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Based on observation and interview, the facility did not provide and maintain the required building construction type. Wood was present and not protected or covered with rated fire-proofing. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:04 am, observation revealed on the 1st floor in the Nurse Office Room 1169, in the green smoke compartment Unit B, fire proofing was missing around the exposed wood when used above the suspended ceiling. This does not meet 'limited combustibility requirements' per NFPA 101 s. 3.3.118 for fire-rating of this hospital building Type II (000), and adds to the fuel source above the unprotected ceiling areas. Wood was left behind from the original construction as part of the framing and was never removed after completion. This was observed throughout the hospital above the ceilings. This situation was not compliant with NFPA 101 (2000 ed.), sections 3.3.118 and 19.1.6.2.

2. On 04/12/2016 at 10:14 am, observation revealed on the 1st floor in the Corridor 1171, in the orange smoke compartment Zone 1, above Door 1181, fire proofing was missing around the exposed wood when used above the suspended ceiling. This does not meet 'limited combustibility requirements' per NFPA 101 s. 3.3.118 for fire-rating of this hospital building Type II (000), and adds to the fuel source above the unprotected ceiling areas. This situation was not compliant with NFPA 101 (2000 ed.), sections 3.3.118 and 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight corridor frames. This deficiency occurred in 1 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/12/2016 at 1:25 pm, observation revealed on the 1st floor in the Visitors Lounge Room 1098, in the orange smoke compartment Zone 2, the door had a frame that would not resist the passage of smoke because the door frame was designed with no door frame 'butt' to stop the spread of smoke to the corridor. The room had no smoke detection if open to the corridor. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with properly rated door and frame assemblies, ducts in fire-rated wall assemblies with fire dampers and sealed floor or vertical shaft penetrations. These deficiencies occurred in 4 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:55 am, observation revealed on the 1st floor in the Conference Room 1161 in orange smoke compartment Zone 1, penetrations in a vertical shaft were not sealed according to an approved method. The deficiencies included abandoned pipes and metal sleeves above ceiling through the floor deck assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

2. On 04/12/2016 at 2:00 pm, observation revealed on the 1st floor in the Stairwell 1090 in orange smoke compartment Zone 2, the shaft door frame could not be verified that it had the correct fire-rating. The label was recently painted over and the label could not be read. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.1.1, 8.2.5.4 and 8.2.3.2.

3. On 04/12/2016 at 2:10 pm, observation revealed on the 1st & Basement floors in the Stairwell 1090 in orange smoke compartment Zone 2, one or more air ducts penetrated the vertical shaft enclosure and could not be confirmed to have a properly installed fire damper. The mechanical duct penetrating the Stairwell 1090 was not fire-dampered and smoke-dampered. Under new construction requirements, ducts are not allowed to penetrate a Stairwell, if not serving the stairwell. Mechanical ducts must be outside the Stairwell unless serving it. This observed situation was not compliant with NFPA 90A (1999 ed.), section 3-3.4.

4. On 04/12/2016 at 2:15 pm, observation revealed on the 1st & Basement floors in the Stairwell 1090 at 1st floor landing in orange smoke compartment Zone 2, penetrations in a vertical shaft were not sealed according to an approved method. The deficiencies included multiple electrical conduits and wires not serving the Stairwell. The wiring was added after the original Stairs were constructed. Items are not allowed to enter a Stairwell unless serving the Stairwell. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

5. On 04/12/2016 at 3:07 pm, observation revealed on the Mechanical Penthouse above 1st Floor floor in the Mechanical Room for AHU #2, that penetrations through the fire-rated floor assembly were not fire-sealed according to an approved method. The deficiency included a 1 inch diameter pipe penetrating the floor assembly between 1st floor and mechanical room penthouse. Smoke and hot gases could easily penetrate the opening, compromising any occupants within the penthouse. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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, with incorrect fire-rating stenciling and sealed wall penetrations. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 9:39 am, observation revealed on the 1st floor in the Staff Mail Room 1164 & Inpatient Unit 1150 in the green smoke compartment Unit A, penetrations were not sealed according to an approved method. The deficiency included a 2 inch diameter sleeve not properly fire-sealed at Room 1164 and a 1 inch diameter pipe sleeve at West wall of Room 1150. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

2. On 04/12/2016 at 9:45 am, observation revealed on the 1st floor in the Nurse Office Room 1153 in the green smoke compartment Unit A, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. There was a 4" x 4" patch not properly edge taped and screws mudded. Could not confirm if screws were anchored into metal studs per the UL assembly. There was also a 1 inch diameter metal sleeve not properly fire-sealed through the 60 minute assembly. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

3. On 04/12/2016 at 10:01 am, observation revealed on the 1st floor in the Nurse Office Room 1169 in the green smoke compartment Unit B, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. There was a 2" x 4" patch not properly edge taped and screws mudded. Could not confirm if screws were anchored into metal studs. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

4. On 04/12/2016 at 10:18 am, observation revealed on the 1st floor in the Corridor 1171 in the orange smoke compartment Zone 1, penetrations were not sealed according to an approved method. The deficiencies included three open conduits above the ceiling at the East wall of the smoke barrier. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

5. On 04/12/2016 at 10:25 am, observation revealed on the 1st floor in the Office Room 1162 in the orange smoke compartment Zone 1, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because the construction joints were not sealed where the wall met the deck above. At the time of construction (1993), the smoke barriers were required to meet a 60 minute fire-rating and now cannot be diminished unless approved by the authority having jurisdiction (AHJ). This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

6. On 04/12/2016 at 11:11 am, observation revealed on the 1st floor in the Office Room 1154 in the orange smoke compartment Zone 1, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. Seams above ceiling between horizontal and vertical gypsum wallboard panels only had mud at seams and were missing joint taping as required by the fire-rated assembly. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

7. On 04/12/2016 at 11:15 am, observation revealed on the 1st floor in the Psychologist Office Room 1152 in the orange smoke compartment Zone 1, that the smoke barrier wall was not compliant. It was incorrectly identified as the wrong fire-rating by the stenciling (2 hour verses 1 hour). The smoke barrier was incorrectly stenciled at the South Smoke Barrier. The stenciling showed the smoke barrier extending farther than what was actually the case and miss-represented the actual conditions of the rated assembly. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

8. On 04/12/2016 at 11:21 am, observation revealed on the 1st floor in the Treatment Room next to Room 1152 in orange smoke compartment at Zone 1, penetrations were not sealed according to an approved method. The deficiency included the smoke barrier (walls) with open sleeves above the ceiling at the East & South Walls. The sleeves were not fire-sealed. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

9. On 04/12/2016 at 2:40 pm, observation revealed on the 1st floor in the spaces along the orange and yellow smoke compartment barrier, that the smoke barrier (wall) was not constructed to a 60 minute fire resistance rating because the construction joint was not sealed where the wall met the deck above. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

10. On 04/12/2016 at 3:42 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment, that penetrations were not sealed according to an approved method. The deficiencies included multiple steel roof joists not properly fire-sealed where they penetrated the 1-hour and 2-hour stenciled fire and smoke barriers (walls) above the ceiling. The room straddled the smoke barrier separating the red from the yellow smoke compartments. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

11. On 04/12/2016 at 3:50 pm, observation revealed on the 1st floor in the Main East-West Corridor outside the Medical Records File Room in the yellow smoke compartment, the smoke barrier wall was not compliant. It was incorrectly identified as the wrong fire-rating stenciling. The stenciling above the ceiling in the corridor was incorrect. It was shown as a 2-hour wall assembly, but was not identified the same as the Life Safety Plans. The stenciling was incorrect according to an interview with staff A and staff B. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

12. On 04/12/2016 at 4:10 pm, observation revealed on the 1st floor in the In North-South Corridor along 2-hour Smoke Barrier, across from Room 1074, penetrations were not sealed according to an approved method. The deficiency included a metal sleeve through the wall abocve the ceiling not fire-sealed. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, review of life safety plans, and interview, the facility did not enclose hazardous rooms (built in 1993 to the NFPA 101 (1991 ed.) Life Safety Code, section 12-3.2.1) with fire-rated wall construction, sealed wall penetrations, rated fire doors and closers on all hazardous room doors. Buildings cannot be down-graded from the level of original construction unless approved by the authority having jurisdiction (AHJ) per NFPA 101 (2000 ed.), section 4.6.7. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:49 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that the wall of this hazardous room was not constructed to the required fire resistance rating. Some of the construction joints were not sealed above the ceiling where the wall met the deck above. A (8" x 8") hole was observed at the South wall above-the-ceiling. The room was considered hazardous because it exceeded 100 square feet in area and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

2. On 04/12/2016 at 10:51 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included all pipes and flex ducts penetrating this 1-hour fire-rated room above the ceiling. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

3. On 04/12/2016 at 10:53 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158 in the orange smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The hospital was built in 1993 and the NFPA 101 (2000 edition), section 4.6.7 does not allow a building to be down-graded from the level of original construction unless approved by the authority having jursidiction (AHJ) requiring hazardous rooms to be sprinkled and fire-rated if over 100 square feet at the time of construction for a Building Type II (000) Limited Combustible Construction. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

4. On 04/12/2016 at 11:31 am, observation revealed on the 1st floor in the Inpatient Laundry Room 1117 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not properly fire rated for this hazardous space based on the room being a laundry room with considerable linens and cotton products within the room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

5. On 04/12/2016 at 11:33 am, observation revealed on the 1st floor in the Soiled Linen Room 1116 & Soiled Utility Room 1115 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

6. On 04/12/2016 at 11:36 am, observation revealed on the 1st floor in the Locker Room 1114 in the orange smoke compartment Zone 1, that the door would not self-close because the door closer was removed from the rated door. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

7. On 04/12/2016 at 11:38 am, observation revealed on the 1st floor in the Supply Room 1113 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

8. On 04/12/2016 at 1:15 pm, observation revealed on the 1st floor in the Equipment Holding Room 1102 in the orange smoke compartment Zone 2, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire rated to 1-hour construction above the ceiling for a hazardous room. The room was considered hazardous because it was holding 3 mattresses and 5 to 6 wood pallets (not fire treated) and other combustible elements deemed combustible. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 4.6.7.

9. On 04/12/2016 at 1:18 pm, observation revealed on the 1st floor in the Occupational Therapy Room 1085 in the orange smoke compartment Zone 2, that the hazardous room was not compliant. The room was considered hazardous because of a Toaster Oven positioned under a particle wood wall cabinets on the counter top. The wood cabinets did not provide any protection from the toaster oven and the upper cabinets were about 12 inches from the top of the toaster, its worst heat source. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6 Cooking Facilities.

10. On 04/12/2016 at 1:45 pm, observation revealed on the 1st floor in the Loading Dock 1096, General Storage Room 1095 and Kitchen Storage Room 1088A in the orange smoke compartment Zone 2, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall in each room was not properly fire-rated. The seams were not taped and screws not mudded and top of wall not sealed to the deck above. Multiple penetrations were observed through the walls with no fire sealant or fire dampers where flex-duct was used. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

11. On 04/12/2016 at 3:40 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included two sleeves on both North and South Walls were not fire-sealed per the Life Safety Code requirements for a hazardous space exceeding 100 square feet. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

12. On 04/12/2016 at 3:45 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The fire door protecting the Medical Records File Room was not labeled. The label was painted over or was missing. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101(2000 ed.), 4.6.7.

13. On 04/12/2016 at 4:00 pm, observation revealed on the 1st floor in the Main East-West Corridor on opposite side of the Corridor from Medical Records File Room (Storage Room 1079) in the yellow smoke compartment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire-rated to 1-hour construction above the ceiling in the corner for a hazardous room. The room was considered hazardous because it was holding combustible elements. The corner construction was improperly installed per the listing agencies minimum requirements for a rated enclosure. The wall edge was not taped and screws were not mudded. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

14. On 04/13/2016 at 12:10 pm, observation revealed on the Basement floor in the Storage Room B105, that the hazardous room was not compliant. The walls were missing both 1-hour and 2-hour fire-rating on the hazardous room walls. Fire Evacuation and Life Safety Plans did not show what rooms were fire-rated, therefore need identification on walls themselves for proper fire-rating identification. This Storage Room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

15. On 04/13/2016 at 12:15 pm, observation revealed on the Basement floor in the Fuel Oil Tanks Room B104, that the door would not self-close because door stops' were used, per interview with staff D (Waukesha County Facility Manager), the staff use door stops to keep the door open when accessing and removing things out or in this room. This room contained fuel used for the boilers. The fuel oil tanks contained a considerable amount of fuel oil. The room smelled like fuel oil. The room had a ventilation exhaust fan that was running at the time. The door and walls were at least 2-hours fire construction and the bottom of the room had a concrete catch basin of at least 12 inches to catch whatever fuel oil may have leaked. This room appeared to be a high hazard room enclosure because of the large amount of fuel oil in the tanks. Blocking the door open with a wood wedge is not allowed at any time per the Life Safety Code. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1, and 4.6.7.

16. On 04/13/2016 at 12:16 pm, observation revealed on the Basement floor in the Housekeeping Supplies Room B103, that the door would not self-close because a door hold-open device was placed at the bottom of the 90 minute fire-rated door and prevented the fire door from self-closing, in the event of a fire emergency. The room was hazardous based on the amount of combustibles within the room including; rags, paper supplies, towels, mops, boxes, wood pallets and detergents for cleaning the floors and walls. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7 and 8.4.1.

17. On 04/13/2016 at 12:18 pm, observation revealed on the Basement floor in the Maintenance Shop B100, that the door would not self-close because the closer was removed from the door. You could still see the screw openings within the door where the door closer was previously placed. The door would not automatically self-close in the event of a fire emergency. The door was fire-rated for 90 minutes. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7 and 8.4.1.

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.), and staff C (Waukesha Co. MHC Administrator) on all days, and staff D (Waukesha Co. Fac. Mgr.) on 4/13/2016 only.
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Based on interview and review of record documents, the facility did not conduct fire drills as required by the 2000 edition of the Life Safety Code NFPA 101, to ensure that staff are familiar with fire response procedures of fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency affected 7 out of 7 smoke compartments within the facility including all inpatients, outpatients, staff and visitors.

FINDINGS INCLUDED:
On 04/11/2016 at 2:30 pm, document review revealed that the facility fire drill record for the past 12 Months revealed that fire drills were not conducted at varied locations by quarter and by shift. During the document review of the Facility Fire Drills, the fire drills were found to be using the same location (Front Lobby Pull Station) in the same Quarter (4th) on multiple Shifts (2nd & 3rd). This situation was not compliant with NFPA 101 (2000 ed.), section 19.7.1.2.

This condition was confirmed at the time of discovery by a concurrent review of document records and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and to the Life Safety Code, section 9.6.1.4. These Codes require approval by the authority having jurisdiction (AHJ) in an existing healthcare facility when not installed in compliance with NFPA 72. The Centers for Medicare and Medicaid Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable fire alarm system to defend-in-place. This is consistent with NFPA 72 (1999 edition) section 1-2.3, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with smoke detectors at required locations and did not provide visual alarm notification at all required locations. These deficiencies occurred in 3 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 11:41 am, observation revealed on the Penthouse floor in the Mechanical Room for AHU #1, that the smoke detectors were not located in accordance with NFPA 72 requirements. The smoke detectors were located greater than 12 inches below the highest point of the roof. The smoke detectors were located at the bottom of the steel beams that appeared to be at least 20 - 24 inches in depth. This exceeds the maximum allowed distance from the highest point by the NFPA 72 (1999 edition) Fire Alarm Code. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

2. On 04/12/2016 at 3:12 pm, observation revealed on the Mechanical Penthouse above 1st Floor floor in the Mechanical Room for AHU #2 above the yellow smoke compartment, that the smoke detectors were not located in accordance with NFPA 72 requirements. Several smoke detectors were not located within 12 inches of the highest point of the ceiling and/or deck within the mechanical room. These detectors were located at the bottom of the steel beams and the beams were greater than 18 inches in depth. The mechanical room was separated from the 1st Floor by 2-hour floor decking. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

3. On 04/12/2016 at 3:30 pm, observation revealed on the 1st floor in the Medical Records Office 1021 in red smoke compartment Zone 1, that the facility did not install a visual fire alarm notification device correctly for notification to staff in this space for a fire emergency. Private mode notification requires staff to be aware of all fire alarm situations including visual notification. The visual alarm notification device mounted on the North wall of this Room was blocked by a newly installed upper wall cabinets. The wall cabinets were mounted up-tight against the visual notification device on it's left. This was not to Code per NFPA 72 (1999 ed.). This situation was not compliant with NFPA 72 (1999 ed.), section 4-5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on a review of maintenance documents and interview with facility staff, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications per NFPA 101 (2000 ed.), section 9.6.1.3 and did not have complete Smoke Detector Sensitivity Test Records. These deficiencies would affect 7 out of 7 smoke compartments and all the inpatient, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

On 04/11/2016 at 1:30 pm, record review of the of smoke detector sensitivity tests revealed that the documents did not contain all the required information. During the Fire Alarm Smoke Sensitivity Testing Review, the Annual Report by Action Fire & Alarm, Inc., Waukesha, WI 53187 dated: 08/17/2015 was in-complete. The following locations were missing smoke detector sensitivity readings at: Dock Elevator Shaft; Basement Storage Rooms B105-N & B105-S; Housekeeping Storage Room B103; Patient Rooms 1182, 1184, 1195, 1198 & 1199; Patient Quiet Rooms 1180 & 1177; East Entrance Security Doors at Vestibule; Unit B Restraint Room 1174; and Security Door Entry to Patient Unit B Room 1170. could not tell if the smoke detectors were within the manufacturers range. This situation was not compliant with NFPA 101 (2000 ed.), section 9.6.1.3.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and a compliant sprinkler support system. These deficiencies occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 9:52 am, observation revealed on the 1st floor in the Inpatient Unit A & B at Entry Doors of Room 1150 & 1170, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. This condition was found throughout the hospital, in all smoke compartments, and in both patient areas and non-patient areas. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

2. On 04/12/2016 at 10:08 am, observation revealed on the 1st floor in the Room 1181 in the green smoke compartment of Inpatient Unit B, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. Per NFPA 13, section 6-1.1.1, the components of hanger assemblies that directly attach to the pipe or to the building structure shall be 'listed'. Where a item or object is not shown to be 'listed' as part of this assembly, it cannot be hung from the sprinkler system support system. This condition was throughout the hospital. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

3. On 04/12/2016 at 10:19 am, observation revealed on the 1st floor in the Corridor 1171 in the orange smoke compartment Zone 1, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical flex wiring and conduits within this section of the space. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have the appropriate quantity of spare sprinklers, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint or dust. These deficiencies occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/11/2016 at 3:40 pm, record review and observation revealed that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. All the spare sprinklers were not provided for per the Annual Report of Sprinkler Inspection by SimplexGrinnell Fire Protection Company, dated 10/26/2015 on page 3 of 4. Not all the spare heads were provided for within the spare sprinkler cabinet per observation. The minimum of 2 sprinkler heads by style and temperature were not accounted for. Documentation could not be provided at time of document review from the outside 3rd Party Report. The documents were missing this information. This situation was not compliant with NFPA 25 (1998 ed.), section 2-4.1.4.

2. On 04/12/2016 at 9:30 am, observation revealed on the 1st floor in the Inpatient Charting Room 1167 in the green smoke compartment Units A & B, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

3. On 04/12/2016 at 10:36 am, observation revealed on the 1st floor in the Sally-Port Vestibule at North side of the building in the orange smoke compartment Zone 1, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

4. On 04/12/2016 at 2:50 pm, observation revealed on the 1st floor in the Classrooms 1064 & 1069 in the yellow smoke compartment, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. Numerous other spaces within this smoke compartment were also observed to have dirty and dusty sprinkler heads. There was not an established frequency for cleaning sprinkler heads within the facility. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

5. On 04/12/2016 at 3:20 pm, observation revealed on the 1st floor in the Reception Area 1077 in the yellow smoke compartment, that the escutcheon ring of a sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

6. On 04/13/2016 at 12:25 pm, observation revealed on the 1st floor in the Administrative Corridors 1007 & 1034 in the Red smoke compartment Zone 1, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. This situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

7. On 04/13/2016 at 12:40 pm, observation revealed on the 1st floor in the Administrative Men's Toilet Room 1036 in Red smoke compartment Zone 1, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

8. On 04/13/2016 at 12:43 pm, observation revealed on the 1st floor in the Administrative Corridors 1012 & 1017 in the Red smoke compartment Zone 1 & 2, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

9. On 04/13/2016 at 12:48 pm, observation revealed on the 1st floor in the Vestibules at Exits #14 & #15 in the orange smoke compartment Zone 1, that there was one or more unsealed holes near the ceiling. The holes included 24" x 24" ceiling tiles out at each location and no maintenance personnel were present per interview and the Facility Maintenance personnel did not know who left the ceiling tiles open, nor did anyone else in the facility contact them to alert them when the ceiling tiles were left open. There was no facility Policy that prevented anyone from opening up the ceiling without alerting the facilities Department. These holes would reduce the response time of the sprinklers in the rooms and did not duplicate the tight conditions that were used in the sprinkler UL certification test. These situations were not compliant with NFPA 25 (1998 ed.), section 1-11.1.

10. On 04/13/2016 at 12:59 pm, observation revealed on the 1st floor in the Administrative Conference Room 1058 in the Red smoke compartment Zone 1, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. Based on the review of sprinkler heads in smoke compartments yellow, orange and red, all sprinkler heads need to be monitored and cleaned more regularly. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation, review of records and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, record review and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A with required damper maintenance, compliant air distribution installation and compliant fire dampers. These deficiencies occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/11/2016 at 3:15 pm, a review of documents revealed that all required maintenance procedures were not performed. Dampers were not all identified as TESTED in the documentation review including the following missing Smoke Dampers at: Room #10 - Damper #4 - VAV #10; Room #11 - Damper #6 - VAV #11; Room #13 - Damper #3 - VAV #13; Room #14 - Damper #5 - VAV #14; Room #3 - Damper #2 - VAV #3; Room #23 - Damper #1 - VAV #33; Room #52 - Damper #8 - VAV #52; and Room #60 - Damper #7 - VAV #60. Since no documentation was available for these dampers, nothing could be shown was maintained on them since the last federal survey. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). CMS directs their inspectors to use NFPA 90A as the Guideline that should be followed in all existing facilities and used in surveys. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), section 3-4.7 .

2. On 04/12/2016 at 11:31 am, observation revealed on the 1st floor in the Inpatient Laundry Room 1117 in the orange smoke compartment Zone 1, that a flexible duct (air connector) was installed through the rated wall of the space. Flexible duct is not allowed from a laundry dryer to the outside of a hospital building. The flex duct is a fire hazard and collects dust and lint that add to the potential of a fire occurrence. This situation was not compliant with NFPA 90A (1999 ed.), section 2-3.2.1.4.

3. On 04/12/2016 at 4:19 pm, observation revealed on the 1st floor in the In North-South Corridor and East-West Corridor of the smoke compartments yellow and red, 2-hour smoke barriers above the ceilings, fire dampers were not installed in air ducts that penetrated 2-hour fire-rated wall assemblies. 2-hour wall assemblies were confirmed via stenciling on the walls above the ceilings. These barriers (walls) were originally designed as a 2-hour separation walls, separating the Hospital Occupancy from the Business Occupancy. This situation has changed per interview with staff 'C' and both areas are now combined under the Hospital Occupancy. This same wall is now being used as a smoke barrier, separating the red from the yellow smoke compartments. A 2-hour wall assembly requires a fire damper where a duct passes though it. All ducts passing through this 2-hour wall assembly could not be proved to have fire dampers. This situation was not compliant with NFPA 101 (2000 ed.), section 19.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.

This condition was confirmed at the time of discovery by a concurrent observation, documentation review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, documentation review and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 and kitchen hoods per the Code, range hoods cleaned semi-annually, hoods constructed per the Code and proper fire extinguishers with identification. These deficiencies occurred in 3 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/11/2016 at 3:30 pm, record review revealed that the kitchen hood suppression system was not compliant. During a review of the Kitchen Hood Extinguishing System, per NFPA 96, documentation was not available. The last time the kitchen exhaust hood was inspected was September 2014. Verification was made during the Survey Tour on 04/12/2016 at 1:30 pm, via the Kitchen Hood maintenance identification for the last known inspection documentation. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6, 9.2.3 and NFPA 96.

2. On 04/12/2016 at 1:30 pm, observation revealed on the 1st floor in the Main Kitchen Production Room (used to make meals for other facilities within the County) in the orange smoke compartment Zone 2, a label was not installed on the surface of the hood or elsewhere in the kitchen that showed the date of the last cleaning. The existing kitchen hood was being used over a pizza oven, producing grease laden vapors. The Commercial Exhaust Hood had not been inspected since September 2014 and is supposed to be inspected and cleaned 'semi-annually' per NFPA 96. This situation was not compliant with NFPA 96 (1998 ed.), section 8-3.2.

3. On 04/12/2016 at 2:43 pm, observation revealed on the 1st floor in the Staff Lounge 1074 in the yellow smoke compartment, that two pizza ovens that produce grease laden vapors were missing a Type 1 Kitchen Hood per Code, tied to the fire alarm system and having a special extinguishing system. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6, 9.2.3 and NFPA 96.

4. On 04/12/2016 at 2:45 pm, observation revealed on the 1st floor in the Staff Lounge 1074 in the yellow smoke compartment, that a Type-K, fire extinguisher, was not provided. This situation was not compliant with NFPA 96 (1998 ed.), section 7-10.1.

These conditions were confirmed at the time of discovery by a concurrent observation, documentation review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not implement a policy on the use of portable space heating devices with space heaters that comply with Hospital Code requirements. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDED:

1. On 04/12/2016 at 1:07 pm, observation revealed on the 1st floor in the Office Room in orange smoke compartment Zone 2, that a space heater was used that was designed for 1500 watts and 15 amp circuit (exceeding 212 degrees) with no emergency shut-off of power should it start to over heat. According to the Hospital Policy and Procedures, space heaters are not allowed on-site and 'within' the hospital building. This situation was not compliant with NFPA 101 (2000 ed.), section 19.7.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, staff interviews and review of facility documents, the facility did not have (1.) fire dampers through 2-hour fire-rated assemblies, (2.) proper separation of hazardous spaces to exit stairwells and (3.) a Fire Response Plan that contained all code-required elements including a written fire control plan with correct placement of fire extinguishers per the Life Safety Plan that contained provisions for access of extinguishers (portable fire extinguishers) to assist in putting out a small fires. The facility did not have a building that complied with regulations that were in effect at time of construction and approved to the federal standards. These collective deficiencies occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 1:50 pm, observation revealed on the 1st floor in the Main Electrical Vault Room 1093 in the orange smoke compartment Zone 2, that the two means of exit access was not provided at each end of the electrical working space, which had equipment rated at 1200 amperes or more or was 6' wide or more. The room had combined electrical panels that exceeded 1200 amps, requiring a minimum 1-hour room enclosure. The hospital elected to have a 2-hour enclosure to remove the fire protection system, so as not to mix water and electricity. This then requires any mechanical ducts going into the room to be fire/smoke dampered for a two-hour fire assembly. The fire/smoke dampers were missing. This situation was not compliant with NFPA 70 (1999 ed.), 110-26(c) and NFPA 101 (2000 ed.) section 8.2.3.2.4.1 Penetrations and Miscellaneous Openings to Fire Barriers and 9.2.1 HVAC systems.

2. On 04/12/2016 at 2:20 pm, observation revealed on the 1st floor in the Loading Dock 1096 in orange smoke compartment Zone 2, during a review of facility documents and survey tour the facility failed to maintained the loading dock in accordance with federal laws that were in effect at the time of construction. The Loading Dock used as a Storage Room was not allowed to be opening onto a Stairwell where storag was present. The facility did not have a fire-rated vestibule in front of the stairwell to provide a smoke chamber in front of the stairwell in the event of one door being left open to the hazardous space, protecting the stairwell from smoke and gases, plus maintaining the smoke-tightness of the stairwell in the event of a fire emergency. This situation was not compliant with 42 CFR 482.41(c).

3. On 04/13/2016 at 11:41 am, observation revealed on the Basement floor in the Basement Corridor between Stairs under orange smoke compartment, that during a review of facility documents the facility did not have a written fire response plan that contained a map including the location of all fire extinguishing within that smoke compartment. The plan showed three locations of fire extinguishers and none were located where it was drawn on the Evacuation Plan (dated 08/14). This was in non-compliance for requirements of NFPA 101 (2000 ed.) section 19.7.2.2(8) Extinguishment of fire, and NFPA 10 (1998 ed.) Standard for Portable Fire Extinguishers. This situation was not compliant with 42 CFR 482.41(b)(7).

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and NFPA 99, with fixed wiring rather than temporary wiring above ceiling, electrical outlets and switches with identification back to its power source and electrical panels with complete directories. These deficiencies occurred in 2 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/12/2016 at 10:02 am, observation revealed on the 1st floor in the Nurse Office Room 1169 in the green smoke compartment Unit B, that the temporary electrical wires and lighting was left-up above the ceiling in several places within the hospital facility after construction completion for temporary power and lighting during construction. This situation was not compliant with NFPA 70 (1999 ed.), section 400-8 (1), article 517-18 and NFPA 99.

2. On 04/12/2016 at 11:00 am, observation revealed on the 1st floor in the Green and Orange smoke compartment spaces, with electrical outlets and switches that are part of the Essential Electrical System (EES) per NFPA 99 (1999 ed.) at 1st and Basement Areas within the Hospital, the electrical outlets and switches were not labeled to identify were its power came from in the EES. Per interview with staff A & B all outlets and switches throughout the patient and staff areas of the hospital are on the Essential Electrical System (EES). This situation was not compliant with NFPA 99 (1999 edition), Chapter 3, Identification and NFPA 70 (1999 ed.), Section 110-22.

3. On 04/12/2016 at 11:23 am, observation revealed on the 1st floor in the Corridor outside Unit A in orange smoke compartment at Zone 1, that the electrical panel breakers were not labeled to identify the loads they fed. Panel #HH SEC 2, was observed to have a switch #48 in the 'ON' position and was identified to be a 'Spare'. This situation was not compliant with NFPA 70 (1999 ed.), Section 110-22 and NFPA 99.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not provide and maintain the required building construction type. Wood was present and not protected or covered with rated fire-proofing. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:04 am, observation revealed on the 1st floor in the Nurse Office Room 1169, in the green smoke compartment Unit B, fire proofing was missing around the exposed wood when used above the suspended ceiling. This does not meet 'limited combustibility requirements' per NFPA 101 s. 3.3.118 for fire-rating of this hospital building Type II (000), and adds to the fuel source above the unprotected ceiling areas. Wood was left behind from the original construction as part of the framing and was never removed after completion. This was observed throughout the hospital above the ceilings. This situation was not compliant with NFPA 101 (2000 ed.), sections 3.3.118 and 19.1.6.2.

2. On 04/12/2016 at 10:14 am, observation revealed on the 1st floor in the Corridor 1171, in the orange smoke compartment Zone 1, above Door 1181, fire proofing was missing around the exposed wood when used above the suspended ceiling. This does not meet 'limited combustibility requirements' per NFPA 101 s. 3.3.118 for fire-rating of this hospital building Type II (000), and adds to the fuel source above the unprotected ceiling areas. This situation was not compliant with NFPA 101 (2000 ed.), sections 3.3.118 and 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight corridor frames. This deficiency occurred in 1 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/12/2016 at 1:25 pm, observation revealed on the 1st floor in the Visitors Lounge Room 1098, in the orange smoke compartment Zone 2, the door had a frame that would not resist the passage of smoke because the door frame was designed with no door frame 'butt' to stop the spread of smoke to the corridor. The room had no smoke detection if open to the corridor. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with properly rated door and frame assemblies, ducts in fire-rated wall assemblies with fire dampers and sealed floor or vertical shaft penetrations. These deficiencies occurred in 4 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:55 am, observation revealed on the 1st floor in the Conference Room 1161 in orange smoke compartment Zone 1, penetrations in a vertical shaft were not sealed according to an approved method. The deficiencies included abandoned pipes and metal sleeves above ceiling through the floor deck assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

2. On 04/12/2016 at 2:00 pm, observation revealed on the 1st floor in the Stairwell 1090 in orange smoke compartment Zone 2, the shaft door frame could not be verified that it had the correct fire-rating. The label was recently painted over and the label could not be read. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.1.1, 8.2.5.4 and 8.2.3.2.

3. On 04/12/2016 at 2:10 pm, observation revealed on the 1st & Basement floors in the Stairwell 1090 in orange smoke compartment Zone 2, one or more air ducts penetrated the vertical shaft enclosure and could not be confirmed to have a properly installed fire damper. The mechanical duct penetrating the Stairwell 1090 was not fire-dampered and smoke-dampered. Under new construction requirements, ducts are not allowed to penetrate a Stairwell, if not serving the stairwell. Mechanical ducts must be outside the Stairwell unless serving it. This observed situation was not compliant with NFPA 90A (1999 ed.), section 3-3.4.

4. On 04/12/2016 at 2:15 pm, observation revealed on the 1st & Basement floors in the Stairwell 1090 at 1st floor landing in orange smoke compartment Zone 2, penetrations in a vertical shaft were not sealed according to an approved method. The deficiencies included multiple electrical conduits and wires not serving the Stairwell. The wiring was added after the original Stairs were constructed. Items are not allowed to enter a Stairwell unless serving the Stairwell. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

5. On 04/12/2016 at 3:07 pm, observation revealed on the Mechanical Penthouse above 1st Floor floor in the Mechanical Room for AHU #2, that penetrations through the fire-rated floor assembly were not fire-sealed according to an approved method. The deficiency included a 1 inch diameter pipe penetrating the floor assembly between 1st floor and mechanical room penthouse. Smoke and hot gases could easily penetrate the opening, compromising any occupants within the penthouse. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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, with incorrect fire-rating stenciling and sealed wall penetrations. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 9:39 am, observation revealed on the 1st floor in the Staff Mail Room 1164 & Inpatient Unit 1150 in the green smoke compartment Unit A, penetrations were not sealed according to an approved method. The deficiency included a 2 inch diameter sleeve not properly fire-sealed at Room 1164 and a 1 inch diameter pipe sleeve at West wall of Room 1150. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

2. On 04/12/2016 at 9:45 am, observation revealed on the 1st floor in the Nurse Office Room 1153 in the green smoke compartment Unit A, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. There was a 4" x 4" patch not properly edge taped and screws mudded. Could not confirm if screws were anchored into metal studs per the UL assembly. There was also a 1 inch diameter metal sleeve not properly fire-sealed through the 60 minute assembly. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

3. On 04/12/2016 at 10:01 am, observation revealed on the 1st floor in the Nurse Office Room 1169 in the green smoke compartment Unit B, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. There was a 2" x 4" patch not properly edge taped and screws mudded. Could not confirm if screws were anchored into metal studs. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

4. On 04/12/2016 at 10:18 am, observation revealed on the 1st floor in the Corridor 1171 in the orange smoke compartment Zone 1, penetrations were not sealed according to an approved method. The deficiencies included three open conduits above the ceiling at the East wall of the smoke barrier. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

5. On 04/12/2016 at 10:25 am, observation revealed on the 1st floor in the Office Room 1162 in the orange smoke compartment Zone 1, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because the construction joints were not sealed where the wall met the deck above. At the time of construction (1993), the smoke barriers were required to meet a 60 minute fire-rating and now cannot be diminished unless approved by the authority having jurisdiction (AHJ). This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

6. On 04/12/2016 at 11:11 am, observation revealed on the 1st floor in the Office Room 1154 in the orange smoke compartment Zone 1, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because patches in the drywall were not coated with joint compound at screws and at gypsum wallboard joints. Seams above ceiling between horizontal and vertical gypsum wallboard panels only had mud at seams and were missing joint taping as required by the fire-rated assembly. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

7. On 04/12/2016 at 11:15 am, observation revealed on the 1st floor in the Psychologist Office Room 1152 in the orange smoke compartment Zone 1, that the smoke barrier wall was not compliant. It was incorrectly identified as the wrong fire-rating by the stenciling (2 hour verses 1 hour). The smoke barrier was incorrectly stenciled at the South Smoke Barrier. The stenciling showed the smoke barrier extending farther than what was actually the case and miss-represented the actual conditions of the rated assembly. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

8. On 04/12/2016 at 11:21 am, observation revealed on the 1st floor in the Treatment Room next to Room 1152 in orange smoke compartment at Zone 1, penetrations were not sealed according to an approved method. The deficiency included the smoke barrier (walls) with open sleeves above the ceiling at the East & South Walls. The sleeves were not fire-sealed. These situations were not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

9. On 04/12/2016 at 2:40 pm, observation revealed on the 1st floor in the spaces along the orange and yellow smoke compartment barrier, that the smoke barrier (wall) was not constructed to a 60 minute fire resistance rating because the construction joint was not sealed where the wall met the deck above. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

10. On 04/12/2016 at 3:42 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment, that penetrations were not sealed according to an approved method. The deficiencies included multiple steel roof joists not properly fire-sealed where they penetrated the 1-hour and 2-hour stenciled fire and smoke barriers (walls) above the ceiling. The room straddled the smoke barrier separating the red from the yellow smoke compartments. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

11. On 04/12/2016 at 3:50 pm, observation revealed on the 1st floor in the Main East-West Corridor outside the Medical Records File Room in the yellow smoke compartment, the smoke barrier wall was not compliant. It was incorrectly identified as the wrong fire-rating stenciling. The stenciling above the ceiling in the corridor was incorrect. It was shown as a 2-hour wall assembly, but was not identified the same as the Life Safety Plans. The stenciling was incorrect according to an interview with staff A and staff B. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

12. On 04/12/2016 at 4:10 pm, observation revealed on the 1st floor in the In North-South Corridor along 2-hour Smoke Barrier, across from Room 1074, penetrations were not sealed according to an approved method. The deficiency included a metal sleeve through the wall abocve the ceiling not fire-sealed. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, review of life safety plans, and interview, the facility did not enclose hazardous rooms (built in 1993 to the NFPA 101 (1991 ed.) Life Safety Code, section 12-3.2.1) with fire-rated wall construction, sealed wall penetrations, rated fire doors and closers on all hazardous room doors. Buildings cannot be down-graded from the level of original construction unless approved by the authority having jurisdiction (AHJ) per NFPA 101 (2000 ed.), section 4.6.7. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 10:49 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that the wall of this hazardous room was not constructed to the required fire resistance rating. Some of the construction joints were not sealed above the ceiling where the wall met the deck above. A (8" x 8") hole was observed at the South wall above-the-ceiling. The room was considered hazardous because it exceeded 100 square feet in area and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

2. On 04/12/2016 at 10:51 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included all pipes and flex ducts penetrating this 1-hour fire-rated room above the ceiling. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

3. On 04/12/2016 at 10:53 am, observation revealed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158 in the orange smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The hospital was built in 1993 and the NFPA 101 (2000 edition), section 4.6.7 does not allow a building to be down-graded from the level of original construction unless approved by the authority having jursidiction (AHJ) requiring hazardous rooms to be sprinkled and fire-rated if over 100 square feet at the time of construction for a Building Type II (000) Limited Combustible Construction. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

4. On 04/12/2016 at 11:31 am, observation revealed on the 1st floor in the Inpatient Laundry Room 1117 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not properly fire rated for this hazardous space based on the room being a laundry room with considerable linens and cotton products within the room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

5. On 04/12/2016 at 11:33 am, observation revealed on the 1st floor in the Soiled Linen Room 1116 & Soiled Utility Room 1115 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

6. On 04/12/2016 at 11:36 am, observation revealed on the 1st floor in the Locker Room 1114 in the orange smoke compartment Zone 1, that the door would not self-close because the door closer was removed from the rated door. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

7. On 04/12/2016 at 11:38 am, observation revealed on the 1st floor in the Supply Room 1113 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

8. On 04/12/2016 at 1:15 pm, observation revealed on the 1st floor in the Equipment Holding Room 1102 in the orange smoke compartment Zone 2, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire rated to 1-hour construction above the ceiling for a hazardous room. The room was considered hazardous because it was holding 3 mattresses and 5 to 6 wood pallets (not fire treated) and other combustible elements deemed combustible. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 4.6.7.

9. On 04/12/2016 at 1:18 pm, observation revealed on the 1st floor in the Occupational Therapy Room 1085 in the orange smoke compartment Zone 2, that the hazardous room was not compliant. The room was considered hazardous because of a Toaster Oven positioned under a particle wood wall cabinets on the counter top. The wood cabinets did not provide any protection from the toaster oven and the upper cabinets were about 12 inches from the top of the toaster, its worst heat source. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.6 Cooking Facilities.

10. On 04/12/2016 at 1:45 pm, observation revealed on the 1st floor in the Loading Dock 1096, General Storage Room 1095 and Kitchen Storage Room 1088A in the orange smoke compartment Zone 2, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall in each room was not properly fire-rated. The seams were not taped and screws not mudded and top of wall not sealed to the deck above. Multiple penetrations were observed through the walls with no fire sealant or fire dampers where flex-duct was used. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

11. On 04/12/2016 at 3:40 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included two sleeves on both North and South Walls were not fire-sealed per the Life Safety Code requirements for a hazardous space exceeding 100 square feet. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

12. On 04/12/2016 at 3:45 pm, observation revealed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The fire door protecting the Medical Records File Room was not labeled. The label was painted over or was missing. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101(2000 ed.), 4.6.7.

13. On 04/12/2016 at 4:00 pm, observation revealed on the 1st floor in the Main East-West Corridor on opposite side of the Corridor from Medical Records File Room (Storage Room 1079) in the yellow smoke compartment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire-rated to 1-hour construction above the ceiling in the corner for a hazardous room. The room was considered hazardous because it was holding combustible elements. The corner construction was improperly installed per the listing agencies minimum requirements for a rated enclosure. The wall edge was not taped and screws were not mudded. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

14. On 04/13/2016 at 12:10 pm, observation revealed on the Basement floor in the Storage Room B105, that the hazardous room was not compliant. The walls were missing both 1-hour and 2-hour fire-rating on the hazardous room walls. Fire Evacuation and Life Safety Plans did not show what rooms were fire-rated, therefore need identification on walls themselves for proper fire-rating identification. This Storage Room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

15. On 04/13/2016 at 12:15 pm, observation revealed on the Basement floor in the Fuel Oil Tanks Room B104, that the door would not self-close because door stops' were used, per interview with staff D (Waukesha County Facility Manager), the staff use door stops to keep the door open when accessing and removing things out or in this room. This room contained fuel used for the boilers. The fuel oil tanks contained a considerable amount of fuel oil. The room smelled like fuel oil. The room had a ventilation exhaust fan that was running at the time. The door and walls were at least 2-hours fire construction and the bottom of the room had a concrete catch basin of at least 12 inches to catch whatever fuel oil may have leaked. This room appeared to be a high hazard room enclosure because of the large amount of fuel oil in the tanks. Blocking the door open with a wood wedge is not allowed at any time per the Life Safety Code. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.1 and 8.4.1, and 4.6.7.

16. On 04/13/2016 at 12:16 pm, observation revealed on the Basement floor in the Housekeeping Supplies Room B103, that the door would not self-close because a door hold-open device was placed at the bottom of the 90 minute fire-rated door and prevented the fire door from self-closing, in the event of a fire emergency. The room was hazardous based on the amount of combustibles within the room including; rags, paper supplies, towels, mops, boxes, wood pallets and detergents for cleaning the floors and walls. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7 and 8.4.1.

17. On 04/13/2016 at 12:18 pm, observation revealed on the Basement floor in the Maintenance Shop B100, that the door would not self-close because the closer was removed from the door. You could still see the screw openings within the door where the door closer was previously placed. The door would not automatically self-close in the event of a fire emergency. The door was fire-rated for 90 minutes. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7 and 8.4.1.

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.), and staff C (Waukesha Co. MHC Administrator) on all days, and staff D (Waukesha Co. Fac. Mgr.) on 4/13/2016 only.
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Based on interview and review of record documents, the facility did not conduct fire drills as required by the 2000 edition of the Life Safety Code NFPA 101, to ensure that staff are familiar with fire response procedures of fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency affected 7 out of 7 smoke compartments within the facility including all inpatients, outpatients, staff and visitors.

FINDINGS INCLUDED:
On 04/11/2016 at 2:30 pm, document review revealed that the facility fire drill record for the past 12 Months revealed that fire drills were not conducted at varied locations by quarter and by shift. During the document review of the Facility Fire Drills, the fire drills were found to be using the same location (Front Lobby Pull Station) in the same Quarter (4th) on multiple Shifts (2nd & 3rd). This situation was not compliant with NFPA 101 (2000 ed.), section 19.7.1.2.

This condition was confirmed at the time of discovery by a concurrent review of document records and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and to the Life Safety Code, section 9.6.1.4. These Codes require approval by the authority having jurisdiction (AHJ) in an existing healthcare facility when not installed in compliance with NFPA 72. The Centers for Medicare and Medicaid Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable fire alarm system to defend-in-place. This is consistent with NFPA 72 (1999 edition) section 1-2.3, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with smoke detectors at required locations and did not provide visual alarm notification at all required locations. These deficiencies occurred in 3 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 11:41 am, observation revealed on the Penthouse floor in the Mechanical Room for AHU #1, that the smoke detectors were not located in accordance with NFPA 72 requirements. The smoke detectors were located greater than 12 inches below the highest point of the roof. The smoke detectors were located at the bottom of the steel beams that appeared to be at least 20 - 24 inches in depth. This exceeds the maximum allowed distance from the highest point by the NFPA 72 (1999 edition) Fire Alarm Code. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

2. On 04/12/2016 at 3:12 pm, observation revealed on the Mechanical Penthouse above 1st Floor floor in the Mechanical Room for AHU #2 above the yellow smoke compartment, that the smoke detectors were not located in accordance with NFPA 72 requirements. Several smoke detectors were not located within 12 inches of the highest point of the ceiling and/or deck within the mechanical room. These detectors were located at the bottom of the steel beams and the beams were greater than 18 inches in depth. The mechanical room was separated from the 1st Floor by 2-hour floor decking. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

3. On 04/12/2016 at 3:30 pm, observation revealed on the 1st floor in the Medical Records Office 1021 in red smoke compartment Zone 1, that the facility did not install a visual fire alarm notification device correctly for notification to staff in this space for a fire emergency. Private mode notification requires staff to be aware of all fire alarm situations including visual notification. The visual alarm notification device mounted on the North wall of this Room was blocked by a newly installed upper wall cabinets. The wall cabinets were mounted up-tight against the visual notification device on it's left. This was not to Code per NFPA 72 (1999 ed.). This situation was not compliant with NFPA 72 (1999 ed.), section 4-5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on a review of maintenance documents and interview with facility staff, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications per NFPA 101 (2000 ed.), section 9.6.1.3 and did not have complete Smoke Detector Sensitivity Test Records. These deficiencies would affect 7 out of 7 smoke compartments and all the inpatient, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

On 04/11/2016 at 1:30 pm, record review of the of smoke detector sensitivity tests revealed that the documents did not contain all the required information. During the Fire Alarm Smoke Sensitivity Testing Review, the Annual Report by Action Fire & Alarm, Inc., Waukesha, WI 53187 dated: 08/17/2015 was in-complete. The following locations were missing smoke detector sensitivity readings at: Dock Elevator Shaft; Basement Storage Rooms B105-N & B105-S; Housekeeping Storage Room B103; Patient Rooms 1182, 1184, 1195, 1198 & 1199; Patient Quiet Rooms 1180 & 1177; East Entrance Security Doors at Vestibule; Unit B Restraint Room 1174; and Security Door Entry to Patient Unit B Room 1170. could not tell if the smoke detectors were within the manufacturers range. This situation was not compliant with NFPA 101 (2000 ed.), section 9.6.1.3.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and a compliant sprinkler support system. These deficiencies occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 9:52 am, observation revealed on the 1st floor in the Inpatient Unit A & B at Entry Doors of Room 1150 & 1170, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. This condition was found throughout the hospital, in all smoke compartments, and in both patient areas and non-patient areas. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

2. On 04/12/2016 at 10:08 am, observation revealed on the 1st floor in the Room 1181 in the green smoke compartment of Inpatient Unit B, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. Per NFPA 13, section 6-1.1.1, the components of hanger assemblies that directly attach to the pipe or to the building structure shall be 'listed'. Where a item or object is not shown to be 'listed' as part of this assembly, it cannot be hung from the sprinkler system support system. This condition was throughout the hospital. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

3. On 04/12/2016 at 10:19 am, observation revealed on the 1st floor in the Corridor 1171 in the orange smoke compartment Zone 1, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical flex wiring and conduits within this section of the space. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have the appropriate quantity of spare sprinklers, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint or dust. These deficiencies occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/11/2016 at 3:40 pm, record review and observation revealed that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. All the spare sprinklers were not provided for per the Annual Report of Sprinkler Inspection by SimplexGrinnell Fire Protection Company, dated 10/26/2015 on page 3 of 4. Not all the spare heads were provided for within the spare sprinkler cabinet per observation. The minimum of 2 sprinkler heads by style and temperature were not accounted for. Documentation could not be provided at time of document review from the outside 3rd Party Report. The documents were missing this information. This situation was not compliant with NFPA 25 (1998 ed.), section 2-4.1.4.

2. On 04/12/2016 at 9:30 am, observation revealed on the 1st floor in the Inpatient Charting Room 1167 in the green smoke compartment Units A & B, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

3. On 04/12/2016 at 10:36 am, observation revealed on the 1st floor in the Sally-Port Vestibule at North side of the building in the orange smoke compartment Zone 1, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

4. On 04/12/2016 at 2:50 pm, observation revealed on the 1st floor in the Classrooms 1064 & 1069 in the yellow smoke compartment, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. Numerous other spaces within this smoke compartment were also observed to have dirty and dusty sprinkler heads. There was not an established frequency for cleaning sprinkler heads within the facility. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

5. On 04/12/2016 at 3:20 pm, observation revealed on the 1st floor in the Reception Area 1077 in the yellow smoke compartment, that the escutcheon ring of a sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

6. On 04/13/2016 at 12:25 pm, observation revealed on the 1st floor in the Administrative Corridors 1007 & 1034 in the Red smoke compartment Zone 1, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. This situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

7. On 04/13/2016 at 12:40 pm, observation revealed on the 1st floor in the Administrative Men's Toilet Room 1036 in Red smoke compartment Zone 1, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

8. On 04/13/2016 at 12:43 pm, observation revealed on the 1st floor in the Administrative Corridors 1012 & 1017 in the Red smoke compartment Zone 1 & 2, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

9. On 04/13/2016 at 12:48 pm, observation revealed on the 1st floor in the Vestibules at Exits #14 & #15 in the orange smoke compartment Zone 1, that there was one or more unsealed holes near the ceiling. The holes included 24" x 24" ceiling tiles out at each location and no maintenance personnel were present per interview and the Facility Maintenance personnel did not know who left the ceiling tiles open, nor did anyone else in the facility contact them to alert them when the ceiling tiles were left open. There was no facility Policy that prevented anyone from opening up the ceiling without alerting the facilities Department. These holes would reduce the response time of the sprinklers in the rooms and did not duplicate the tight conditions that were used in the sprinkler UL certification test. These situations were not compliant with NFPA 25 (1998 ed.), section 1-11.1.

10. On 04/13/2016 at 12:59 pm, observation revealed on the 1st floor in the Administrative Conference Room 1058 in the Red smoke compartment Zone 1, that sprinklers were not kept free of lint or other foreign materials and maintained to keep the system fully-operable as designed. Based on the review of sprinkler heads in smoke compartments yellow, orange and red, all sprinkler heads need to be monitored and cleaned more regularly. These situations were not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation, review of records and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, record review and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A with required damper maintenance, compliant air distribution installation and compliant fire dampers. These deficiencies occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/11/2016 at 3:15 pm, a review of documents revealed that all required maintenance procedures were not performed. Dampers were not all identified as TESTED in the documentation review including the following missing Smoke Dampers at: Room #10 - Damper #4 - VAV #10; Room #11 - Damper #6 - VAV #11; Room #13 - Damper #3 - VAV #13; Room #14 - Damper #5 - VAV #14; Room #3 - Damper #2 - VAV #3; Room #23 - Damper #1 - VAV #33; Room #52 - Damper #8 - VAV #52; and Room #60 - Damper #7 - VAV #60. Since no documentation was available for these dampers, nothing could be shown was maintained on them since the last federal survey. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). CMS directs their inspectors to use NFPA 90A as the Guideline that should be followed in all existing facilities and used in surveys. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), section 3-4.7 .

2. On 04/12/2016 at 11:31 am, observation revealed on the 1st floor in the Inpatient Laundry Room 1117 in the orange smoke compartment Zone 1, that a flexible duct (air connector) was installed through the rated wall of the space. Flexible duct is not allowed from a laundry dryer to the outside of a hospital building. The flex duct is a fire hazard and collects dust and lint that add to the potential of a fire occurrence. This situation was not compliant with NFPA 90A (1999 ed.), section 2-3.2.1.4.

3. On 04/12/2016 at 4:19 pm, observation revealed on the 1st floor in the In North-South Corridor and East-West Corridor of the smoke compartments yellow and red, 2-hour smoke barriers above the ceilings, fire dampers were not installed in air ducts that penetrated 2-hour fire-rated wall assemblies. 2-hour wall assemblies were confirmed via stenciling on the walls above the ceilings. These barriers (walls) were originally designed as a 2-hour separation walls, separating the Hospital Occupancy from the Business Occupancy. This situation has changed per interview with staff 'C' and both areas are now combined under the Hospital Occupancy. This same wall is now being used as a smoke barrier, separating the red from the yellow smoke compartments. A 2-hour wall assembly requires a fire damper where a duct passes though it. All ducts passing through this 2-hour wall assembly could not be proved to have fire dampers. This situation was not compliant with NFPA 101 (2000 ed.), section 19.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.

This condition was confirmed at the time of discovery by a concurrent observation, documentation review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, documentation review and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 and kitchen hoods per the Code, range hoods cleaned semi-annually, hoods constructed per the Code and proper fire extinguishers with identification. These deficiencies occurred in 3 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/11/2016 at 3:30 pm, record review revealed that the kitchen hood suppression system was not compliant. During a review of the Kitchen Hood Extinguishing System, per NFPA 96, documentation was not available. The last time the kitchen exhaust hood was inspected was September 2014. Verification was made during the Survey Tour on 04/12/2016 at 1:30 pm, via the Kitchen Hood maintenance identification for the last known inspection documentation. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6, 9.2.3 and NFPA 96.

2. On 04/12/2016 at 1:30 pm, observation revealed on the 1st floor in the Main Kitchen Production Room (used to make meals for other facilities within the County) in the orange smoke compartment Zone 2, a label was not installed on the surface of the hood or elsewhere in the kitchen that showed the date of the last cleaning. The existing kitchen hood was being used over a pizza oven, producing grease laden vapors. The Commercial Exhaust Hood had not been inspected since September 2014 and is supposed to be inspected and cleaned 'semi-annually' per NFPA 96. This situation was not compliant with NFPA 96 (1998 ed.), section 8-3.2.

3. On 04/12/2016 at 2:43 pm, observation revealed on the 1st floor in the Staff Lounge 1074 in the yellow smoke compartment, that two pizza ovens that produce grease laden vapors were missing a Type 1 Kitchen Hood per Code, tied to the fire alarm system and having a special extinguishing system. This situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6, 9.2.3 and NFPA 96.

4. On 04/12/2016 at 2:45 pm, observation revealed on the 1st floor in the Staff Lounge 1074 in the yellow smoke compartment, that a Type-K, fire extinguisher, was not provided. This situation was not compliant with NFPA 96 (1998 ed.), section 7-10.1.

These conditions were confirmed at the time of discovery by a concurrent observation, documentation review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation and interview, the facility did not implement a policy on the use of portable space heating devices with space heaters that comply with Hospital Code requirements. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDED:

1. On 04/12/2016 at 1:07 pm, observation revealed on the 1st floor in the Office Room in orange smoke compartment Zone 2, that a space heater was used that was designed for 1500 watts and 15 amp circuit (exceeding 212 degrees) with no emergency shut-off of power should it start to over heat. According to the Hospital Policy and Procedures, space heaters are not allowed on-site and 'within' the hospital building. This situation was not compliant with NFPA 101 (2000 ed.), section 19.7.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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Based on observation, staff interviews and review of facility documents, the facility did not have (1.) fire dampers through 2-hour fire-rated assemblies, (2.) proper separation of hazardous spaces to exit stairwells and (3.) a Fire Response Plan that contained all code-required elements including a written fire control plan with correct placement of fire extinguishers per the Life Safety Plan that contained provisions for access of extinguishers (portable fire extinguishers) to assist in putting out a small fires. The facility did not have a building that complied with regulations that were in effect at time of construction and approved to the federal standards. These collective deficiencies occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/12/2016 at 1:50 pm, observation revealed on the 1st floor in the Main Electrical Vault Room 1093 in the orange smoke compartment Zone 2, that the two means of exit access was not provided at each end of the electrical working space, which had equipment rated at 1200 amperes or more or was 6' wide or more. The room had combined electrical panels that exceeded 1200 amps, requiring a minimum 1-hour room enclosure. The hospital elected to have a 2-hour enclosure to remove the fire protection system, so as not to mix water and electricity. This then requires any mechanical ducts going into the room to be fire/smoke dampered for a two-hour fire assembly. The fire/smoke dampers were missing. This situation was not compliant with NFPA 70 (1999 ed.), 110-26(c) and NFPA 101 (2000 ed.) section 8.2.3.2.4.1 Penetrations and Miscellaneous Openings to Fire Barriers and 9.2.1 HVAC systems.

2. On 04/12/2016 at 2:20 pm, observation revealed on the 1st floor in the Loading Dock 1096 in orange smoke compartment Zone 2, during a review of facility documents and survey tour the facility failed to maintained the loading dock in accordance with federal laws that were in effect at the time of construction. The Loading Dock used as a Storage Room was not allowed to be opening onto a Stairwell where storag was present. The facility did not have a fire-rated vestibule in front of the stairwell to provide a smoke chamber in front of the stairwell in the event of one door being left open to the hazardous space, protecting the stairwell from smoke and gases, plus maintaining the smoke-tightness of the stairwell in the event of a fire emergency. This situation was not compliant with 42 CFR 482.41(c).

3. On 04/13/2016 at 11:41 am, observation revealed on the Basement floor in the Basement Corridor between Stairs under orange smoke compartment, that during a review of facility documents the facility did not have a written fire response plan that contained a map including the location of all fire extinguishing within that smoke compartment. The plan showed three locations of fire extinguishers and none were located where it was drawn on the Evacuation Plan (dated 08/14). This was in non-compliance for requirements of NFPA 101 (2000 ed.) section 19.7.2.2(8) Extinguishment of fire, and NFPA 10 (1998 ed.) Standard for Portable Fire Extinguishers. This situation was not compliant with 42 CFR 482.41(b)(7).

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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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 and NFPA 99, with fixed wiring rather than temporary wiring above ceiling, electrical outlets and switches with identification back to its power source and electrical panels with complete directories. These deficiencies occurred in 2 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

1. On 04/12/2016 at 10:02 am, observation revealed on the 1st floor in the Nurse Office Room 1169 in the green smoke compartment Unit B, that the temporary electrical wires and lighting was left-up above the ceiling in several places within the hospital facility after construction completion for temporary power and lighting during construction. This situation was not compliant with NFPA 70 (1999 ed.), section 400-8 (1), article 517-18 and NFPA 99.

2. On 04/12/2016 at 11:00 am, observation revealed on the 1st floor in the Green and Orange smoke compartment spaces, with electrical outlets and switches that are part of the Essential Electrical System (EES) per NFPA 99 (1999 ed.) at 1st and Basement Areas within the Hospital, the electrical outlets and switches were not labeled to identify were its power came from in the EES. Per interview with staff A & B all outlets and switches throughout the patient and staff areas of the hospital are on the Essential Electrical System (EES). This situation was not compliant with NFPA 99 (1999 edition), Chapter 3, Identification and NFPA 70 (1999 ed.), Section 110-22.

3. On 04/12/2016 at 11:23 am, observation revealed on the 1st floor in the Corridor outside Unit A in orange smoke compartment at Zone 1, that the electrical panel breakers were not labeled to identify the loads they fed. Panel #HH SEC 2, was observed to have a switch #48 in the 'ON' position and was identified to be a 'Spare'. This situation was not compliant with NFPA 70 (1999 ed.), Section 110-22 and NFPA 99.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
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