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Based on record review and staff interview, the facility did not conduct semi-annual training of the emergency preparedness plan per 42 CFR Subpart 485.625. This deficient practice could affect all of the residents, as well as undetermined number of staff and visitors.

Findings include:

On 07/20/2021 at 10:25 am, record review of the emergency preparedness plan (EPP) revealed that the facility did not have documentation of the staff annual education in the EPP policies and procedures, prior to December 2019. Staff AA stated that the Marshfield Clinic Health System (MCHS) acquired the hospital in December 2019, and that records prior to MCHS ownership could not be located.

This deficient practice was confirmed at the time of discovery by a concurrent interviews with Staffs V, Z, AA, BB.

Based on observation and interview, the facility did not provide a two-hour rated building separation in accordance with the requirements of NFPA 101 (2012 edition) Sections 18.1.3, 18.1.3.3, 8.3, 8.3.1, 8.3.1.2, 8.3.3, 8.3.3.1, 8.3.3.2.3, 8.3.4.2, & 8.3.5. This deficient practice has the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/19/2021 at 11:25 am, observation revealed that the 90-minute fire-rated double doors (frame no. A182) in the two-hour fire-rated barrier, separating the Hospital from the Clinic, did not positively latch.

2. On 07/19/2021 at 11:32 am, observation revealed that the double doors (frame no. F183) in the two-hour fire-rated barrier, separating the Hospital from the Clinic, were not fire-rated and were not equipped with latching hardware.

3. On 07/19/2021 at 12:20 pm, observation revealed that the door (frame no. G114) in the two-hour fire-rated barrier, separating the Hospital from the Clinic, was not fire-rated. The door was located between the pharmacy store-front and the Emergency Department (ED) entrance vestibule.

4. On 07/19/2021 at 12:24 pm, observation above the ceiling in the ED Waiting Room revealed a 1/2-inch conduit sleeve penetration in the two-hour fire-rated barrier, separating the Hospital from the Clinic, that was not fire stopped according to an approved method.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs V & W.

Based on record review, observation, and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 18.3.5.1, 9.7.5, & 9.7.1.1; NFPA 25 (2011 edition) Sections 5.4.1.4, 5.4.1.5, 5.2.1, 5.1.1.2, 14.2.1. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/19/2021 at 1:11 pm, observation revealed a missing ceiling tile in the Patient Room 8. This missing tile does not duplicate the tight conditions that were used in the sprinkler UL certification test.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V & W.

2. On 07/20/2021 at 11:12 am, observation in the C-Plant Room revealed that four (4) sidewall sprinkler heads located in the spare sprinkler head box. Review of the sprinkler head inventory sheet, located at the sprinkler riser, revealed that six (6) sidewall sprinkler spare heads were required. A hand written note in the spare sprinkler head box stated that the spare heads were on back-order. The Facilities Manager, Staff V, stated he was not notified about missing sprinkler spare heads.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V, W, & AA.

3. On 07/20/2021 at 11:44 am, observation revealed two (2) missing ceiling tiles in the H133 EVS. These missing tiles do not duplicate the tight conditions that were used in the sprinkler UL certification test.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V, W, & AA.

Based on record review, observation, and interview the facility failed to provide a fire evacuation and relation plan in accordance with NFPA 101 (2012 edition) Sections 18.7.1, 18.7.2. This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 07/19/2021 at 3:51 pm, review of the document titled "Fire Response Plan - MMC Neillsville", dated 6/23/21, revealed that the facility's written fire safety plan did not instruct staff to call the fire department in the event of a fire. The plan instructs staff to call 888 to "connect to telecommunications staff, and communications center operator will notify building services and security."

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V & X.

2. On 07/19/2021 at 3:55 pm, review of the Fire Response Plan revealed that the fire plan instructs staff to "evacuate all occupants beyond the nearest fire doors." Observation revealed that multiple sets of cross-corridor doors located in the corridor were installed for privacy and security purposes only, and were not part of a fire or smoke barrier. It was not clear which doors were fire/smoke doors and which doors were privacy/security doors, without the use of the Life Safety Code (LSC) Plan. No LSC plans were included in the Fire Response Plan.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V & X.

3. On 07/20/2021 at 11:30 am, observation in the Emergency Department (ED) revealed three (3) sets of cross-corridor doors separating the ED from the remainder of the hospital. Record review of the LSC Plan reveled that none of these doors were part of a fire or smoke barrier. Interview with an ED Registered Nurse, Staff Y, revealed that they did not know how to relocate residents out of the smoke compartment. Surveyor asked Staff Y where they would have to relocate patients in order to move them out of the current smoke compartment during a fire, and they responded that they "would have to call maintenance to ask."

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs V, W, Y, & AA.