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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 2:10 pm, observation revealed on the 1st Floor at the Production Kitchen to the Loading Dock, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, but it would not hold the door in the latched position. Wood wedges were observed under the doors to prevent them from closing. The building was 'not sprinkled', creating a hazard to life in the event of a fire emergency. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/23/2013 at 5:30 pm, observation revealed on the Wing area 5/ Level 3-B floor in the Room 12 off Corridor 3305, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, yet it would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

2. On 04/24/2013 at 3:25 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Conference Room 3203-13, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, yet it would not hold the door in the latched position. The double fire doors were blocked-open by staff to maintain visibility of patient activities occuring within adjacent Conference Room. Large brown waste containers were used to block the doors open and prevent them from closing. These fire doors were also observed to have a 'deadbolt' that is not permitted in a hospital for patient egress purposes per NFPA 101 section 7.2.1.5.4. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

3. On 04/24/2013 at 9:38 am, observation revealed on the Wing area 2/ Level 3 floor in the Elevator Lobby, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and were designed to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching. The door coordinator installed to "coordinate" closure of the two doors was broken. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 2:20 pm, observation revealed on the 1st Floor in the two Exit Stairwells, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit discharge doors in both stairwells leading to a public way. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 (2000 ed.) sections 7.10.1.4 and 39.2.10.

Based on observation, interview, and record review the facility did not ensure the path of egress was clearly identified by appropriate exit signage. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 11:05 am, observation revealed on the Wing area 5/ Level 2-B floor in the Door 2303, that signage was installed in the egress path that made the exact exit route confusing. The Exit Sign is blocked or miss-placed. This observation was from the Inspection 9/25/2012 completed by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as yet. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.10 and 7.10.1.2.

2. On 04/24/2013 at 8:42 am, observation revealed on the Wing area 1/ Level 1 floor in the Exit Passageway from Corridor 1006, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit and exit discharge doors in the Exit Passageway. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 7.10.1.4.
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies held-open with the required safe guards. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/25/2013 at 10:06 am, observation revealed on the Wing area 5/ Level 2-C floor in the Tray-Line Food Storage Room, that the hazardous room door located within a smoke barrier wall was prevented from self-closing by orange cones places on the floor in front of the doors.

2. On 04/25/2013 at 11:00 am, observation revealed on the Wing area 5/ Level 2-A floor in the Laundry Room 2336A, that the hazardous room door located within a smoke barrier wall was prevented from self-closing by a wood pie-shaped door-stop placed under the door. The room was over 100 square feet and had a large amount of combustibles within the room.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These observed situations were not compliant with NFPA 101 section 7.2.1.8.
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency had the potential to affect all patients, staff and visitors in 4 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 8:33 am, observation revealed on the Wing area 3/ Level 1-A floor in the Human Resources File Room, that the door would not self-close because the door was blocked-open to prevent the door closer from working. The door had a door closer due to the significant amount of combustibles within the room and to keep the door closed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). 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 sections 19.3.2.1 and 8.4.1.

2. On 04/24/2013 at 11:00 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Sleeping Room 7 used as an Office, that the door would not self-close because the door was missing a door closer. The shower had numerous boxes piled high in the shower area of the toilet room. The toilet/shower room was not original designed to be a storage room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 sections 19.3.2.1 and 8.4.1.

3. On 04/24/2013 at 11:06 am, observation revealed on the Wing area 5/ Level 3-A floor in the Art Storage Room 3322-4, that the door would not self-close because door to room did not have a door closer. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 19.3.2.1 and 8.4.1.

4. On 04/25/2013 at 9:45 am, observation revealed on the Wing area 4/ Level 3-H floor in the Telecommunication Room 3202-9, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1 inch diameter hole in the wall. The space had a significant amount of combustible materials. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 section 19.3.2.1.

5. On 04/25/2013 at 11:34 am, observation revealed on the Wing area 5/ Level 2 floor in the Material Management Office 2316 adjacent to Loading Dock, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The hole included a 24 inch x 30 inch duct penetration through a 2-hour fire-rated wall assembly. The Loading Dock has stacks of wood pallets and stacked cardboard from the break-out process for all supplies coming into the hospital. The Loading Dock is a hazardous space with a non-rated oxygen storage room enclosure within the confines of the dock area. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 section 19.3.2.1.
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Based on observation and interview, the facility did not provide complete enclosures around exit stairs. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/24/2013 at 10:08 am, observation revealed on the Wing area 5/ Level 3-C floor in the Stairwell 5-1, that the stairwell was not compliant. The Stairwell was found to have a patch that was not completed to the required construction for a fire rated shaft assembly. Screws and drywall edges were exposed and did not meet the 2-hour fire-rated assembly requirement.

2. On 04/25/2013 at 9:27 am, observation revealed on the Wing area 4/ Level 3-C floor in the Stairwell 4-14, that the stairwell was not compliant. The Stairwell was found to have a patch that was not completed to the required construction for a shaft assembly. A repaired area showing screws and drywall edges were exposed and did not meet the 2-hour fire-rated assembly requirement for this building type.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These observations were not compliant with NFPA 101 section 19.3.1
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Based on observation, interview, and record review, the facility did not maintain all exit stair treads. This deficiency had the potential to affect all patients, staff and visitors in 3 of the 22 smoke compartments.

FINDINGS INCLUDE: On 04/22/2013 at 10:35 am, observation revealed on the Wing area 4/ Level 2 floor at the lowest level in Stairwell 4-11, that the stairwell was not compliant. During the last Annual Fire Department Inspection report dated 9/25/2012, the stair tread was found to be in need of repair. The deficiency has not been found to be corrected as of the time of this survey. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.2.3 and 7.2.2.
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Based on observation and interview, the facility did not minimize the length of dead-ends present within their corridor system. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 8:41 am, observation revealed on the Wing area 1/ Level 1 floor (Main Entrance of Hospital) in the Corridor 1006 leading to the Old Day Hospital, that a dead-end corridor of greater than 30 feet was observed. The original hospital building did not have this condition, but was created in 2010 when the Old Day Hospital was separated from the 'revised' hospital building footprint. The surveyor observed that the abandoned exit passageway door (originally designed for this condition), adjacent to the separation doors, was not marked as an exit. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.2.5.10.
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Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, doors that opened with the necessary force, travel interruption at stairs that go below the level of exit discharge, and door hardware that operated with a single release motion. This deficiency had the potential to affect all patients, staff and visitors in 6 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/23/2013 at 5:35 pm, observation revealed on the Wing area 5/ Level 3-B floor in the Conference Room 13, that the exit path was not readily accessible because the door had a deadbolt on the door. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

2. On 04/24/2013 at 8:44 am, observation at the exterior of the building at the Wing area 1/ Level 1, that the exit path was not readily accessible because there was a drop-off of at least 4 inches to the ground from the concrete stoop and the egress pathway was not a 'hard surface' capable of supporting a wheelchair in all weather conditions. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

3. On 04/24/2013 at 4:29 pm, observation revealed on the Wing area 4/ Level 1-A floor in the Corridor at Administration, that the exit path was not readily accessible because the Door #1031 had a deadbolt on the door. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

4. On 04/25/2013 at 9:24 am, observation revealed on the Wing area 4/ Level 3-C floor in the Inpatient Sleeping & Toilet/Shower Rooms 26 & 29, that the exit path was not readily accessible because the room doors had deadbolts. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

5. On 04/22/2013 at 2:22 pm, observation revealed on the 1st Floor floor in the Two Stairwells, Exit doors & Exit discharge doors, that the door in the path of egress opened when a force of greater than 35 pounds was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 section 7.2.1.4.5.

6. On 04/22/2013 at 2:25 pm, observation revealed on the 1st Floor floor in the Two Stairwells, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 section 7.7.3.

7. On 04/24/2013 at 11:08 am, observation at the exterior of the building at the Wing area 5/ Level 3-A & B, that the door release hardware required more than a single motion to release the door for exiting. The hardware included chain-link devices with keyed locks. I was told all staff have keys to these locks. The fenced-in outside courtyards, used by inpatients, were locked by chains around the entire campus. The lock and chain assemblies required several hand motions to open. These conditions do not meet provide a reliable means to egress. This observed situation was not compliant with NFPA 101 section 7.2.1.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain minimum clear aisles width. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 10:53 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Toilet/Shower Rooms #6 & #38, that the clear and unobstructed width of the aisle was less than 32 inches of width within the bathroom because 11 large cooler water bottles were being stored 'on-the-floor' and under-the-handwashing-counter at Room #6. Six (6) water bottles were being stored in a similar fashion in Room #38. The proper width of corridors & aisles in adjunct areas is 48 inches used by staff with door openings having 32 inches in clear opening. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (utilities engineer) and staff Y (maintenance supervisor). These observed situation were not compliant with NFPA 101 section 19.2.3.3.
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Based on observation and interview, the facility did not provide and maintain means of egress ilumination, including the minimum 2-bulbs from the exit discharge to a public way. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/24/2013 at 8:45 am, observation at the exterior of the Building #3, Wing area 1/ Level 1, that the path of egress was illuminated by a single light fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 section 7.8.1.4.

2. On 04/24/2013 at 9:34 am, observation revealed at Building #3, Wing area 2/ Level 3 floor in the 3000 Public Toilet Room & 3000A Housekeeping Closet, that the room lights were burnt out. This observed situation was not compliant with NFPA 101 section 19.2.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation, interview, and record review, the facility did not maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 2:35 pm, observation revealed that the facility did not test the battery-powered emergency lights for 90 minutes each year. There were 6 battery-power lights located on the three levels and in the stairs. Adequate testing of emergency batteries was missing in the documentation review of the facility maintenance records. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 7.9, 7.9.3 & 39.2.9.1(1).
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Based on observation, interview, and record review, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 3:05 pm, observation revealed on the 1st Floor, in the Hot Food Cooking area near the Large Commercial Oven, that staff were not familiar with their responsibilities in the event of a fire, including; the sequence of actions required per the hospital's Fire Safety Plan (Policy & Procedures last reviewed 11/7/2011), the staff did not know the correct sequence of the RACE procedure: including; Rescue, Alarm, Contain and Extinguish/Escape (RACE). The employee knew about using the fire extinguisher and pulling the device alarm, but missed the Rescue and Contain portion of the requirement. The employee stated he was trained in the Fire Safety Plan. This information was collected during the survey tour, with the chief cook, who was asked to review their understanding of what to do in the event of a fire in the food cooking area (ovens). According to administration personnel, training on this subject (Fire Safety Plan) is required for employment, including outside contractors. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.7.1.3.
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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, due to an obstructed pull station. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/25/2013 at 3:33 pm, observation revealed in Buiding #3, on the Wing area 3/ Level 1 floor, at the Fire Alarm Pull Station of Corridor 1071 - Human Resources, that a manual pull station was not located in accordance with NFPA 72 requirements. The manual pull station was obstructed by a cart and boxes. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 9.6.1.4 and NFPA 72 (1999 ed.).
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Based on a review of maintenance documents, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications. The facility was missing a complete smoke detector sensitivity test record. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 11:43 am, observation revealed that during a review of facility maintenance records, documentation was not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. The Annual Fire Alarm Report completed on March 18, 2013 thru March 22, 2013, was missing testing results of the smoke detector located in Wing area 4/ Level 3-B, Room #3. This detector can be found in the Annual Fire Alarm Report under Smoke Detector Sensitivity Testing, on page 6 of 22, Serial No. 22020001. This detector was not tested in 2011, 2012 & up to April 22, 2013.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 section 9.6.1.7, and NFPA 72 (1999 ed.) section 7-3.2.1.
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Based on observation, interview and record review, 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 intact escutcheon rings or ceilings sealed above the sprinklers to collect heat. This deficiency had the potential to affect all patients, staff and visitors in 22 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 5:55 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Copier Room 20, that the escutcheon ring on the sprinkler was not tight to theceiling. The sprinkler head was located in the closet within the room. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

2. On 04/24/2013 at 8:35 am, observation revealed on the Wing area 1/ Level 1 floor in the Corridor 1006 outside Main Information Desk, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

3. On 04/24/2013 at 9:21 am, observation revealed on the Wing area 2/ Level 1 floor in the Chapel Vestibule, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 gap may reduce the response time of the sprinkler in the room This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

4. On 04/24/2013 at 9:56 am, observation revealed on the Wing area 5/ Level 3-C floor in the Corridor outside Toilet Room 3314-C, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

5. On 04/24/2013 at 10:05 am, observation revealed on the Wing area 5/ Level 3-C floor in the Office Room 3311, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

6. On 04/24/2013 at 3:23 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Activity & Dining Room 12 and Conference Room 13 , that the escutcheon ring on the sprinkler was is not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

7. On 04/25/2013 at 9:30 am, observation revealed on the Wing area 4/ Level 3-C floor in the Closet Room 3217-D, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

8. On 04/25/2013 at 10:23 am, observation revealed on the Wing area 5/ Level 2 floor in the Dish Room 2339, that the escutcheon ring on the 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

9. On 04/25/2013 at 2:04 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Room 1030, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

10. On 04/25/2013 at 3:15 pm, observation revealed on the Wing area 3/ Level 1 floor in the Closet 1101 & 1100 in Day Hospital, that the escutcheon ring on the 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

11. On 04/23/2013 at 6:00 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Nurses Station, open to Corridor, that there was one or more unsealed holes near the ceiling. The hole(s) included several 1/2 inch diameter holes within different locations around the nurses station. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

12. On 04/24/2013 at 8:49 am, observation revealed on the Wing area 1/ Level 1 floor in the Gift Shop Room 1008, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1/2 inch x 12 inches opening from a ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

13. On 04/24/2013 at 8:56 am, observation revealed on the Wing area 1/ Level 1 floor in the Pantry at Snack Shop Room 1009, that there was one or more unsealed holes near the ceiling. The hole(s) included 12 inches x 24 inches from a patch of the ceiling. The ceiling system is rated to 2-hours from metal lath and plaster from original construction. The patch is only a 1/2 or 5/8 inch gypsum wallboard that could not be positively identified and the screws were exposed and not double mudded along with the edge of the drywall patch. This is a non-compliant fire-rated assembly in a hazardous area. Documentation was not provided to prove its UL assembly at time of survey. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

14. On 04/24/2013 at 9:22 am, observation revealed on the Wing area 2/ Level 1 floor in the Chapel Vestibule, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch x 12 inches at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

15. On 04/24/2013 at 9:47 am, observation revealed on the Wing area 5/ Level 3-C floor in the General Office Suite 3304 outside Room 3304-5, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12 inch x 12 inch damaged ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

16. On 04/24/2013 at 9:53 am, observation revealed on the Wing area 5/ Level 3-C floor in the Corridor outside Toilet Room 3314-C, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

17. On 04/24/2013 at 9:59 am, observation revealed on the Wing area 5/ Level 3-C floor in the General Office 3300, that there was one or more unsealed holes near the ceiling. The hole(s) included 1/2 inch diameter hole at electrical conduit next to speaker in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

18. On 04/24/2013 at 10:02 am, observation revealed on the Wing area 5/ Level 3-C floor in the Office Room 3312, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

19. On 04/24/2013 at 10:14 am, observation revealed on the Wing area 5/ Level 3 floor in the Men's Public Toilet on Main Corridor, that there was one or more unsealed holes near the ceiling. The hole(s) included a 5 inch x 12 inch opening in ceiling above the door. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

20. On 04/24/2013 at 10:17 am, observation revealed on the Wing area 5/ Level 3 floor in the Corridor near Door 3324, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch x 6 inch opening in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

21. On 04/24/2013 at 11:11 am, observation revealed on the Wing area 5/ Level 3-C floor in the Main Corridor 3308, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling light fixture cap between the ceiling tiles and fixture. One of the openings was a missing cap about 3 inches x 6 inches in area and the other location was farther down the same corridor next to the wall valence at ceiling light fixture. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

22. On 04/24/2013 at 11:45 am, observation revealed on the Wing area 5/ Level 3-A floor in the Corridor 3308 above Fire Extinguisher across from interior Court Yard 5-3-3, that there was one or more unsealed holes near the ceiling. The hole(s) included a missing 6 inch x 12 inch ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

23. On 04/24/2013 at 2:30 pm, observation revealed on the Wing area 4/ Level 3-A, B, C, D, E & F floor in the Housekeeping Closet Rooms 3203-3, 3221-3, 3219-3, 3230-3, 3223-3, & 3246-3, that there was one or more unsealed holes near the ceiling. The hole(s) included Several open ceiling tiles. Staff F stated they are removing all the humidification units out of the ceiling in the Housekeeping Closets at Units 3-A, 3-B, 3-C, 3-D, 3-E & 3-F and putting them into new stainless steel wall cabinet to reduce operational costs. However, the maintenance staff forgot to replace the ceiling tile after leaving the construction area and were not following the Hospital's Policy and Procedures. This was observed at several housekeeping locations within the hospital. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

24. On 04/24/2013 at 3:32 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Patient Toilet Room 8, Soiled Utility Room 9, Electrical Closet 23 & Conference Room 13 , that there was one or more unsealed holes near the ceiling. The hole(s) included numerous holes in ceiling of varying sizes at numerous locations. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

25. On 04/24/2013 at 3:42 pm, observation revealed on the Wing area 4/ Level 3-B floor in the Staff Work & Charting Room 3221-24, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch diameter near the ceiling corner by the vent. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

26. On 04/25/2013 at 9:33 am, observation revealed on the Wing area 4/ Level 3-H floor in the Corridor outside Room 3209, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1/2 inch diameter hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

27. On 04/25/2013 at 10:10 am, observation revealed on the Wing area 5/ Level 2-C floor in the Corridor outside tray line entry, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch x 12 inches at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

28. On 04/25/2013 at 12:53 pm, observation revealed on the Wing area 4/ Level 2-A floor in the Outpatient Corridor outside Room 2214, that there was one or more unsealed holes near the ceiling. The hole(s) included a 24 inch x 48 inch opening in the ceiling caused by a electrical cover plate falling through the acoustical ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

29. On 04/25/2013 at 2:03 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Room 1030, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch diameter hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

30. On 04/22/2013 at 10:40 am, observation revealed on the Wing area 4/ Level 4 floor in the Room 4345-9, that a sprinkler had paint on the head. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

31. On 04/23/2013 at 9:30 am, observation revealed that during a review of documents the facility could not verify that all elements of the fire pump system's annual test were performed. The Annual Fire Pump Test was performed by Grunau Company, Milwaukee, WI. During review of the report is was observed the record motor 'amps' were missing. This is a required field that must be filled out annually. Also missing was the 30 minute churn. No start time or stop time was recorded. Documentation of the 'lubing of the coupling' was missing in the Report. This observed situation was not compliant with NFPA 25 (1998 ed.), sectionn 5-3.

32. On 04/23/2013 at 9:15 am, observation revealed that during a review of documents the facility could not verify that the fire pump system's weekly 10-minute churn test was performed. observed a conflict of directions to the Milwaukee County Behavioral Health campus Plumber doing the weekly Fire Pump testing. Documentation stated to run 1-2 minutes, when in fact you are to run the Fire Pump a minimum of 10 minutes. This observed situation was not compliant with NFPA 25 (1998 ed.), 5-3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with fully visible extinguishers, and complete inspection documentation. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 5:30 pm, observation revealed that not all fire extinguishers were inspected monthly. During record review the hospital's fire extinguisher records revealed the total quantities of extinguishers was incomplete and the quantity pulled for testing purposes was imcomplete. The the extinguishers were last tested on May 25 & 26, 2011. Observed also revealed all fire extinguishers were beyond the 40 days of review. This observed situation was not compliant with NFPA 101 sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

2. On 04/22/2013 at 3:03 pm, observation revealed on the 1st Floor, in the Open Food Production area, that during a review of documents, records were not available to confirm that portable fire extinguishers were inspected monthly. Observed several fire extinguishers in the building not inspected since March 4, 2013. This means they have not been checked for 48 days, which is out of range for on-going maintenance requirements of inspection and testing per NFPA 10, Portable Fire Extinguishers. This observed situation was not compliant with NFPA 101 (2000 ed.) sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, interview, and record review, the facility did not provide fully visible extinguishers with complete inspection documentation. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/25/2013 at 3:34 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Fire Extinguisher Cabinet at Corridor 1071 of Human Resources, that a fire extinguisher was obstructed from view and blocked from access because a cart and boxes were placed in front of the fire extinguisher cabinet. This observed situation was not compliant with NFPA 101 (2000 ed.) sections 19.3.5.6 and 9.7.4.1, NFPA 10 (1998 ed.) sections 1-6.6 and 4-3.2(b).

2. On 04/25/2013 at 10:00 am, observation revealed on the Wing area 1/ Level 1 floor in the Snack Shop Kitchen, that during a review of documents, records were not available to confirm that teh fire extinguisher was inspected monthly. The tag on the ABC fire extinguisher was blank, except for the installed date of August 2012. All other fire extinguishers through-out the health care campus had the Monthly review on the tag itself. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A required damper maintenance. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 2:00 pm, observation revealed that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not all shown on the hospital plans and in the HVAC Annual Report, by Advanced Technologies Group. Documentation noted the fire dampers were last exercised in Fall of 2007 (allowed 6-years for exercising in hospital areas), but the documentation was missing as to where the 'smoke dampers' are located through-out the hospital campus. Currently the pneumatic controlled smoke dampers are not integrated to a smart system to test them remotely. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.5.2.1 and 9.2.1; and NFPA 90A (1999 ed.) section 3-4.7.

2. On 04/24/2013 at 3:15 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Serving Pantry Room 3203-28, that a fire damper was not installed in an air duct that penetrated the rated wall. Observation revealed an open exhaust duct in a wood cabinet of the pantry, previously used for food preparation. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.
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Based on observation and interview, the facility did not provide semi-annually cleaning of the range hood, and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspection and cleaning documents were incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, would the oven doors lock upon alarm activation, was the exit access route to safety reviewed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1.
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Based on observation, interview, and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96. Missing information in the range hood semi-annual cleaning, and hoods and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspected and cleaning documentation was incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, would the oven doors lock upon alarm activation, was the exit access route to safety reviewed. This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1.

2. On 04/24/2013 at 9:00 am, observation revealed the hood exhaust ducts were found not to be 'steel ducts' as required per NFPA 96, sections 4-5.1 through 4-5.2.2 Materials. This observed situation was not compliant with NFPA 101 section 19.3.2.6 and 9.2.3; and NFPA 96 section 8-3.1.

3. On 04/24/2013 at 9:15 am, observation revealed on the Wing area 1/ Level 1 floor in the Mechanical Penthouse above the Snack Shop, that the kitchen hood suppression system did not have liquid-tight seams of its metal ducts, could not verify if upon pulling 'activation button' it would automatically disconnect the fuel & electrical sources to the grill and fryer, ducts were not continuously 2-hour fire-wrapped upon passing through a floor assembly (fire dampers are not allowed) and could not verify the horizontal exhaust duct was sloped to a grease clean-out trap. Access panels did not appear to be the same fire-rating as the duct and did not appear that fasteners, such as bolts, weld nuts, latches, or wing nuts, used to secure the access panels were carbon steel or stainless steel per section NFPA 96 section 4-3.4.4. At the time of the survey, the hospital did not provide information that the grease ducts were installed in accordance with the terms of the listing and the manufacturer's instructions per section NFPA 96 section 4-3.4.5. This observed situation was not compliant with NFPA 101 section 19.3.2.6 and 9.2.3 and NFPA 96.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain trash collection receptacles in compliance with the codes with properly sized storage containers (<32 gallons) for soiled and trash containers. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 9:44 am, observation revealed on the Wing area 5/ Level 3-C floor of Building #3, in the General Office Suite 3304 outside Room 3304-5, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous containment area. Two 65 gallon paper waste containers were located together in a non-hazardous space. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.7.5.5.
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with sealed wall penetrations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/25/2013 at 11:29 am, observation revealed on the Wing area 5/ Level 2 floor in the Oxygen Storage Room located on Loading Dock, that penetration(s) were not sealed according to an approved method. The deficiency also included a mechanical duct exhausting from the Oxygen Storage Room into the Loading Dock. There were 34 e-cylinders that were off-gassing, potentially creating a hazardous situation with the Loading Dock area, that was considered hazardous. Did not see a direct exhaust to the outside of the building from the oxygen storage room. This room was used to store greater than 3,000 cubic feet of compressed gas and was required to be enclosed with 1-hour fire-rated construction. This observed situation was not compliant with NFPA 101 section 19.3.2.4 and NFPA 99 (1999 ed.) section 8-3.1.11.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, staff interviews and record review, the facility did not provide limited combustible partitions. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/25/2013 at 12:40 pm, observation revealed on the Wing area 4/ Level 2-B & C floor in the Central Supply Storage Room 2208, Maintenance, Plumbers, Carpenters, Painters, HVAC, and Electrical Shops 2210, 2211, 2216, 2220, 2221 & 2324, that during a review of facility documents the Hospital Building is a Type 1 (332) fire resistive construction. All wood partitions used in a Type 1 facility shall be of limited-combustibility or enclosed in a fire-rated assembly. The hospital could not provide documentation that the exposed wood studs meet a limited-combustibility requirement per NFPA 259.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels and closed electrical raceways. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 3:20 pm, observation revealed on the 1st Floor, in the area next to the Kitchen Exhaust Hood, that access to electrical panel was less than 3'-0" clearance. Panels 1/P3-2A & 1/P3-2 were located adjacent to a food preparation counter that was less than 36 inches from the face of the electrical panels. These panels were located on a column near the Kitchen Exhaust Hood. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-26.

2. On 04/22/2013 at 3:30 pm, observation revealed on the 1st Floor, in the Kitchen Equipment Holding area that access to electrical panel was less than 3'-0" clearance. Panel 1/P3-1 was observed with equipment in front of the electrical panel, with less than 36 inches clearance. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-26.

3. On 04/22/2013 at 2:52 pm, observation revealed on the 1st Floor, in the area near Walk-In Cooler #8, that a 4" x 4" electrical box was missing its cover plate and exposed electrical wires were observed within. Electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

4. On 04/22/2013 at 3:10 pm, observation revealed on the 1st Floor, in the Slicing Meat Counter, that a electrical outlet was pulled out from the meat preparation counter/base cabinet wall. The exposed wires were dangling from the cabinet and still attached to the electrical box, with the cover plate partly remove. Staff could not tell me how long this condition existed. This location is within distance of the 'wet mop' use by housekeeping staff during the cleaning of the food production area daily. Water and electricity could have a negative outcome to the person making contact. Electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation, interview, and record review, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, closed electrical raceways, electrical panels with complete directories, and proper working clearances. This deficiency had the potential to affect all patients, staff and visitors in 12 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/24/2013 at 10:25 am, observation revealed on the Wing area 5/ Level 3-A floor in the Patient Educational Computer Classroom, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to inpatient used computers. Numerous electrical cables were open and loose on the floor presenting a trip hazard to the occupants. This observed situation was not compliant with NFPA 70 (1999 ed.), sections 400-8(1) and 517-18.

2. On 04/24/2013 at 10:55 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Computer Teaching Room 6, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to inpatient used computers. Numerous electrical cables were open and loose on the floor presenting a trip hazard to the occupants. This observed situation was not compliant with NFPA 70 (1999 ed.), sections 400-8(1) and 517-18.

3. On 04/24/2013 at 11:13 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Educational Conference Room 13, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to patient computers. Direct plug-in of computers in patient areas is required. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

4. On 04/25/2013 at 11:16 am, observation revealed on the Wing area 5/ Level 2 floor in the Materials Management Storeroom 2310, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the refrigerator. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

5. On 04/25/2013 at 11:45 am, observation revealed on the Wing area 4/ Level 2-A floor in the Pharmacy Breakout Room 2201, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to both the microwave and refrigerator. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

6. On 04/23/2013 at 5:45 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Copier Room 20, that a 2-1/2 inch x 4 inch electrical box was open next to the copier machine. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

7. On 04/24/2013 at 11:07 am, observation revealed on the Wing area 5/ Level 3-A floor in the Soiled Utility Room 9, that a 4 inch x 4 inch electrical box was open at the ceiling. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

8. On 04/25/2013 at 12:54 pm, observation revealed on the Wing area 4/ Level 2-A floor in the Outpatient Corridor outside Room 2214, that a 4 inch x 4 inch electrical box was open above the ceiling in the interstitial area. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

9. On 04/22/2013 at 10:30 am, observation revealed on the Wing area 4/ Level 2-A floor in the Central Supply Equipment Holding Room 2208, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #4/1A was found to have an open electrical breaker plate during the last inspection 9/25/2012. This was part of the Annual Inspection by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as of the time of this survey. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

10. On 04/22/2013 at 11:15 am, observation revealed on the Wing area 5/ Level 2-C1 floor in the Food Serving area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel # Kitchen, was missing a required latching mechanism to the panel itself to keep it closed. This was part of the Annual Inspection by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as of the time of this survey. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

11. On 04/23/2013 at 5:39 pm, observation revealed on the Wing area 5/ Level 3-B & 3-A floor in the Electrical Rooms B-24 & A-24, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 5/2B-breaker #5 and Panel 5/2A-breaker #32 were observed to be in the 'ON' position, but the identification card stated they were 'Spares'. These electrical panels serve the floor below, yet they where not marked. The single-line electrical drawings need to reflect this condition of panels located on a different floors that the areas they serve. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

12. On 04/24/2013 at 9:12 am, observation revealed on the Wing area 1/ Level 1 floor in the Mechanical Penthouse above the Snack Shop, that electrical panel breaker(s) were not labeled to identify the loads they fed. The panel 1/GB-breakers 20, 21, 26, 28, 30, 32 and panel 1/GA-breakers 18, 19, 20, 21, 22, 24, 26, 30, 31, 33, 35, 38, 40, 41 & 42 were missing correct identification. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

13. On 04/24/2013 at 9:25 am, observation revealed on the Wing area 2/ Level 1 floor in the Room 1016A, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panels 1/GA, 1G/X & 1G/XA were missing the identification card or mis-marked and the panels were blocked with less than 36 inches of clearance in front of them. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

14. On 04/24/2013 at 9:50 am, observation revealed on the Wing area 5/ Level 3-C floor in the Room 3304-9, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 5/2C-breakers 31, 34 & 36 were incorrectly labeled. This electrical panel was identified as serving the electrical needs of the floor below and not shown correctly on the electrical drawings. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

15. On 04/24/2013 at 3:35 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Storage Closet 3203-19 & Electrical Closet 3203-23, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 'Kitchen'-breaker #8 of Rm. 19, Panel 4/2A-breakers #39, #41, #40 & #42 and Panel 4/2B-breaker #32 of Rm. 23 were labeled as SPARE but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

16. On 04/24/2013 at 3:36 pm, observation revealed on the Wing area 4/ Level 3-B floor in the Electrical Closet 3221-23 & Storage Room 3221-19, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 'Kitchen'-breaker #7 of Rm. 19 and Panel 4/3B-breakers #30 & #31 of Rm. 23 were labeled as SPARE but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

17. On 04/25/2013 at 9:40 am, observation revealed on the Wing area 4/ Level 3-H floor in the Suite Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 4/2H-breakers 25 & 27 were in the 'ON' position and the identification card stated they were SPARES. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

18. On 04/25/2013 at 10:30 am, observation revealed on the Wing area 5/ Level 2 floor, that the Level of service was incorrect. It was observed that the single-line electrical drawings incorrectly show the Level for the electrical panels. Example: The 2nd Level is shown as Level 1. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 2:10 pm, observation revealed on the 1st Floor at the Production Kitchen to the Loading Dock, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, but it would not hold the door in the latched position. Wood wedges were observed under the doors to prevent them from closing. The building was 'not sprinkled', creating a hazard to life in the event of a fire emergency. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/23/2013 at 5:30 pm, observation revealed on the Wing area 5/ Level 3-B floor in the Room 12 off Corridor 3305, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, yet it would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

2. On 04/24/2013 at 3:25 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Conference Room 3203-13, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, yet it would not hold the door in the latched position. The double fire doors were blocked-open by staff to maintain visibility of patient activities occuring within adjacent Conference Room. Large brown waste containers were used to block the doors open and prevent them from closing. These fire doors were also observed to have a 'deadbolt' that is not permitted in a hospital for patient egress purposes per NFPA 101 section 7.2.1.5.4. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

3. On 04/24/2013 at 9:38 am, observation revealed on the Wing area 2/ Level 3 floor in the Elevator Lobby, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and were designed to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching. The door coordinator installed to "coordinate" closure of the two doors was broken. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 2:20 pm, observation revealed on the 1st Floor in the two Exit Stairwells, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit discharge doors in both stairwells leading to a public way. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 (2000 ed.) sections 7.10.1.4 and 39.2.10.

Based on observation, interview, and record review the facility did not ensure the path of egress was clearly identified by appropriate exit signage. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 11:05 am, observation revealed on the Wing area 5/ Level 2-B floor in the Door 2303, that signage was installed in the egress path that made the exact exit route confusing. The Exit Sign is blocked or miss-placed. This observation was from the Inspection 9/25/2012 completed by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as yet. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.10 and 7.10.1.2.

2. On 04/24/2013 at 8:42 am, observation revealed on the Wing area 1/ Level 1 floor in the Exit Passageway from Corridor 1006, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit and exit discharge doors in the Exit Passageway. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 7.10.1.4.
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies held-open with the required safe guards. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/25/2013 at 10:06 am, observation revealed on the Wing area 5/ Level 2-C floor in the Tray-Line Food Storage Room, that the hazardous room door located within a smoke barrier wall was prevented from self-closing by orange cones places on the floor in front of the doors.

2. On 04/25/2013 at 11:00 am, observation revealed on the Wing area 5/ Level 2-A floor in the Laundry Room 2336A, that the hazardous room door located within a smoke barrier wall was prevented from self-closing by a wood pie-shaped door-stop placed under the door. The room was over 100 square feet and had a large amount of combustibles within the room.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These observed situations were not compliant with NFPA 101 section 7.2.1.8.
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency had the potential to affect all patients, staff and visitors in 4 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 8:33 am, observation revealed on the Wing area 3/ Level 1-A floor in the Human Resources File Room, that the door would not self-close because the door was blocked-open to prevent the door closer from working. The door had a door closer due to the significant amount of combustibles within the room and to keep the door closed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). 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 sections 19.3.2.1 and 8.4.1.

2. On 04/24/2013 at 11:00 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Sleeping Room 7 used as an Office, that the door would not self-close because the door was missing a door closer. The shower had numerous boxes piled high in the shower area of the toilet room. The toilet/shower room was not original designed to be a storage room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 sections 19.3.2.1 and 8.4.1.

3. On 04/24/2013 at 11:06 am, observation revealed on the Wing area 5/ Level 3-A floor in the Art Storage Room 3322-4, that the door would not self-close because door to room did not have a door closer. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 19.3.2.1 and 8.4.1.

4. On 04/25/2013 at 9:45 am, observation revealed on the Wing area 4/ Level 3-H floor in the Telecommunication Room 3202-9, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1 inch diameter hole in the wall. The space had a significant amount of combustible materials. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 section 19.3.2.1.

5. On 04/25/2013 at 11:34 am, observation revealed on the Wing area 5/ Level 2 floor in the Material Management Office 2316 adjacent to Loading Dock, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The hole included a 24 inch x 30 inch duct penetration through a 2-hour fire-rated wall assembly. The Loading Dock has stacks of wood pallets and stacked cardboard from the break-out process for all supplies coming into the hospital. The Loading Dock is a hazardous space with a non-rated oxygen storage room enclosure within the confines of the dock area. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). 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 section 19.3.2.1.
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Based on observation and interview, the facility did not provide complete enclosures around exit stairs. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE: 1. On 04/24/2013 at 10:08 am, observation revealed on the Wing area 5/ Level 3-C floor in the Stairwell 5-1, that the stairwell was not compliant. The Stairwell was found to have a patch that was not completed to the required construction for a fire rated shaft assembly. Screws and drywall edges were exposed and did not meet the 2-hour fire-rated assembly requirement.

2. On 04/25/2013 at 9:27 am, observation revealed on the Wing area 4/ Level 3-C floor in the Stairwell 4-14, that the stairwell was not compliant. The Stairwell was found to have a patch that was not completed to the required construction for a shaft assembly. A repaired area showing screws and drywall edges were exposed and did not meet the 2-hour fire-rated assembly requirement for this building type.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These observations were not compliant with NFPA 101 section 19.3.1
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Based on observation, interview, and record review, the facility did not maintain all exit stair treads. This deficiency had the potential to affect all patients, staff and visitors in 3 of the 22 smoke compartments.

FINDINGS INCLUDE: On 04/22/2013 at 10:35 am, observation revealed on the Wing area 4/ Level 2 floor at the lowest level in Stairwell 4-11, that the stairwell was not compliant. During the last Annual Fire Department Inspection report dated 9/25/2012, the stair tread was found to be in need of repair. The deficiency has not been found to be corrected as of the time of this survey. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.2.3 and 7.2.2.
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Based on observation and interview, the facility did not minimize the length of dead-ends present within their corridor system. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 8:41 am, observation revealed on the Wing area 1/ Level 1 floor (Main Entrance of Hospital) in the Corridor 1006 leading to the Old Day Hospital, that a dead-end corridor of greater than 30 feet was observed. The original hospital building did not have this condition, but was created in 2010 when the Old Day Hospital was separated from the 'revised' hospital building footprint. The surveyor observed that the abandoned exit passageway door (originally designed for this condition), adjacent to the separation doors, was not marked as an exit. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.2.5.10.
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Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, doors that opened with the necessary force, travel interruption at stairs that go below the level of exit discharge, and door hardware that operated with a single release motion. This deficiency had the potential to affect all patients, staff and visitors in 6 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/23/2013 at 5:35 pm, observation revealed on the Wing area 5/ Level 3-B floor in the Conference Room 13, that the exit path was not readily accessible because the door had a deadbolt on the door. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

2. On 04/24/2013 at 8:44 am, observation at the exterior of the building at the Wing area 1/ Level 1, that the exit path was not readily accessible because there was a drop-off of at least 4 inches to the ground from the concrete stoop and the egress pathway was not a 'hard surface' capable of supporting a wheelchair in all weather conditions. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

3. On 04/24/2013 at 4:29 pm, observation revealed on the Wing area 4/ Level 1-A floor in the Corridor at Administration, that the exit path was not readily accessible because the Door #1031 had a deadbolt on the door. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

4. On 04/25/2013 at 9:24 am, observation revealed on the Wing area 4/ Level 3-C floor in the Inpatient Sleeping & Toilet/Shower Rooms 26 & 29, that the exit path was not readily accessible because the room doors had deadbolts. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1.

5. On 04/22/2013 at 2:22 pm, observation revealed on the 1st Floor floor in the Two Stairwells, Exit doors & Exit discharge doors, that the door in the path of egress opened when a force of greater than 35 pounds was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 section 7.2.1.4.5.

6. On 04/22/2013 at 2:25 pm, observation revealed on the 1st Floor floor in the Two Stairwells, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 section 7.7.3.

7. On 04/24/2013 at 11:08 am, observation at the exterior of the building at the Wing area 5/ Level 3-A & B, that the door release hardware required more than a single motion to release the door for exiting. The hardware included chain-link devices with keyed locks. I was told all staff have keys to these locks. The fenced-in outside courtyards, used by inpatients, were locked by chains around the entire campus. The lock and chain assemblies required several hand motions to open. These conditions do not meet provide a reliable means to egress. This observed situation was not compliant with NFPA 101 section 7.2.1.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain minimum clear aisles width. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 10:53 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Toilet/Shower Rooms #6 & #38, that the clear and unobstructed width of the aisle was less than 32 inches of width within the bathroom because 11 large cooler water bottles were being stored 'on-the-floor' and under-the-handwashing-counter at Room #6. Six (6) water bottles were being stored in a similar fashion in Room #38. The proper width of corridors & aisles in adjunct areas is 48 inches used by staff with door openings having 32 inches in clear opening. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (utilities engineer) and staff Y (maintenance supervisor). These observed situation were not compliant with NFPA 101 section 19.2.3.3.
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Based on observation and interview, the facility did not provide and maintain means of egress ilumination, including the minimum 2-bulbs from the exit discharge to a public way. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/24/2013 at 8:45 am, observation at the exterior of the Building #3, Wing area 1/ Level 1, that the path of egress was illuminated by a single light fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 section 7.8.1.4.

2. On 04/24/2013 at 9:34 am, observation revealed at Building #3, Wing area 2/ Level 3 floor in the 3000 Public Toilet Room & 3000A Housekeeping Closet, that the room lights were burnt out. This observed situation was not compliant with NFPA 101 section 19.2.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation, interview, and record review, the facility did not maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 2:35 pm, observation revealed that the facility did not test the battery-powered emergency lights for 90 minutes each year. There were 6 battery-power lights located on the three levels and in the stairs. Adequate testing of emergency batteries was missing in the documentation review of the facility maintenance records. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 7.9, 7.9.3 & 39.2.9.1(1).
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Based on observation, interview, and record review, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 3:05 pm, observation revealed on the 1st Floor, in the Hot Food Cooking area near the Large Commercial Oven, that staff were not familiar with their responsibilities in the event of a fire, including; the sequence of actions required per the hospital's Fire Safety Plan (Policy & Procedures last reviewed 11/7/2011), the staff did not know the correct sequence of the RACE procedure: including; Rescue, Alarm, Contain and Extinguish/Escape (RACE). The employee knew about using the fire extinguisher and pulling the device alarm, but missed the Rescue and Contain portion of the requirement. The employee stated he was trained in the Fire Safety Plan. This information was collected during the survey tour, with the chief cook, who was asked to review their understanding of what to do in the event of a fire in the food cooking area (ovens). According to administration personnel, training on this subject (Fire Safety Plan) is required for employment, including outside contractors. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.7.1.3.
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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, due to an obstructed pull station. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/25/2013 at 3:33 pm, observation revealed in Buiding #3, on the Wing area 3/ Level 1 floor, at the Fire Alarm Pull Station of Corridor 1071 - Human Resources, that a manual pull station was not located in accordance with NFPA 72 requirements. The manual pull station was obstructed by a cart and boxes. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 9.6.1.4 and NFPA 72 (1999 ed.).
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Based on a review of maintenance documents, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications. The facility was missing a complete smoke detector sensitivity test record. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 11:43 am, observation revealed that during a review of facility maintenance records, documentation was not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. The Annual Fire Alarm Report completed on March 18, 2013 thru March 22, 2013, was missing testing results of the smoke detector located in Wing area 4/ Level 3-B, Room #3. This detector can be found in the Annual Fire Alarm Report under Smoke Detector Sensitivity Testing, on page 6 of 22, Serial No. 22020001. This detector was not tested in 2011, 2012 & up to April 22, 2013.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 section 9.6.1.7, and NFPA 72 (1999 ed.) section 7-3.2.1.
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Based on observation, interview and record review, 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 intact escutcheon rings or ceilings sealed above the sprinklers to collect heat. This deficiency had the potential to affect all patients, staff and visitors in 22 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 5:55 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Copier Room 20, that the escutcheon ring on the sprinkler was not tight to theceiling. The sprinkler head was located in the closet within the room. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

2. On 04/24/2013 at 8:35 am, observation revealed on the Wing area 1/ Level 1 floor in the Corridor 1006 outside Main Information Desk, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

3. On 04/24/2013 at 9:21 am, observation revealed on the Wing area 2/ Level 1 floor in the Chapel Vestibule, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 gap may reduce the response time of the sprinkler in the room This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

4. On 04/24/2013 at 9:56 am, observation revealed on the Wing area 5/ Level 3-C floor in the Corridor outside Toilet Room 3314-C, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

5. On 04/24/2013 at 10:05 am, observation revealed on the Wing area 5/ Level 3-C floor in the Office Room 3311, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

6. On 04/24/2013 at 3:23 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Activity & Dining Room 12 and Conference Room 13 , that the escutcheon ring on the sprinkler was is not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

7. On 04/25/2013 at 9:30 am, observation revealed on the Wing area 4/ Level 3-C floor in the Closet Room 3217-D, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

8. On 04/25/2013 at 10:23 am, observation revealed on the Wing area 5/ Level 2 floor in the Dish Room 2339, that the escutcheon ring on the 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

9. On 04/25/2013 at 2:04 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Room 1030, that the escutcheon ring on the sprinkler was not tight to the ceiling. 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

10. On 04/25/2013 at 3:15 pm, observation revealed on the Wing area 3/ Level 1 floor in the Closet 1101 & 1100 in Day Hospital, that the escutcheon ring on the 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 observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

11. On 04/23/2013 at 6:00 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Nurses Station, open to Corridor, that there was one or more unsealed holes near the ceiling. The hole(s) included several 1/2 inch diameter holes within different locations around the nurses station. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

12. On 04/24/2013 at 8:49 am, observation revealed on the Wing area 1/ Level 1 floor in the Gift Shop Room 1008, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1/2 inch x 12 inches opening from a ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

13. On 04/24/2013 at 8:56 am, observation revealed on the Wing area 1/ Level 1 floor in the Pantry at Snack Shop Room 1009, that there was one or more unsealed holes near the ceiling. The hole(s) included 12 inches x 24 inches from a patch of the ceiling. The ceiling system is rated to 2-hours from metal lath and plaster from original construction. The patch is only a 1/2 or 5/8 inch gypsum wallboard that could not be positively identified and the screws were exposed and not double mudded along with the edge of the drywall patch. This is a non-compliant fire-rated assembly in a hazardous area. Documentation was not provided to prove its UL assembly at time of survey. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

14. On 04/24/2013 at 9:22 am, observation revealed on the Wing area 2/ Level 1 floor in the Chapel Vestibule, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch x 12 inches at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

15. On 04/24/2013 at 9:47 am, observation revealed on the Wing area 5/ Level 3-C floor in the General Office Suite 3304 outside Room 3304-5, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12 inch x 12 inch damaged ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

16. On 04/24/2013 at 9:53 am, observation revealed on the Wing area 5/ Level 3-C floor in the Corridor outside Toilet Room 3314-C, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

17. On 04/24/2013 at 9:59 am, observation revealed on the Wing area 5/ Level 3-C floor in the General Office 3300, that there was one or more unsealed holes near the ceiling. The hole(s) included 1/2 inch diameter hole at electrical conduit next to speaker in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

18. On 04/24/2013 at 10:02 am, observation revealed on the Wing area 5/ Level 3-C floor in the Office Room 3312, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

19. On 04/24/2013 at 10:14 am, observation revealed on the Wing area 5/ Level 3 floor in the Men's Public Toilet on Main Corridor, that there was one or more unsealed holes near the ceiling. The hole(s) included a 5 inch x 12 inch opening in ceiling above the door. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

20. On 04/24/2013 at 10:17 am, observation revealed on the Wing area 5/ Level 3 floor in the Corridor near Door 3324, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch x 6 inch opening in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

21. On 04/24/2013 at 11:11 am, observation revealed on the Wing area 5/ Level 3-C floor in the Main Corridor 3308, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling light fixture cap between the ceiling tiles and fixture. One of the openings was a missing cap about 3 inches x 6 inches in area and the other location was farther down the same corridor next to the wall valence at ceiling light fixture. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

22. On 04/24/2013 at 11:45 am, observation revealed on the Wing area 5/ Level 3-A floor in the Corridor 3308 above Fire Extinguisher across from interior Court Yard 5-3-3, that there was one or more unsealed holes near the ceiling. The hole(s) included a missing 6 inch x 12 inch ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

23. On 04/24/2013 at 2:30 pm, observation revealed on the Wing area 4/ Level 3-A, B, C, D, E & F floor in the Housekeeping Closet Rooms 3203-3, 3221-3, 3219-3, 3230-3, 3223-3, & 3246-3, that there was one or more unsealed holes near the ceiling. The hole(s) included Several open ceiling tiles. Staff F stated they are removing all the humidification units out of the ceiling in the Housekeeping Closets at Units 3-A, 3-B, 3-C, 3-D, 3-E & 3-F and putting them into new stainless steel wall cabinet to reduce operational costs. However, the maintenance staff forgot to replace the ceiling tile after leaving the construction area and were not following the Hospital's Policy and Procedures. This was observed at several housekeeping locations within the hospital. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

24. On 04/24/2013 at 3:32 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Patient Toilet Room 8, Soiled Utility Room 9, Electrical Closet 23 & Conference Room 13 , that there was one or more unsealed holes near the ceiling. The hole(s) included numerous holes in ceiling of varying sizes at numerous locations. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

25. On 04/24/2013 at 3:42 pm, observation revealed on the Wing area 4/ Level 3-B floor in the Staff Work & Charting Room 3221-24, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch diameter near the ceiling corner by the vent. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

26. On 04/25/2013 at 9:33 am, observation revealed on the Wing area 4/ Level 3-H floor in the Corridor outside Room 3209, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1/2 inch diameter hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

27. On 04/25/2013 at 10:10 am, observation revealed on the Wing area 5/ Level 2-C floor in the Corridor outside tray line entry, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch x 12 inches at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

28. On 04/25/2013 at 12:53 pm, observation revealed on the Wing area 4/ Level 2-A floor in the Outpatient Corridor outside Room 2214, that there was one or more unsealed holes near the ceiling. The hole(s) included a 24 inch x 48 inch opening in the ceiling caused by a electrical cover plate falling through the acoustical ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

29. On 04/25/2013 at 2:03 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Room 1030, that there was one or more unsealed holes near the ceiling. The hole(s) included a 1 inch diameter hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

30. On 04/22/2013 at 10:40 am, observation revealed on the Wing area 4/ Level 4 floor in the Room 4345-9, that a sprinkler had paint on the head. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2.1.1.

31. On 04/23/2013 at 9:30 am, observation revealed that during a review of documents the facility could not verify that all elements of the fire pump system's annual test were performed. The Annual Fire Pump Test was performed by Grunau Company, Milwaukee, WI. During review of the report is was observed the record motor 'amps' were missing. This is a required field that must be filled out annually. Also missing was the 30 minute churn. No start time or stop time was recorded. Documentation of the 'lubing of the coupling' was missing in the Report. This observed situation was not compliant with NFPA 25 (1998 ed.), sectionn 5-3.

32. On 04/23/2013 at 9:15 am, observation revealed that during a review of documents the facility could not verify that the fire pump system's weekly 10-minute churn test was performed. observed a conflict of directions to the Milwaukee County Behavioral Health campus Plumber doing the weekly Fire Pump testing. Documentation stated to run 1-2 minutes, when in fact you are to run the Fire Pump a minimum of 10 minutes. This observed situation was not compliant with NFPA 25 (1998 ed.), 5-3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with fully visible extinguishers, and complete inspection documentation. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 3 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 5:30 pm, observation revealed that not all fire extinguishers were inspected monthly. During record review the hospital's fire extinguisher records revealed the total quantities of extinguishers was incomplete and the quantity pulled for testing purposes was imcomplete. The the extinguishers were last tested on May 25 & 26, 2011. Observed also revealed all fire extinguishers were beyond the 40 days of review. This observed situation was not compliant with NFPA 101 sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

2. On 04/22/2013 at 3:03 pm, observation revealed on the 1st Floor, in the Open Food Production area, that during a review of documents, records were not available to confirm that portable fire extinguishers were inspected monthly. Observed several fire extinguishers in the building not inspected since March 4, 2013. This means they have not been checked for 48 days, which is out of range for on-going maintenance requirements of inspection and testing per NFPA 10, Portable Fire Extinguishers. This observed situation was not compliant with NFPA 101 (2000 ed.) sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, interview, and record review, the facility did not provide fully visible extinguishers with complete inspection documentation. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/25/2013 at 3:34 pm, observation revealed on the Wing area 3/ Level 1-A floor in the Fire Extinguisher Cabinet at Corridor 1071 of Human Resources, that a fire extinguisher was obstructed from view and blocked from access because a cart and boxes were placed in front of the fire extinguisher cabinet. This observed situation was not compliant with NFPA 101 (2000 ed.) sections 19.3.5.6 and 9.7.4.1, NFPA 10 (1998 ed.) sections 1-6.6 and 4-3.2(b).

2. On 04/25/2013 at 10:00 am, observation revealed on the Wing area 1/ Level 1 floor in the Snack Shop Kitchen, that during a review of documents, records were not available to confirm that teh fire extinguisher was inspected monthly. The tag on the ABC fire extinguisher was blank, except for the installed date of August 2012. All other fire extinguishers through-out the health care campus had the Monthly review on the tag itself. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.5.6 and 9.7.4.1 and NFPA 10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A required damper maintenance. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 2:00 pm, observation revealed that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not all shown on the hospital plans and in the HVAC Annual Report, by Advanced Technologies Group. Documentation noted the fire dampers were last exercised in Fall of 2007 (allowed 6-years for exercising in hospital areas), but the documentation was missing as to where the 'smoke dampers' are located through-out the hospital campus. Currently the pneumatic controlled smoke dampers are not integrated to a smart system to test them remotely. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.5.2.1 and 9.2.1; and NFPA 90A (1999 ed.) section 3-4.7.

2. On 04/24/2013 at 3:15 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Serving Pantry Room 3203-28, that a fire damper was not installed in an air duct that penetrated the rated wall. Observation revealed an open exhaust duct in a wood cabinet of the pantry, previously used for food preparation. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.
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Based on observation and interview, the facility did not provide semi-annually cleaning of the range hood, and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspection and cleaning documents were incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, would the oven doors lock upon alarm activation, was the exit access route to safety reviewed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1.
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Based on observation, interview, and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96. Missing information in the range hood semi-annual cleaning, and hoods and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspected and cleaning documentation was incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, would the oven doors lock upon alarm activation, was the exit access route to safety reviewed. This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1.

2. On 04/24/2013 at 9:00 am, observation revealed the hood exhaust ducts were found not to be 'steel ducts' as required per NFPA 96, sections 4-5.1 through 4-5.2.2 Materials. This observed situation was not compliant with NFPA 101 section 19.3.2.6 and 9.2.3; and NFPA 96 section 8-3.1.

3. On 04/24/2013 at 9:15 am, observation revealed on the Wing area 1/ Level 1 floor in the Mechanical Penthouse above the Snack Shop, that the kitchen hood suppression system did not have liquid-tight seams of its metal ducts, could not verify if upon pulling 'activation button' it would automatically disconnect the fuel & electrical sources to the grill and fryer, ducts were not continuously 2-hour fire-wrapped upon passing through a floor assembly (fire dampers are not allowed) and could not verify the horizontal exhaust duct was sloped to a grease clean-out trap. Access panels did not appear to be the same fire-rating as the duct and did not appear that fasteners, such as bolts, weld nuts, latches, or wing nuts, used to secure the access panels were carbon steel or stainless steel per section NFPA 96 section 4-3.4.4. At the time of the survey, the hospital did not provide information that the grease ducts were installed in accordance with the terms of the listing and the manufacturer's instructions per section NFPA 96 section 4-3.4.5. This observed situation was not compliant with NFPA 101 section 19.3.2.6 and 9.2.3 and NFPA 96.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain trash collection receptacles in compliance with the codes with properly sized storage containers (<32 gallons) for soiled and trash containers. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/24/2013 at 9:44 am, observation revealed on the Wing area 5/ Level 3-C floor of Building #3, in the General Office Suite 3304 outside Room 3304-5, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous containment area. Two 65 gallon paper waste containers were located together in a non-hazardous space. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with NFPA 101 section 19.7.5.5.
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with sealed wall penetrations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/25/2013 at 11:29 am, observation revealed on the Wing area 5/ Level 2 floor in the Oxygen Storage Room located on Loading Dock, that penetration(s) were not sealed according to an approved method. The deficiency also included a mechanical duct exhausting from the Oxygen Storage Room into the Loading Dock. There were 34 e-cylinders that were off-gassing, potentially creating a hazardous situation with the Loading Dock area, that was considered hazardous. Did not see a direct exhaust to the outside of the building from the oxygen storage room. This room was used to store greater than 3,000 cubic feet of compressed gas and was required to be enclosed with 1-hour fire-rated construction. This observed situation was not compliant with NFPA 101 section 19.3.2.4 and NFPA 99 (1999 ed.) section 8-3.1.11.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, staff interviews and record review, the facility did not provide limited combustible partitions. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/25/2013 at 12:40 pm, observation revealed on the Wing area 4/ Level 2-B & C floor in the Central Supply Storage Room 2208, Maintenance, Plumbers, Carpenters, Painters, HVAC, and Electrical Shops 2210, 2211, 2216, 2220, 2221 & 2324, that during a review of facility documents the Hospital Building is a Type 1 (332) fire resistive construction. All wood partitions used in a Type 1 facility shall be of limited-combustibility or enclosed in a fire-rated assembly. The hospital could not provide documentation that the exposed wood studs meet a limited-combustibility requirement per NFPA 259.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels and closed electrical raceways. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 3:20 pm, observation revealed on the 1st Floor, in the area next to the Kitchen Exhaust Hood, that access to electrical panel was less than 3'-0" clearance. Panels 1/P3-2A & 1/P3-2 were located adjacent to a food preparation counter that was less than 36 inches from the face of the electrical panels. These panels were located on a column near the Kitchen Exhaust Hood. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-26.

2. On 04/22/2013 at 3:30 pm, observation revealed on the 1st Floor, in the Kitchen Equipment Holding area that access to electrical panel was less than 3'-0" clearance. Panel 1/P3-1 was observed with equipment in front of the electrical panel, with less than 36 inches clearance. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-26.

3. On 04/22/2013 at 2:52 pm, observation revealed on the 1st Floor, in the area near Walk-In Cooler #8, that a 4" x 4" electrical box was missing its cover plate and exposed electrical wires were observed within. Electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

4. On 04/22/2013 at 3:10 pm, observation revealed on the 1st Floor, in the Slicing Meat Counter, that a electrical outlet was pulled out from the meat preparation counter/base cabinet wall. The exposed wires were dangling from the cabinet and still attached to the electrical box, with the cover plate partly remove. Staff could not tell me how long this condition existed. This location is within distance of the 'wet mop' use by housekeeping staff during the cleaning of the food production area daily. Water and electricity could have a negative outcome to the person making contact. Electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation, interview, and record review, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, closed electrical raceways, electrical panels with complete directories, and proper working clearances. This deficiency had the potential to affect all patients, staff and visitors in 12 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/24/2013 at 10:25 am, observation revealed on the Wing area 5/ Level 3-A floor in the Patient Educational Computer Classroom, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to inpatient used computers. Numerous electrical cables were open and loose on the floor presenting a trip hazard to the occupants. This observed situation was not compliant with NFPA 70 (1999 ed.), sections 400-8(1) and 517-18.

2. On 04/24/2013 at 10:55 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Computer Teaching Room 6, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to inpatient used computers. Numerous electrical cables were open and loose on the floor presenting a trip hazard to the occupants. This observed situation was not compliant with NFPA 70 (1999 ed.), sections 400-8(1) and 517-18.

3. On 04/24/2013 at 11:13 am, observation revealed on the Wing area 5/ Level 3-A floor in the Inpatient Educational Conference Room 13, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to patient computers. Direct plug-in of computers in patient areas is required. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

4. On 04/25/2013 at 11:16 am, observation revealed on the Wing area 5/ Level 2 floor in the Materials Management Storeroom 2310, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the refrigerator. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

5. On 04/25/2013 at 11:45 am, observation revealed on the Wing area 4/ Level 2-A floor in the Pharmacy Breakout Room 2201, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to both the microwave and refrigerator. This observed situation was not compliant with NFPA 70 (1999 ed.) sections 400-8(1) and 517-18.

6. On 04/23/2013 at 5:45 pm, observation revealed on the Wing area 5/ Level 3-A floor in the Copier Room 20, that a 2-1/2 inch x 4 inch electrical box was open next to the copier machine. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

7. On 04/24/2013 at 11:07 am, observation revealed on the Wing area 5/ Level 3-A floor in the Soiled Utility Room 9, that a 4 inch x 4 inch electrical box was open at the ceiling. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

8. On 04/25/2013 at 12:54 pm, observation revealed on the Wing area 4/ Level 2-A floor in the Outpatient Corridor outside Room 2214, that a 4 inch x 4 inch electrical box was open above the ceiling in the interstitial area. The electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 ed.) section 517-12.

9. On 04/22/2013 at 10:30 am, observation revealed on the Wing area 4/ Level 2-A floor in the Central Supply Equipment Holding Room 2208, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #4/1A was found to have an open electrical breaker plate during the last inspection 9/25/2012. This was part of the Annual Inspection by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as of the time of this survey. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

10. On 04/22/2013 at 11:15 am, observation revealed on the Wing area 5/ Level 2-C1 floor in the Food Serving area, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel # Kitchen, was missing a required latching mechanism to the panel itself to keep it closed. This was part of the Annual Inspection by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as of the time of this survey. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

11. On 04/23/2013 at 5:39 pm, observation revealed on the Wing area 5/ Level 3-B & 3-A floor in the Electrical Rooms B-24 & A-24, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 5/2B-breaker #5 and Panel 5/2A-breaker #32 were observed to be in the 'ON' position, but the identification card stated they were 'Spares'. These electrical panels serve the floor below, yet they where not marked. The single-line electrical drawings need to reflect this condition of panels located on a different floors that the areas they serve. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

12. On 04/24/2013 at 9:12 am, observation revealed on the Wing area 1/ Level 1 floor in the Mechanical Penthouse above the Snack Shop, that electrical panel breaker(s) were not labeled to identify the loads they fed. The panel 1/GB-breakers 20, 21, 26, 28, 30, 32 and panel 1/GA-breakers 18, 19, 20, 21, 22, 24, 26, 30, 31, 33, 35, 38, 40, 41 & 42 were missing correct identification. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

13. On 04/24/2013 at 9:25 am, observation revealed on the Wing area 2/ Level 1 floor in the Room 1016A, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panels 1/GA, 1G/X & 1G/XA were missing the identification card or mis-marked and the panels were blocked with less than 36 inches of clearance in front of them. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

14. On 04/24/2013 at 9:50 am, observation revealed on the Wing area 5/ Level 3-C floor in the Room 3304-9, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 5/2C-breakers 31, 34 & 36 were incorrectly labeled. This electrical panel was identified as serving the electrical needs of the floor below and not shown correctly on the electrical drawings. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

15. On 04/24/2013 at 3:35 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Storage Closet 3203-19 & Electrical Closet 3203-23, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 'Kitchen'-breaker #8 of Rm. 19, Panel 4/2A-breakers #39, #41, #40 & #42 and Panel 4/2B-breaker #32 of Rm. 23 were labeled as SPARE but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

16. On 04/24/2013 at 3:36 pm, observation revealed on the Wing area 4/ Level 3-B floor in the Electrical Closet 3221-23 & Storage Room 3221-19, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 'Kitchen'-breaker #7 of Rm. 19 and Panel 4/3B-breakers #30 & #31 of Rm. 23 were labeled as SPARE but were in the 'ON' position. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

17. On 04/25/2013 at 9:40 am, observation revealed on the Wing area 4/ Level 3-H floor in the Suite Corridor, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel 4/2H-breakers 25 & 27 were in the 'ON' position and the identification card stated they were SPARES. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

18. On 04/25/2013 at 10:30 am, observation revealed on the Wing area 5/ Level 2 floor, that the Level of service was incorrect. It was observed that the single-line electrical drawings incorrectly show the Level for the electrical panels. Example: The 2nd Level is shown as Level 1. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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