 11:15 am surveyor #18107 was told the 32-C1 (56-OP) smoke compartment on the 2nd floor, in the Corridor by Smoke Barrier, the smoke barrier wall was not constructed to a 30 minute fire resistance rating because it requires duct work to be removed to provide access. The wall was not enclosed at the top of two (2) mechanical ducts. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.), and Staff EE (Associate Dir. - Operations).

3. On June 29, 2010 at 9:15 am surveyor #18107 observed in the 53-B1 (15-IP) smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of the wall at the deck above was not sealed. The vertical side joints and joint against door frame header were not completely sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

4. Completed 9/1/2010.

5. On June 29, 2010 at about 8:25 am surveyor #18107 was told during an on-site meeting prior to the tour, area 31-B (0-IP) smoke compartment, on the 1st floor at the Old Library Room now used as Medical Records/Transcription/Filing and Archives Storage, the smoke barrier wall was not finished. This reviewed situation confirmed that the hospital was still out of compliance with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discussion by a interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

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 that had smoke-tight seals at meeting edges, and closers on all doors. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 0 of the 96 inpatients and 56 of the 56 outpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On June 29, 2010 at 11:25 am surveyor #18107 observed in the 32-D1 (56-OP) smoke compartment on the 2nd floor that in the Corridor at Smoke Barrier the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The doors were warped. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.), and Staff EE (Associate Dir. - Operations).

2. On June 29, 2010 at 9:10 am surveyor #18107 observed in the 53-C (0-IP) smoke compartment on the 3rd floor in the space #3308-Smoke Barrier Corridor Doors, the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated doors, doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 15 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On June 29, 2010 at 8:25 am surveyor #18107 was told by staff in a pre-verification visit meeting on-site, this deficiency is not corrected in the 52-B1 smoke compartment on the 2nd floor that in the #2307A & #2311- Patient Storage Rooms the enclosing walls were not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a duct penetration that was not sealed and fire caulked through the 1-hour concrete block wall assembly. The room was used to store patient clothing and shelves were filled from 4 inches above the floor to at least 8 feet above the floor. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of initial discussion meeting prior to start of verification visit tour with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not provide egress paths at all times that had doors that were unlockable in the egress path, no swinging door obstructions, doors that swing in the direction of egress, and level walking surfaces in the path of egress. This deficiency occurred in 6 of the 36 smoke compartments, and would affect 68 of the 96 inpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:

1. On June 29, 2010 at 8:48 am surveyor #18107 observed in the 52-A2 (15-IP) smoke compartment on the 2nd floor that in the 52-A Stair Discharge a portion of the path of egress had an abrupt change in elevation of 4" to 5" between two (2) concrete slabs due to soil erosion. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

2. On June 29, 2010 at 9:03 am surveyor #18107 observed in the 53-C (30-IP) smoke compartment on the 3rd floor that in the Staff Entrance a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

3. On June 29, 2010 at 9:08 am surveyor #18107 observed in the 53-C (30-IP) smoke compartment on the 3rd floor that in the Stair #5-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) and Staff EE (Associate Dir. - Operations).

4. On June 29, 2010 at 9:55 am surveyor #18107 observed in the 43-C2 (30-IP) smoke compartment on the 3rd floor that in the Stair #4-3-Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

5. On June 29, 2010 at 8:15 am surveyor #18107 was told during an on-site meeting prior to the tour that this deficiency was not corrected in the 42-A1 (0-IP) smoke compartment on the 2nd floor that in the Stair #4-2 Exit Discharge a portion of the path of egress had an abrupt change in elevation were 8 panels of sidewalk that were broken and this created an un-level egress path to a public way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed by Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

6. On June 29, 2010 at 8:15 am surveyor #18107 was told during an on-site meeting prior to the tour that this deficiency was not corrected in the 43-B1 (30-IP) smoke compartment on the 5th floor that in the Stair #4-5 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed by Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

7. On June 29, 2010 at 8:15 am surveyor #18107 was told during an on-site meeting prior to the tour that this deficiency was not corrected in the 43-A1 (30-IP) smoke compartment on the 3rd floor that in the Stair #4-1 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed by Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

8. On June 29, 2010 at 8:15 am surveyor #18107 was told during an on-site meeting prior to the tour that this deficiency was not corrected in the 31-A (0-IP) smoke compartment on the 1st floor that in the Stair #3-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not provide and maintain multiple light fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed and the egress paths would be walk-able with redundant lighting. This deficiency occurred in 8 of the 36 smoke compartments, and would affect 60 of the 96 inpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:

1. On June 29, 2010 at 8:15 am surveyor #18107 was told during an on-site meeting prior to the tour that this deficiency was not corrected at the following exit discharges at 1st, 2nd & 3rd floors in buildings 5, 4 and 3 at various Exit Discharges, and the path of egress to a public way is required to be lighted by a light fixture with more than one lamp should one of the lamps burn-out leaving the area in darkness outside. The lighted path to a public way shall provide at least 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This condition was observed at various locations in the path of egress to a public way including, but not limited to, the following examples:
43-H2: Stair #4-15 Exit Discharge;
43-C1: Stair #4-14 Exit Discharge;
43-C2: Stair #4-3 Exit Discharge;
43-D2: Exit Discharge;
52-A2: Stair #52A Exit Discharge;
52-B: Stair #52B & 52D Exit Discharges;
53-A1: Stair #5-3 Exit Discharge;
53-C: Stair #5-1 Exit Discharge;
This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above 2000 NFPA 101 Life Safety Code.

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 that had sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required sprinkling, and Stairwells with sprinklers. This deficiency occurred in 8 of the 36 smoke compartments, and would affect 70 out of the 96 in-patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:

1. On June 29, 2010 at 8:20 am surveyor #18107 was told by staff that the following deficiency has not been corrected in the 31-B smoke compartment on the 1st floor of the Data Room where Halon was the source of fire-suppression, the room was not sprinkler protected at time of original survey. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The room was equipped with a Halon extinguishing system, but was not considered effective because the mechanical ducts were not smoke-dampered to contain the gas within the room upon activation. This observed situation was not compliant with NFPA 101 (2000 edition). The deficiency was confirmed during the meeting with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

2. On June 29, 2010 at 8:20 am surveyor #18107 was told by staff that the following deficiency has not been corrected in the following identified Stairwells. The following stairwells did not have a sprinkler at the first landing above the bottom of the shaft. The surveyor observed this deficiency in Stairwells; #4-10, #4-3, #4-2, #3-2, #3-3, #3-4, and #4-3 during the original survey May 6, 2010. This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.3. These deficiencies were confirmed during the meeting with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 9/02/2010 the facility remains out of compliance with the above 2000 NFPA 101 Life Safety Code. Received copy of purchase order showing progress to correct deficiency.