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Based on observation and interview, the facility did not provide a common separation wall with and sealed wall penetrations. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10-15-2012 at 11:20 am, observation revealed on the 2nd floor in the Corridor Wall, above the ceiling across from the elevator, that penetration(s) were not sealed according to an approved method. The deficiency included 1/2 inch annular gaps on two separate 2-inch pipes penetrating the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

2. On 10-15-2012 at 11:27 am, observation revealed on the 1st floor in the Corridor Wall above the ceiling behind the elevator, that penetration(s) were not sealed according to an approved method. The deficiency included a 1-inch hole in the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

3. On 10-15-2012 at 11:30 am, observation revealed on the 1st floor in the Corridor Wall above the ceiling by the temperature control compressor room, that penetration(s) were not sealed according to an approved method. The deficiency included a 4-inch by 4-inch hole and a 6-inch by 6-inch hole. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in 1 of the smoke compartments, and had the potential to affect 100 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/15/2012 at 1:15 pm surveyor #28616 observed in the 1A smoke compartment on the first floor in the corridor at suite, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, no combustible material storage, and rooms open to the corridor with the required safe-guards. This deficiency occurred in 3 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10/16/2012 at 12:00 PM, observation revealed on the Basement floor in the Corridor in front of the maintenance shop, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included nine (9) unused beds. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1, and 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

2. On 10/17/2012 at 9:10 am, observation revealed on the 2nd floor in the Control room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

3. On 10/17/2012 at 10:15 am, observation revealed on the 2nd floor in the Storage Space (SW204) in the Corridor in front of Store Room (2203), that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included combustible card board boxes. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1, and 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

Based on observation and interview, the facility did not provide corridor separation doors with self-latching inactive doors. This deficiency occurred in 2 of the smoke compartments, and had the potential to affect 10 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/15/2012 at 10:59 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the 42-mechanical room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 6 of the smoke compartments, and had the potential to affect 50 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/15/2012 at 3:35 pm surveyor #28616 observed in the 7B smoke compartment on the seventh floor in the corridor, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door latch and frame strike did not align. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

2. On 10/15/2012 at 2:11 pm surveyor #28616 observed in the 2B smoke compartment on the second floor in the stair enclosure, that penetration(s) in a vertical shaft were not sealed according to according to an approved method. The deficiency included a 3" diameter hole, medical gas lines and mechanical utilities that are not serving the rated stair enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

3. On 10/15/2012 at 2:48 pm surveyor #28616 observed in the 4B2 smoke compartment on the fourth floor in the stair enclosure, that penetration(s) in a vertical shaft were not sealed according to according to an approved method. The deficiency included an unsealed low voltage wire penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10/17/2012 at 9:30 am, observation revealed on the 2nd floor in the Anesthesia supply room, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

2. On 10/16/2012 at 3:00 PM, observation revealed on the 1st floor in the fire barrier wall near cancer out-patient, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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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 occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 10:40 am, observation revealed on the Basement floor in the Stair S-10, that the path of egress in the stair enclosure was not readily apparent and an exit sign was not provided. Fixed exterior glass windows permit viewing of the exterior causing confusion for users of the exit stair. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with and rated wall construction. This deficiency occurred in 3 of the smoke compartments, and had the potential to affect 50 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/15/2012 at 1:20 pm surveyor #28616 observed in the 1A smoke compartment on the first floor in the waiting area at suite wall, that the smoke barrier wall was not compliant. The suite separation smoke barrier wall had a 6" diameter fire protection sprinkler pipe, (2) 1" conduit penetrations and (1) 3" diameter hole that were not sealed to maintain a smoke and fire resistive rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

2. On 10/15/2012 at 1:23 pm surveyor #28616 observed in the 1B smoke compartment on the first floor in the corridor at emergency department suite, that the smoke barrier wall was not compliant. The suite separation smoke barrier wall had (2) 4" x 3" holes above the ceiling that were not sealed to maintain a smoke and fire resistive rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

3. On 10/15/2012 at 1:26 pm surveyor #28616 observed in the 1B smoke compartment on the first floor in the corridor at emergency department suite, that the smoke barrier wall was not compliant. The suite separation smoke barrier wall had a 3" x 4" hole above the ceiling that was not sealed to maintain a smoke and fire resistive rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with and an adjacent smoke detector. This deficiency occurred in 3 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10/16/2012 at 10:45 am, observation revealed on the Basement floor in the Smoke barrier door between the tunnel and the corridor near the Mechanical room, that the smoke barrier door was magnetically held open and did not have a smoke detector. The door header was greater than 30 inches in height. This observed situation was not compliant with NFPA 101(2000 ed.), 19.3.7.6 and 19.2.2.2.6, and NFPA 72(1999 ed.), 2-10.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff M7 (Safety Coordinator) and staff M8 (Quality Coordinator).

2. On 10/17/2012 at 10:05 am, observation revealed on the 2nd floor in the Smoke barrier doors near OR-3 and OR-4, that the smoke barrier door was magnetically held open and did not have smoke detectors on either sides of the doors and door header was 2'-6" in height on both sides of the door. This observed situation was not compliant with NFPA 101(2000 ed.), 19.3.7.6 and 19.2.2.2.6, and NFPA 72(1999 ed.), 2-10.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, closers on all doors, doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 11 of the smoke compartments, and had the potential to affect 100 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/15/2012 at 11:04 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the pharmacy room, that the door would not self-close because the door did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

2. On 10/15/2012 at 11:15 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the B101 storage room, that the door would not self-close because the door did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

3. On 10/15/2012 at 11:41 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the EB17 storage room, that the door would not self-close because the door did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

4. On 10/15/2012 at 12:59 pm surveyor #28616 observed in the 1A smoke compartment on the first floor in the storage/shell space, that the door would not self-close because the pair of doors did not have a coordinator to allow for latching. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

5. On 10/15/2012 at 1:36 pm surveyor #28616 observed in the 1B smoke compartment on the first floor in the C3-storage room, that the door would not self-close because the door did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

6. On 10/15/2012 at 2:58 pm surveyor #28616 observed in the 4B2 smoke compartment on the fourth floor in the clean utility room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door was equipped with push/pull hardware. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

7. On 10/15/2012 at 2:58 pm surveyor #28616 observed in the 4B2 smoke compartment on the fourth floor in the soiled utility room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door was equipped with push/pull hardware. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

8. On 10/15/2012 at 11:18 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the stair enclosure, that penetration(s) were not sealed according to an approved method. The deficiency included a 3" diameter electrical conduit that did not serve the stair enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

9. On 10/15/2012 at 2:32 pm surveyor #28616 observed in the 3B smoke compartment on the third floor in the soiled utility room, that penetration(s) were not sealed according to an approved method. The deficiency included (2) 2" diameter pipes above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

10. On 10/15/2012 at 2:35 pm surveyor #28616 observed in the 3B smoke compartment on the third floor in the clean utility room, that penetration(s) were not sealed according to an approved method. The deficiency included a 12" x 12" access to the toilet on the other side of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

11. On 10/15/2012 at 1:10 pm surveyor #28616 observed in the 1A smoke compartment on the first floor in the soiled utility room, that penetration(s) were not sealed according to an approved method. The deficiency included a 6" x 1" hole in the gypsum board with conduit penetrations and an open junction box above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide enclosures around exit stairs with sealed wall penetrations. This deficiency occurred in 8 of the smoke compartments, and had the potential to affect 100 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/15/2012 at 10:51 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the S20 stair enclosure, that penetration(s) were not sealed according to an approved method. The deficiency included multiple mechanical and building utilities passing through the rated stair enclosure that were not serving the enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain all stairs to meet code requirements with exits free of storage. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 11:45 am, observation revealed on the Basement floor in the Stair S-3, that a portion of the stair enclosure was being used as storage space. A 4' x 8' plywood door was stored inside the stair enclosure. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfere with egress". This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.3 and 7.2.2.5.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force. This deficiency occurred in 2 of the smoke compartments, and had the potential to affect 50 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/15/2012 at 1:37 pm surveyor #28616 observed in the 1B smoke compartment on the first floor in the corridor, that the door in the path of egress would not unlatch when a force of 200# pounds was applied, which exceeded the maximum 15 pounds needed to unlatch an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs with exit signs that were continuously illuminated. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 1:50 pm, observation revealed on the 1st floor in the Lab-A room, that the exit sign was not continuously illuminated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.10.1 and 7.10. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/15/2012 at 3:45 PM, record review revealed that the facility fire drill records showed that fire drills were conducted in a pattern so they were not held at unexpected times. The facility's fire drill records from October 2011 to September 2012 indicated that 3 (2nd, 3rd and 4th quarter) of 4 third-shift drills were held between 5:35 AM and 5:41 AM. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Security Supervisor) and staff M5 (Security Supervisor).

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Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing, and on-time inspection. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10/15/2012 at 10:45 am, observation revealed that the fire alarm maintenance was not compliant. The Quarterly Sprinkler inspection conducted on 3/29/2012 entitled 'Report of Inspection and Testing of Water Based Fire Protection Systems' did not provide the time the fire alarm signal was transmitted to the monitoring agency and the time of the alarm restoration. Per NFPA 72 - 1999 edition Section 5-2.2.2, the fire alarm system must transmit alarm, trouble, and supervisory signals to the central monitoring station. Per NFPA 72 1999 edition Section 7-5.2, the facility must inspect the transmissions of the alarm, supervisory, and trouble signals are sent to monitoring station with the times the signals were received and the restoration of the alarm and supervisory signals. The observed situation was not compliant with NFPA 101 (2000 edition), 9.7.2.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Plumber/ Pipe Fitter), staff M2 (Electrician) and staff M3 (Quality Coordinator).

2. On 10/15/2012 at 12:15 PM, observation revealed that during a review of facility documents the required semi-annual inspections were not performed on a 6 month basis. Sealed lead acid type batteries for the Fire Alarm System were only tested once, on 11/30/2011, within the last year. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Plumber/ Pipe Fitter), staff M2 (Electrician) and staff M3 (Quality Coordinator).

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/15/2012 at 11:30 am, record review revealed that during a review of facility documents, records were not available to verify that smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Plumber/ Pipe Fitter), staff M2 (Electrician) and staff M3 (Quality Coordinator).

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Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system with and unobstructed water distribution. This deficiency occurred in 1 of the smoke compartments, and had the potential to affect 10 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/15/2012 at 11:35 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the EB18 storage room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a 52" wide duct. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

2. On 10/15/2012 at 11:47 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the air handler equipment room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a 60" duct. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and sprinkler gauges with the required maintenance. This deficiency occurred in 8 of the smoke compartments, and had the potential to affect 100 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/15/2012 at 3:50 pm surveyor #28616 observed in the 8B smoke compartment on the eighth floor in the closet, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

2. On 10/15/2012 at 11:52 am surveyor #28616 observed in the 0A smoke compartment on the basement floor in the fire pump room, that during the inspection the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. The fire protection sprinkler guages were not dated. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

3. On 10/15/2012 at 12:55 pm surveyor #28616 observed in the 1A smoke compartment on the first floor in the EMS office, that during the inspection the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. The fire protection sprinkler guages were not dated. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).

4. On 10/15/2012 at 3:53 pm surveyor #28616 observed in the 8B smoke compartment on the eighth floor in the closet, that there was one or more unsealed holes near the ceiling. The hole(s) included (2) 1" diameter holes. 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 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).


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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete five year inspection, a complete annual inspection. This deficiency occurred in all smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10/15/2012 at 10:30 am, observation revealed that during a review of facility documents that all components five year sprinkler inspection were not conducted. Gauges were replaced in August 2010. Check valves were not inspected internally and pipes were not investigated for obstructions within the last five years. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2, 9-2.8.2, 9-4.2.1, 9-4.4.1.5, 9-4.3.1.3 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Plumber/ Pipe Fitter), staff M2 (Electrician) and staff M3 (Quality Coordinator).


2. On 10/15/2012 at 4:00 pm, observation revealed that the sprinkler system maintenance was not compliant. During a review of documents the facility could not verify that the fire pump's Level 1 and Level 2 Transfer Switches monthly exercise was performed. This observed situation was not compliant with NFPA 110 (1999 edition) Section 6-4.5. Also facility could not verify that EPSS circuit breakers for Level 1 system usage were exercised annually within the EPS in the off position per NFPA 110 (1999 edition) Section 6-4.6 This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.
This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Plumber/ Pipe Fitter), staff M2 (Electrician) and staff M3 (Quality Coordinator).

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Based on observation and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A with a flange or sleeve around the fire damper. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 11:32 am, observation revealed on the Basement floor in the Maintenance Shop, that a fire damper was installed in an air duct but its installation could not be confirmed to be compliant with codes, or the manufacture's instructions. The fire damper was installed in the wall with a flange and sleeve and the annular space was filled with intumescent material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not maintain an egress path that was free of obstructions. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10-17-2012 at 9:08 am, observation revealed on the Rawson Basement South floor in the G-30 Nurse Station-B Corridor, that items were stored in the exit access pathway, including 3 wood carts, 2-feet deep by 6-feet long by 4-feet high with medical record files. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6), and 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

2. On 10-17-2012 at 9:13 am, observation revealed on the Rawson Basement South floor in the G-30 Exit Corridor, that items were stored in the exit access pathway, including 15 wood carts, 2-feet deep by 6-feet long by 4-feet high with medical record files. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6), and 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

Based on interview and observation, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 1:30 pm, observation revealed on the 1st floor in the Men's Locker room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower space. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/16/2012 at 11:30 am, observation revealed on the Basement floor in the Micro lab room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Eight 32 gallon and one 96 gallon capacity trash receptacles were placed in close proximity inside the Micro lab room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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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 oxygen cylinders restrained from falling. This deficiency occurred in of the 37 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10-15-2012 at 2:37 pm, observation revealed on the 1st floor in the Smoke Zone 1G, Kitchen Loading Dock, that cylinders of oxygen in storage were not secured to keep them from falling. There were 30 oxygen tanks in the loading dock area that were not secured to prevent from tipping over and none of the cylinders were labeled with full, partial, or empty tags. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in of the 37 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10-15-2012 at 11:30 am, observation revealed on the Basement floor in the Smoke Zone 0B, Telephone Equipment Room, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with a surface covering consisting of 3 sheets of plywood that were not marked as being fire retardant treated. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

Based on observation and interview, the facility did not provide a code compliant facility designated fire rated vestibule between the surgery suite and elevator. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/17/2012 at 11:15 am, observation revealed on the 2nd floor in the Transition Area serving the surgery suite and Elevator an opening in the 1 hr fire barrier enclosure measuring approximately 2' x 7' for a medical supply refrigerator/ freezer. Additionally, the door and door assembly in the 1 hour rated wall in the same location did not have a listing agency rating label. The facility designated this vestibule as a fire rated 1 hr enclosure and intends to maintain this condition per facility interview and facility life safety code plan. The observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.1 & 8.2.3.2.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (VP, Construction & Facility), staff E (Safety Coordinator) and staff M8 (Quality Coordinator).

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Based on observation and interview, the facility did not provide proper labeling and did not provide separate storage. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 10-15-2012 at 10:45 am, observation revealed on the 2nd floor in the Oxygen Storage Room, that the oxygen transfer room was not compliant because twelve oxygen tanks had no tags indicating whether they were empty or full. This observed situation was not compliant with NFPA 99 (1999 ed.) 8-3.1.11.2(d) and 4-3.1.1.2(b)4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

2. On 10-15-2012 at 11:55 am, observation revealed on the 1st floor in the Oxygen Storage Room, that the oxygen transfer room was not compliant because empty and full tanks were being stored in the same rack. This observed situation was not compliant with NFPA 99 (1999 ed.) 8-3.1.11.2(d) and 4-3.1.1.2(b)4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operations) and staff B (Quality Specialist).

Based on interview and observation, the facility did not test the emergency electrical generator in accordance with the codes with generator with a reliable cooling system. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 10/15/2012 at 3:40 pm, observation revealed that the emergency generator (Main 1500 KW) cooling system was not powered from the tap of EPS terminal. The generator radiator's exterior hot air discharge damper was controlled by a separate circuit from the Johnson Control system. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Electrician) and staff M3 (Quality Coordinator).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels. This deficiency occurred in 1 of the smoke compartments, and had the potential to affect 20 of the 260 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/15/2012 at 1:40 pm surveyor #28616 observed in the 1B smoke compartment on the first floor in the storage room, that access to electrical panel was less than 3'-0" clearance. The access to the electrical panel was obstructed with an equipment cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (VP Construction and Facility), staff D (Safety Coordinator) and staff E (Safety Coordinator).