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Based on observation and interview, the facility did not provide a common separation wall with rated doors. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 11:45 am surveyors observed in the North Patient smoke compartment on the First floor in the Clean Linen Room, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 11:36 am surveyors observed in the North Patient smoke compartment on the First floor in the Vestibule, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with a fire rated astragal to resist the passage of smoke or fire. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, and taped joints on rated walls. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 11:32 am surveyors observed in the North Patient smoke compartment on the First floor in the Vestibule, that penetration(s) were not sealed according to an approved method. The deficiency included sealant missing at pipe penetrations This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

2. On 01/12/2015 at 11:52 am surveyors observed in the North Patient smoke compartment on the First floor in the Soiled Linen Room, that penetration(s) were not sealed according to an approved method. The deficiency included ducts and conduit through wall, above ceiling, that are not sleeved or sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

3. On 01/12/2015 at 11:45 am surveyors observed in the North Patient smoke compartment on the First floor in the Clean Linen Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

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. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 1:32 pm surveyors observed in the North Patient smoke compartment on the First floor in the Receiving Room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There is no sprinkler head located below the overhead door when the overhead door is in the open position. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 12:49 pm surveyors observed in the North Patient smoke compartment on the First floor in the Utility Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a gap at ceiling tiles above all (8) electrical panels and at unistrut framing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

2. On 01/12/2015 at 12:51 pm surveyors observed in the North Patient smoke compartment on the First floor in the Laundry, that there was one or more unsealed holes near the ceiling. The hole(s) included a gap surrounding a pipe at the ceiling. The hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 1:37 pm surveyors observed in the Center Core smoke compartment on the First floor in the Central Storage, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 4 ceiling tile that was missing. This opening would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

2. On 01/12/2015 at 1:43 pm surveyors observed in the Center Core smoke compartment on the First floor in the Kitchen Cooler, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 12:48 pm surveyors observed in the North Patient smoke compartment on the First floor in the Utility Room, that access to electrical panel was less than 3'-0" clearance. A bed was stored in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation and interview, the facility did not provide a common separation wall with rated doors. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 11:45 am surveyors observed in the North Patient smoke compartment on the First floor in the Clean Linen Room, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 11:36 am surveyors observed in the North Patient smoke compartment on the First floor in the Vestibule, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with a fire rated astragal to resist the passage of smoke or fire. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, and taped joints on rated walls. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 11:32 am surveyors observed in the North Patient smoke compartment on the First floor in the Vestibule, that penetration(s) were not sealed according to an approved method. The deficiency included sealant missing at pipe penetrations This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

2. On 01/12/2015 at 11:52 am surveyors observed in the North Patient smoke compartment on the First floor in the Soiled Linen Room, that penetration(s) were not sealed according to an approved method. The deficiency included ducts and conduit through wall, above ceiling, that are not sleeved or sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

3. On 01/12/2015 at 11:45 am surveyors observed in the North Patient smoke compartment on the First floor in the Clean Linen Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance), staff D (Facility Manager) and staff E (Facility Manager).

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. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 1:32 pm surveyors observed in the North Patient smoke compartment on the First floor in the Receiving Room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There is no sprinkler head located below the overhead door when the overhead door is in the open position. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 12:49 pm surveyors observed in the North Patient smoke compartment on the First floor in the Utility Room, that there was one or more unsealed holes near the ceiling. The hole(s) included a gap at ceiling tiles above all (8) electrical panels and at unistrut framing. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

2. On 01/12/2015 at 12:51 pm surveyors observed in the North Patient smoke compartment on the First floor in the Laundry, that there was one or more unsealed holes near the ceiling. The hole(s) included a gap surrounding a pipe at the ceiling. The hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/12/2015 at 1:37 pm surveyors observed in the Center Core smoke compartment on the First floor in the Central Storage, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 x 4 ceiling tile that was missing. This opening would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

2. On 01/12/2015 at 1:43 pm surveyors observed in the Center Core smoke compartment on the First floor in the Kitchen Cooler, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 8 of the 18 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 01/12/2015 at 12:48 pm surveyors observed in the North Patient smoke compartment on the First floor in the Utility Room, that access to electrical panel was less than 3'-0" clearance. A bed was stored in front of an electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Lead Maintenance) and staff D (Facility Manager).