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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 1:45 pm, observation revealed on the 1st floor in the door to the nursing home by the chapel, that the separation wall was not constructed to have a 2-hour fire resistance rating because the wall was not continuous above the door to the cinder block. There was a three inch gap. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

2) On January 28, 2013 at 3:15 pm, observation revealed on the 1st floor in the sleep study monitoring room, that the separation wall was not constructed to have a 2-hour fire resistance rating because there were unsealed penetrations and spaces around the fire damper, and the damper was installed without metal flanges. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

3) On January 29, 2013 at 11:15 am, observation revealed on the lower level floor in the Rural Health Procedure room, that penetrations were not sealed according to an approved method. The deficiency included a hole in the ceiling/floor assembly and 2 holes in the south wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

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

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide corridor finishes with rated wall finish materials. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On January 28, 2013 at 12:45 pm, observation revealed on the 1st floor in the radiology nurse station, that the facility could not confirm the wall had the appropriate rating. The corridor wall was finished with carpet at the nurse station. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.3.1.

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

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and rated walls in a non-sprinkled compartment. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On January 28, 2013 at 12:55 pm, observation revealed on the 1st floor in the corridor near the stair by the surgery area, that the corridor separation wall was not constructed to a 30 minute fire resistance rating. The corridor was not within a fully sprinkled smoke compartment. The holes included a 5 inch diameter hole where the water cooler use to be present. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.2.1.

2. On January 28, 2013 at 1:05 pm, observation revealed on the 1st floor in the corridor by (behind) the radiology nurse station, that the corridor separation wall was not constructed to a 30 minute fire resistance rating. The corridor was not within a fully sprinkled smoke compartment. The walls seams were not taped and the screws were not mudded with plaster. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.2.2.

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

Based on observation and interview, the facility did not provide corridor separation doors with double doors with an astragal seal. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On January 28, 2013 at 10:45 am, observation revealed on the 1st floor in the emergency department, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5-exception 4.

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

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 1:58 pm, observation revealed on the 1st floor in the room 114, ICU, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges, and this gap was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

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

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 1:15 pm, observation revealed on the 1st floor in the across corridor smoke barrier wall by Resp. Therapy, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because screws were not mudded with plaster, seams were not mudded and taped and medical air and electrical conduit was not properly fire stopped. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

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

Based on observation and interview, the facility did not provide and maintain hazardous door assemblies that meet code requirements for hazardous areas with doors held-open with the required safe guards and the facility did not enclose hazardous rooms with rated doors and rated walls. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 10:30 am, observation revealed on the 1st floor in the gift shop storage room, that the hazardous room door was prevented from self-closing by door wedge. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2) On January 28, 2013 at 11:52 am, observation revealed on the 1st floor in the disaster closet, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. In addition, the door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3) On January 28, 2013 at 1:35 pm, observation revealed on the 1st floor in the old record room, that the door to this hazardous room was equipped with a magnetic hold-open device but no a local smoke detector was installed on either side for "door release" requirement. There was not a smoke detector for the corridor door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101(2000 ed.), 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6.

4) On January 28, 2013 at 3:05 pm, observation revealed on the 1st floor in the Medical records room near room 188, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had glass that was not rated and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5) On January 29, 2013 at 10:50 am, observation revealed on the lower level floor in the supply room for the OR, that the door would not self-close because the door had no closer. In addition, the door was not smoke tight. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.

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

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 2:25 pm, observation revealed that staff were not familiar with their responsibilities in the event of a fire, including where the oxygen shut off valve was located for the ICU and when to shut off the oxygen supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

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

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services 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) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with compliant fire alarm. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 9:08 am, observation revealed on the lower level floor in the kitchen, that the fire alarm installation was not compliant. The kitchen hood suppression system was not connected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

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

Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with required testing. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 9:20 am, observation revealed that during a review of facility documents reports that code-required tests of the fire alarm system were not properly conducted. The horn and strobes of the fire alarm system was not checked per annual inspection Report dated 10/31/2012. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

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

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, and no obstructions near the sprinkler. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On January 28, 2013 at 2:50 pm, observation revealed on the 1st floor in rooms 188 and 192, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 3 inches away and 4 inches below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On January 28, 2013 at 3:00 pm, observation revealed on the 1st floor in the Medical records room near room 188, that items were placed near the ceiling, within 18" of the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the movable medical record files. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

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

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping . This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 29, 2013 at 1:15 pm, observation revealed on the lower level floor in the Boiler room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included med gas vacuum discharging into the boiler room instead of the exterior via the roof. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), 4-3.2.1.9.

2) On January 29, 2013 at 2:30 pm, observation revealed on the lower level floor in the Boiler room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the main building shutoff valve was inaccessible because equipment was piled below the valve and it was not possible to put a ladder below to access the valve. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

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

Based on observation and interview, the facility did not provide a code compliant environment with suite travel distance under the required limits. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 10:00 am, observation revealed on the 1st floor in the surgery suite, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance from OR1 to the corridor doors was 60 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

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

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with a complete test program for emergency generators and did not provide a battery warmer. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 10:38 am, observation revealed on the 1st floor in the reception area in Emergency Department, that when the test lights for the emergency generator was lite, the generator is running light did not light up. This observed situation was not compliant with NFPA 110 (1999 ed.), 6-4.2

2) On 1/29/2013 at 9:50 AM, observation revealed that outside of the building, that the emergency generator was not provided with a battery warmer for when the temperature in the enclosure goes below 32 Fareheit. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Administrator).

______________________________________

Based on observation and interview, the facility did not provide a Type I essential electrical system that was in accordance with the codes with a compliant Type 1 emergency electrical system. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1) On January 29, 2013 at 10:25 am, observation revealed on the lower level floor in the PACU that the Type 1 emergency electrical system was not compliant. There was not a normal branch outlet in the PACU. There only was critical branch receptacles. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-3.2.1.2

2) On January 29, 2013 at 10:45 am, observation revealed on the lower level floor in the OR 1, that the Type 1 emergency electrical system was not compliant. There was not a normal branch outlet in the OR. There only was critical branch receptacles. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-3/.2.1.2

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

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 2:00 pm, observation revealed on the lower level floor in the Boiler room, that an extension cord (temporary power tap) was used as a substitute for fixed wiring. The extension cord was used to provide power near the air drier. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

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

Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 1:45 pm, observation revealed on the 1st floor in the door to the nursing home by the chapel, that the separation wall was not constructed to have a 2-hour fire resistance rating because the wall was not continuous above the door to the cinder block. There was a three inch gap. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

2) On January 28, 2013 at 3:15 pm, observation revealed on the 1st floor in the sleep study monitoring room, that the separation wall was not constructed to have a 2-hour fire resistance rating because there were unsealed penetrations and spaces around the fire damper, and the damper was installed without metal flanges. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

3) On January 29, 2013 at 11:15 am, observation revealed on the lower level floor in the Rural Health Procedure room, that penetrations were not sealed according to an approved method. The deficiency included a hole in the ceiling/floor assembly and 2 holes in the south wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

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

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide corridor finishes with rated wall finish materials. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On January 28, 2013 at 12:45 pm, observation revealed on the 1st floor in the radiology nurse station, that the facility could not confirm the wall had the appropriate rating. The corridor wall was finished with carpet at the nurse station. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.3.1.

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

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and rated walls in a non-sprinkled compartment. This deficiency occurred in 2 of the 6 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On January 28, 2013 at 12:55 pm, observation revealed on the 1st floor in the corridor near the stair by the surgery area, that the corridor separation wall was not constructed to a 30 minute fire resistance rating. The corridor was not within a fully sprinkled smoke compartment. The holes included a 5 inch diameter hole where the water cooler use to be present. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.2.1.

2. On January 28, 2013 at 1:05 pm, observation revealed on the 1st floor in the corridor by (behind) the radiology nurse station, that the corridor separation wall was not constructed to a 30 minute fire resistance rating. The corridor was not within a fully sprinkled smoke compartment. The walls seams were not taped and the screws were not mudded with plaster. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.2.2.

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

Based on observation and interview, the facility did not provide corridor separation doors with double doors with an astragal seal. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On January 28, 2013 at 10:45 am, observation revealed on the 1st floor in the emergency department, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5-exception 4.

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

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 1:58 pm, observation revealed on the 1st floor in the room 114, ICU, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges, and this gap was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

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

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 1:15 pm, observation revealed on the 1st floor in the across corridor smoke barrier wall by Resp. Therapy, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because screws were not mudded with plaster, seams were not mudded and taped and medical air and electrical conduit was not properly fire stopped. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

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

Based on observation and interview, the facility did not provide and maintain hazardous door assemblies that meet code requirements for hazardous areas with doors held-open with the required safe guards and the facility did not enclose hazardous rooms with rated doors and rated walls. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 10:30 am, observation revealed on the 1st floor in the gift shop storage room, that the hazardous room door was prevented from self-closing by door wedge. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2) On January 28, 2013 at 11:52 am, observation revealed on the 1st floor in the disaster closet, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. In addition, the door did not have a closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3) On January 28, 2013 at 1:35 pm, observation revealed on the 1st floor in the old record room, that the door to this hazardous room was equipped with a magnetic hold-open device but no a local smoke detector was installed on either side for "door release" requirement. There was not a smoke detector for the corridor door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101(2000 ed.), 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6.

4) On January 28, 2013 at 3:05 pm, observation revealed on the 1st floor in the Medical records room near room 188, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had glass that was not rated and the door was not rated. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5) On January 29, 2013 at 10:50 am, observation revealed on the lower level floor in the supply room for the OR, that the door would not self-close because the door had no closer. In addition, the door was not smoke tight. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.

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

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 28, 2013 at 2:25 pm, observation revealed that staff were not familiar with their responsibilities in the event of a fire, including where the oxygen shut off valve was located for the ICU and when to shut off the oxygen supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

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

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services 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) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with compliant fire alarm. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 9:08 am, observation revealed on the lower level floor in the kitchen, that the fire alarm installation was not compliant. The kitchen hood suppression system was not connected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

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

Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with required testing. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 9:20 am, observation revealed that during a review of facility documents reports that code-required tests of the fire alarm system were not properly conducted. The horn and strobes of the fire alarm system was not checked per annual inspection Report dated 10/31/2012. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

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

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, and no obstructions near the sprinkler. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On January 28, 2013 at 2:50 pm, observation revealed on the 1st floor in rooms 188 and 192, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 3 inches away and 4 inches below the adjacent sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On January 28, 2013 at 3:00 pm, observation revealed on the 1st floor in the Medical records room near room 188, that items were placed near the ceiling, within 18" of the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the movable medical record files. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

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

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping . This deficiency occurred in 1 of the 6 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 29, 2013 at 1:15 pm, observation revealed on the lower level floor in the Boiler room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included med gas vacuum discharging into the boiler room instead of the exterior via the roof. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), 4-3.2.1.9.

2) On January 29, 2013 at 2:30 pm, observation revealed on the lower level floor in the Boiler room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the main building shutoff valve was inaccessible because equipment was piled below the valve and it was not possible to put a ladder below to access the valve. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

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

Based on observation and interview, the facility did not provide a code compliant environment with suite travel distance under the required limits. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 10:00 am, observation revealed on the 1st floor in the surgery suite, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance from OR1 to the corridor doors was 60 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

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

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with a complete test program for emergency generators and did not provide a battery warmer. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 10:38 am, observation revealed on the 1st floor in the reception area in Emergency Department, that when the test lights for the emergency generator was lite, the generator is running light did not light up. This observed situation was not compliant with NFPA 110 (1999 ed.), 6-4.2

2) On 1/29/2013 at 9:50 AM, observation revealed that outside of the building, that the emergency generator was not provided with a battery warmer for when the temperature in the enclosure goes below 32 Fareheit. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Administrator).

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Based on observation and interview, the facility did not provide a Type I essential electrical system that was in accordance with the codes with a compliant Type 1 emergency electrical system. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1) On January 29, 2013 at 10:25 am, observation revealed on the lower level floor in the PACU that the Type 1 emergency electrical system was not compliant. There was not a normal branch outlet in the PACU. There only was critical branch receptacles. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-3.2.1.2

2) On January 29, 2013 at 10:45 am, observation revealed on the lower level floor in the OR 1, that the Type 1 emergency electrical system was not compliant. There was not a normal branch outlet in the OR. There only was critical branch receptacles. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-3/.2.1.2

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On January 29, 2013 at 2:00 pm, observation revealed on the lower level floor in the Boiler room, that an extension cord (temporary power tap) was used as a substitute for fixed wiring. The extension cord was used to provide power near the air drier. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

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