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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 8:45 am, observation revealed on the 1st floor in Telephone room number L426, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a improperly fire-stopped 3 inch diameter hole in the floor with a bundle of wires. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.1.6 and 8.2.3.2.4.2.

2. On 06/03/2014 at 10:30 am, observation revealed on the 1st floor in Store Room Number 158CU, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a not properly fire-stopped 2 inch diameter hole in the floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor that have the required safe-guards, and smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:20 am, observation revealed on the 1st floor in the OR Reception Room 326-1, that a sliding window was installed in the corridor wall, but did not positively latch and did not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide corridor separation doors with self-latching inactive doors. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:45 am, observation revealed on the 1st floor in Patient Room Number 252, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. Similar situations occurred in the inactive door leafs of Room Number 248 and 246. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5, exception 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:00 am, observation revealed on the 1st floor in the fire barrier/smoke barrier wall above the door in the corridor near room number 500, that the separation wall was not constructed to a required resistance rating because the construction joint was not sealed where the wall met the deck above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 06/03/2014 at 10:25 am, observation revealed on the 1st floor in the Smoke Barrier Wall over the Smoke Barrier Door near Room Number 415, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the construction joint was not sealed where the wall met the deck above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of the smoke barrier walls by having sealed wall penetrations. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:35 am, observation revealed on the 1st floor in the Smoke Barrier Wall over the Smoke Barrier Door near Room Number 262, that a penetration was not sealed according to an approved method. The deficiency included a 2 inch diameter hole with metal conduit penetration, without firestop. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings Include:

1. On 06/03/2014 at 10:55 am, observation revealed on the Basement floor in the Storage Room Number L151-2, that the door would not self-close because the door was not equipped with an automatic or self closing device. Approximately 20 card board boxes full of combustibles were stacked in this storage room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials that were considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion. This deficiency occurred in 1 of the 1 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 12:30 pm, observation revealed on the 1st floor in the Exit door, in the Entrance, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt installed 3 feet above the floor in both opposite doors in the Entrance Lobby. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide egress paths with a level walking surface at the doorways. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 8:15 am, observation revealed on the 1st floor at the exit discharge door, from the Stair near room number L409, that the floor on one side of the door had a 3 inch difference from the other floor level. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.3, exception 2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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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 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:45 am, observation revealed on the Basement floor in the Corridor to the PT area, that the clear and unobstructed width of the corridor was six feet. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Staff A mentioned that this Corridor is occasionally used by in- patients. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on interview and record review, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure and did not perform the adequate testing of batteries for the battery powered emergency lightings. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:30 pm, a review of facility documents revealed that the facility did not test the battery-powered emergency lights for 30 seconds each month or 90 minutes each year. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain adequate lighting of the egress path. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 4:10 pm, observation revealed on the Basement floor in the Stair near room number L4015, that there were no light fixtures along the path of egress in the exterior exit discharge area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

2. On 06/03/2014 at 3:15 pm, observation revealed on the 1st floor in the Stair near the waiting area, that there were no light fixtures along the path of egress in the exterior exit discharge area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).

Based on interview and record review, the facility did not conduct fire drills as required by code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company for the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or offsite monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports it was noted that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

3. On 06/02/20014 at 2:30 pm, during a review of facility fire drill records, for the past 12 months, it was noted that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures by having documentation of the alarm transmission to a monitoring station during a fire drill, the required quantity of drills, and fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:52 am, observation revealed on the Basement floor in the Fire Alarm Panel Room Number L151-1, that the fire alarm installation was not compliant. Digital Alarm Communication Systems was equipped with only one phone line to send signals to a Remote Supervising Station Service (Sheriff's office command center as per Staff A). This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), sections 5-5.3.2, 5-5.3.2.1.6.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with on-time inspection. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/20014 at 11:30 am, during a review of facility documents it was noted that the required semi-annual inspections were not performed on a 6 month basis. Sealed lead acid type batteries for the Fire Alarm System were only tested once on 04/01/2014 by Communications Engineering Company of Green Bay, within the last year. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests was conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04.01.2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered, that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:40 am, observation revealed on the 1st floor in the Room Number 251, that the discharge of the sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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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, sprinklers free of lint, and ceilings sealed above the sprinklers. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 11:00 am, during a review of facility documents it was noted that the monthly wet sprinkler inspections were not performed as required by the code. No documentation was available that confirmed monthly visual inspections for the wet sprinkler system were performed on a regular basis in the last one year. Staff A mentioned that they performed visual inspections for the wet sprinkler system on a weekly basis, but did not record nor maintain any documentation. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

2. On 06/02/2014 at 11:15 am, during a review of facility documents it was noted that the quarterly wet sprinkler inspections were not performed as required by the code. Quarterly Sprinkler Inspections of the 2nd and 3rd quarter of 2013 were performed by Communications Engineering Company of Green Bay on 6/18/2013 and 10/03/2013 respectively and the gap between inspection dates was 105 days. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

3. On 06/02/2014 at 4:00 pm, observation revealed on the Basement floor in the Kitchen, that a sprinkler was not kept free of lint or other foreign material nor maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

4. On 06/03/2014 at 8:30 am, observation revealed on the 1st floor in the Corridor near room number L417, that there was one unsealed hole near the ceiling. The hole included a 2' x 2' missing 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 Underwriters Laboratory (UL) certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 06/03/2014 at 10:10 am, observation revealed on the 1st floor in the Soiled Utility Room number 600-SU, that a sprinkler was not kept free of lint or other foreign material nor maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent record review,observation, and interview with staff A (Maintenance Director).
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Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents, it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on interview, observation, and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96 for range hoods being cleaned semi-annually and K-type extinguisher identification. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 11:45 am, during a review of documents, it was discovered that the range hood and ducts were not inspected and cleaned semi-annually for grease contamination. Cleaning records indicated that the last time the range hood was cleaned was on 10/2013 by Great Dane, within the last one year. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1.

2. On 06/02/2014 at 3:50 pm, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).

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Based on observation and interview, the facility did not provide the safe storage and use of medical gases as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 9:00 am, observation revealed on the 1st floor in the Oxygen room number 328, that oxygen cylinders in storage were not secured to keep them from falling. Seventeen loosely chained Type E oxygen cylinders were kept in an upright position without securing their base. Additionally 1 Type E empty oxygen cylinder and 1 Type D carbon-dioxide cylinder were kept in upright position without securing them from falling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

2. On 06/03/2014 at 10:40 am, observation revealed on the 1st floor in the Clean Equipment Room Number 155, that oxygen cylinders in storage were not secured to keep them from falling. Eight Type E Oxygen Cylinders were kept in a 3 inch high open card board box without securing them from falling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 9:15 am, observation revealed on the 1st floor in the corridor near room number L423, that room identifications for the medical gas shut off valves that they were supplying were erased. The observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), 4-3.5.4.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 3:00 pm, observation revealed on the 1st floor in OR Number 332, 339 & 337, that all these 3 OR's did not have one or more battery powered emergency lighting units. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-3.2.1.2(a)5(e).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes for a generator with a remote stop and trouble signals at a continuously monitored location by operating personnel. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:10 am, observation revealed on the 1st floor in the Type 1 Generator Room, that the emergency generator was not provided with a remote stop switch outside the Generator Room. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

2. On 06/03/2014 at 11:15 am, observation revealed on the 1st floor in the Generator Room, that a remote annunciator with storage battery power, was not provided in a location outside of the generating room that was in view of plant operating personnel of a regular work station. This Type 1 remote annunciator was only provided at a nurse station. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-4.1.1.15.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having restricted access. This deficiency occurred in 3 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:55 am, observation revealed on the 1st floor in the Corridor near Room Number 226, that access to the electrical panel was not restricted to authorized use only, because the electrical panel was unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, with electrical panels having restricted access, electrical panels with complete directories, and closed electrical raceways. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:20 am, observation revealed on the 1st floor in the Corridor near room number 412, that access to the electrical panel was not restricted to authorized use only, because the Electrical panel LPC was unlocked. Additionally in the same place, Electrical panel LED did not have a cover. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

2. On 06/03/2014 at 10:50 am, observation revealed on the Basement floor in the Fire Alarm Panel Room Number L151-1, that electrical circuit breakers inside panel LCA did not have a panel directory to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

3. On 06/03/2014 at 11:00 am, observation revealed on the Basement floor in the Exercise Room Number L151, that four 4x4 electrical junction boxes did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.), 517-12.

4. On 06/03/2014 at 10:15 am, observation revealed on the 1st floor in the Corridor near room number 500-2, that access to the electrical panel was not restricted to authorized use only, because the Electrical Panels CEN, LEN, GN were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 8:45 am, observation revealed on the 1st floor in Telephone room number L426, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a improperly fire-stopped 3 inch diameter hole in the floor with a bundle of wires. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.1.6 and 8.2.3.2.4.2.

2. On 06/03/2014 at 10:30 am, observation revealed on the 1st floor in Store Room Number 158CU, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a not properly fire-stopped 2 inch diameter hole in the floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor that have the required safe-guards, and smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:20 am, observation revealed on the 1st floor in the OR Reception Room 326-1, that a sliding window was installed in the corridor wall, but did not positively latch and did not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with self-latching inactive doors. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:45 am, observation revealed on the 1st floor in Patient Room Number 252, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. Similar situations occurred in the inactive door leafs of Room Number 248 and 246. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5, exception 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:00 am, observation revealed on the 1st floor in the fire barrier/smoke barrier wall above the door in the corridor near room number 500, that the separation wall was not constructed to a required resistance rating because the construction joint was not sealed where the wall met the deck above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 06/03/2014 at 10:25 am, observation revealed on the 1st floor in the Smoke Barrier Wall over the Smoke Barrier Door near Room Number 415, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the construction joint was not sealed where the wall met the deck above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of the smoke barrier walls by having sealed wall penetrations. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:35 am, observation revealed on the 1st floor in the Smoke Barrier Wall over the Smoke Barrier Door near Room Number 262, that a penetration was not sealed according to an approved method. The deficiency included a 2 inch diameter hole with metal conduit penetration, without firestop. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings Include:

1. On 06/03/2014 at 10:55 am, observation revealed on the Basement floor in the Storage Room Number L151-2, that the door would not self-close because the door was not equipped with an automatic or self closing device. Approximately 20 card board boxes full of combustibles were stacked in this storage room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials that were considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion. This deficiency occurred in 1 of the 1 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 12:30 pm, observation revealed on the 1st floor in the Exit door, in the Entrance, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt installed 3 feet above the floor in both opposite doors in the Entrance Lobby. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide egress paths with a level walking surface at the doorways. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 8:15 am, observation revealed on the 1st floor at the exit discharge door, from the Stair near room number L409, that the floor on one side of the door had a 3 inch difference from the other floor level. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.3, exception 2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

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 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:45 am, observation revealed on the Basement floor in the Corridor to the PT area, that the clear and unobstructed width of the corridor was six feet. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Staff A mentioned that this Corridor is occasionally used by in- patients. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure and did not perform the adequate testing of batteries for the battery powered emergency lightings. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:30 pm, a review of facility documents revealed that the facility did not test the battery-powered emergency lights for 30 seconds each month or 90 minutes each year. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
_____________________________________

Based on observation and interview, the facility did not provide and maintain adequate lighting of the egress path. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 4:10 pm, observation revealed on the Basement floor in the Stair near room number L4015, that there were no light fixtures along the path of egress in the exterior exit discharge area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

2. On 06/03/2014 at 3:15 pm, observation revealed on the 1st floor in the Stair near the waiting area, that there were no light fixtures along the path of egress in the exterior exit discharge area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).

Based on interview and record review, the facility did not conduct fire drills as required by code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company for the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures, have documentation of the alarm transmission to a monitoring station during a fire drill, have the required quantity of drills, and perform fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or offsite monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports it was noted that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that, 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

3. On 06/02/20014 at 2:30 pm, during a review of facility fire drill records, for the past 12 months, it was noted that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures by having documentation of the alarm transmission to a monitoring station during a fire drill, the required quantity of drills, and fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of facility fire drill reports for the prior 12 months, it was revealed that the fire drills did not include the fire alarm signal transmission verification to the local fire department or monitoring company in the 3rd Quarter of 2013. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

2. On 06/02/2014 at 2:15 pm, during a review of facility fire drill reports, it was revealed that the fire drills were not conducted quarterly on every shift. The facility's fire drill records from June 2013 to May 2014 indicated that 1 (4th quarter) of 4 first-shift (day shift) drills and 1 (3rd quarter) of 4 third shift (night shift) drills were not performed. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 06/02/2014 at 2:30 pm, during a review of facility fire drill records for the past 12 months, it was revealed that the fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that 2 (2nd and 3rd quarter) of 4 first-shift (day shift) drills were held at 7:00 AM, 3 (2nd, 3rd & 4th quarter) of 4 second-shift (PM shift) drills were held between 7:45 PM to 8:20 PM. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:52 am, observation revealed on the Basement floor in the Fire Alarm Panel Room Number L151-1, that the fire alarm installation was not compliant. Digital Alarm Communication Systems was equipped with only one phone line to send signals to a Remote Supervising Station Service (Sheriff's office command center as per Staff A). This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), sections 5-5.3.2, 5-5.3.2.1.6.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with on-time inspection. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/20014 at 11:30 am, during a review of facility documents it was noted that the required semi-annual inspections were not performed on a 6 month basis. Sealed lead acid type batteries for the Fire Alarm System were only tested once on 04/01/2014 by Communications Engineering Company of Green Bay, within the last year. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests was conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04.01.2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors sensitivity in accordance with manufacturer's specifications. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 2:00 pm, during a review of documents it was discovered, that records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Staff A stated that they started keeping the records in digital format in their computer system. Later during the survey, the print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 04/01/2014 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:40 am, observation revealed on the 1st floor in the Room Number 251, that the discharge of the sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6 inches away the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
______________________________________

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, sprinklers free of lint, and ceilings sealed above the sprinklers. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 11:00 am, during a review of facility documents it was noted that the monthly wet sprinkler inspections were not performed as required by the code. No documentation was available that confirmed monthly visual inspections for the wet sprinkler system were performed on a regular basis in the last one year. Staff A mentioned that they performed visual inspections for the wet sprinkler system on a weekly basis, but did not record nor maintain any documentation. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

2. On 06/02/2014 at 11:15 am, during a review of facility documents it was noted that the quarterly wet sprinkler inspections were not performed as required by the code. Quarterly Sprinkler Inspections of the 2nd and 3rd quarter of 2013 were performed by Communications Engineering Company of Green Bay on 6/18/2013 and 10/03/2013 respectively and the gap between inspection dates was 105 days. This situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

3. On 06/02/2014 at 4:00 pm, observation revealed on the Basement floor in the Kitchen, that a sprinkler was not kept free of lint or other foreign material nor maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

4. On 06/03/2014 at 8:30 am, observation revealed on the 1st floor in the Corridor near room number L417, that there was one unsealed hole near the ceiling. The hole included a 2' x 2' missing 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 Underwriters Laboratory (UL) certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 06/03/2014 at 10:10 am, observation revealed on the 1st floor in the Soiled Utility Room number 600-SU, that a sprinkler was not kept free of lint or other foreign material nor maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent record review,observation, and interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents, it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
______________________________________

Based on interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 1:15 pm, during a review of documents it was discovered that all required maintenance procedures were not performed. No documentation was available that confirmed fire/ Smoke damper maintenance was performed within the last six years. Staff A mentioned that he was not aware of any damper maintenance records. This situation was not compliant with NFPA 101 (2000 ed.), sections 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent interview with staff A (Maintenance Director).
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Based on interview, observation, and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96 for range hoods being cleaned semi-annually and K-type extinguisher identification. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/02/2014 at 11:45 am, during a review of documents, it was discovered that the range hood and ducts were not inspected and cleaned semi-annually for grease contamination. Cleaning records indicated that the last time the range hood was cleaned was on 10/2013 by Great Dane, within the last one year. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1.

2. On 06/02/2014 at 3:50 pm, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).

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Based on observation and interview, the facility did not provide the safe storage and use of medical gases as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 9:00 am, observation revealed on the 1st floor in the Oxygen room number 328, that oxygen cylinders in storage were not secured to keep them from falling. Seventeen loosely chained Type E oxygen cylinders were kept in an upright position without securing their base. Additionally 1 Type E empty oxygen cylinder and 1 Type D carbon-dioxide cylinder were kept in upright position without securing them from falling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

2. On 06/03/2014 at 10:40 am, observation revealed on the 1st floor in the Clean Equipment Room Number 155, that oxygen cylinders in storage were not secured to keep them from falling. Eight Type E Oxygen Cylinders were kept in a 3 inch high open card board box without securing them from falling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 9:15 am, observation revealed on the 1st floor in the corridor near room number L423, that room identifications for the medical gas shut off valves that they were supplying were erased. The observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), 4-3.5.4.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 3:00 pm, observation revealed on the 1st floor in OR Number 332, 339 & 337, that all these 3 OR's did not have one or more battery powered emergency lighting units. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-3.2.1.2(a)5(e).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes for a generator with a remote stop and trouble signals at a continuously monitored location by operating personnel. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:10 am, observation revealed on the 1st floor in the Type 1 Generator Room, that the emergency generator was not provided with a remote stop switch outside the Generator Room. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

2. On 06/03/2014 at 11:15 am, observation revealed on the 1st floor in the Generator Room, that a remote annunciator with storage battery power, was not provided in a location outside of the generating room that was in view of plant operating personnel of a regular work station. This Type 1 remote annunciator was only provided at a nurse station. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-4.1.1.15.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having restricted access. This deficiency occurred in 3 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:55 am, observation revealed on the 1st floor in the Corridor near Room Number 226, that access to the electrical panel was not restricted to authorized use only, because the electrical panel was unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, with electrical panels having restricted access, electrical panels with complete directories, and closed electrical raceways. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:20 am, observation revealed on the 1st floor in the Corridor near room number 412, that access to the electrical panel was not restricted to authorized use only, because the Electrical panel LPC was unlocked. Additionally in the same place, Electrical panel LED did not have a cover. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

2. On 06/03/2014 at 10:50 am, observation revealed on the Basement floor in the Fire Alarm Panel Room Number L151-1, that electrical circuit breakers inside panel LCA did not have a panel directory to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

3. On 06/03/2014 at 11:00 am, observation revealed on the Basement floor in the Exercise Room Number L151, that four 4x4 electrical junction boxes did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.), 517-12.

4. On 06/03/2014 at 10:15 am, observation revealed on the 1st floor in the Corridor near room number 500-2, that access to the electrical panel was not restricted to authorized use only, because the Electrical Panels CEN, LEN, GN were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).
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