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Based on observation and staff interview, the facility did not ensure that the fire resistance rating of 2-hour rated fire barrier walls, with sealed penetrations, were maintained in accordance with NFPA 101 (2012 edition), 19.1.3.5 and 8.2.1.3. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff, and visitors.

Findings include:

1. On 07-18-2017 at 10:21 a.m., observation in the 2-hr. rated fire barrier separating the Hospital from the Medical Clinic, above the acoustical ceiling in the east/west corridor near Oncology, revealed an approximate 1/2" diameter low voltage conduit sleeve penetration and an approximate 2" diameter low voltage conduit sleeve penetration that were not properly fire stopped.

2. On 07-18-2017 at 10:31 a.m., observation in the 2-hr. rated fire barrier separating the Hospital from the Medical Clinic, above the acoustical ceiling in the reception area of the Radiology Department, revealed an approximate 1/2" diameter low voltage conduit sleeve penetration that was not properly fire stopped.

3. On 07-18-2017 at 10:40 a.m., observation in the 2-hr. rated fire barrier separating the Hospital from the Medical Clinic, above the acoustical ceiling in the east/west corridor at the double set of fire doors near room 401, revealed an approximate 1" diameter low voltage conduit sleeve penetration that was not properly fire stopped.

4. On 07-18-2017 at 1:35 p.m., observation in the 2-hr. rated fire barrier separating the Hospital from the Nursing Home walkway link, above the acoustical ceiling at the double set of fire doors in the dining area, revealed two (2) approximate 1" square holes, with low voltage wires passing through them, that were not properly fire stopped.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that 1-hr. rated hazardous storage areas are protected in accordance with NFPA 101 (2012 edition), 19.3.2.1. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 07-18-2017 at 11:53 a.m., observation in the 1-hr. rated storage room 314 revealed that the door was neither self-closing nor automatic-closing.

2. On 07-18-2017 at 1:09 p.m., observation in 1-hr. rated electrical rooms 450 and 451 revealed that kick-down door stops were installed on the bottom of each door preventing the door from self-closing.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff O.

Based on observation, record review, and staff interview, the facility did not ensure that the range hood fire suppression system and the range hood exhaust system were maintained as required per NFPA 101 (2012 edition), 19.3.2.5 through 19.3.2.5.5, 9.2.3 and NFPA 96 (2011 edition), 11.2.1, 11.4 and 11.6; and the facility did not ensure that a placard was in place near the kitchen k-type fire extinguisher in accordance with NFPA 101 (2012 edition), 19.3.2.5.3(8) and NFPA 96 (2011 edition), 10.2.2. These deficient practices could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

1. On 07-17-2017 at 3:10 p.m., the latest range hood fire suppression system inspection report dated 03-07-2017 was reviewed. A copy of the previous range hood fire suppression system inspection reports for 2016, dated 11-01-2016 and 04-08-2016, were reviewed. Comparison of the three inspection dates revealed that the period between the range hood fire suppression system inspections exceeded the maximum 6-month interval allowed.

2. On 07-17-2017 at 3:22 p.m., the most recent range hood exhaust duct inspection/cleaning report dated February 2017 was reviewed. A copy of the previous range hood exhaust duct inspection/cleaning report dated February 2016 was also reviewed. No record of a visual inspection of the condition of the exhaust ductwork at six month intervals, between the professional cleaning dates, was provided.

3. On 07-18-2017 at 2:50 p.m., observation in the main kitchen revealed that a placard was missing near the k-type fire extinguisher that states the fire protection system shall be activated prior to using the fire extinguisher.

This deficiency was confirmed at the time of discovery by a concurrent observation, record review and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that the smoke detectors, for the fire alarm system, are installed per NFPA 101 (2012 edition), 9.6 and NFPA 72 (2010 edition), 17.7.4.1. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 07-18-2017 at 11:37 a.m., observation in the emergency department entrance corridor revealed that a smoke detector was installed within the airflow of a supply diffuser.

2. On 07-18-2017 at 11:39 a.m., observation in the emergency department room 323 revealed that a smoke detector was installed within the airflow of a supply diffuser.

3. On 07-18-2017 at 11:40 a.m., observation in the emergency department room 325 revealed that a smoke detector was installed within the airflow of a supply diffuser.

4. On 07-18-2017 at 11:48 a.m., observation in the corridor outside of room 315A revealed that a smoke detector was installed within the airflow of a supply diffuser.

5. On 07-18-2017 at 12:01 p.m., observation in the corridor outside of room 341 revealed that a smoke detector was installed within the airflow of a supply diffuser.

6. On 07-18-2017 at 12:02 p.m., observation in room 339 revealed that a smoke detector was installed within the airflow of a supply diffuser.

7. On 07-18-2017 at 12:03 p.m., observation in room 338 revealed that a smoke detector was installed within the airflow of a supply diffuser.

8. On 07-18-2017 at 1:56 p.m., observation in the main entrance waitingarea in the Medical Clinic revealed that two smoke detectors were installed directly above and within the airflow of ceiling fans.

9. On 07-18-2017 at 2:03 p.m., observation in the Medical Clinic children's waiting room revealed that a smoke detector was installed within the airflow of a supply diffuser.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that the fire alarm outage policy had current contact information and included required language in accordance with NFPA 101 (2012 edition), 9.6.1.6. This deficient practice could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 07-18-2017 at 8:40 a.m., review of the facility policy titled "Failure of Fire Systems" dated "effective 3-2000" and "reviewed 2008; 2009; 2010; 2011; 2015; 2017" revealed that the policy stated "If the system is not returned to normal functions within 4 hours Notify representatives of...". The required code language stating "4 hours within a 24-hour period" was not included within the policy. Additionally, the contact information for the Wisconsin Department of Health was not current. The policy did not mention potential evacuation of the facility, nor did it properly address all elements of an approved fire watch.

This deficiency was confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that the automatic sprinkler system was maintained in accordance with NFPA 101 (2012 edition), 9.7.5 and NFPA 25 (2011 edition), 5.2.1. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings Include:

On 07-17-2017 at 3:50 p.m., record review was conducted of the most recent sprinkler system annual inspection report dated 06-02-2017. Additional review of the two previous annual inspection reports dated 09-16-2016 and 09-25-2015 were also conducted. When Staff O was asked for the most recent quarterly sprinkler inspection reports, he stated that the facility has not conducted any quarterly sprinkler inspections, nor has their hired professional maintenance and inspection contractor conducted any quarterly sprinkler inspections.

This deficiency was confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that a fire sprinkler outage policy was in place addressing all elements in accordance with NFPA 101 (2012 edition), 9.7.5 and NFPA 25 (2011 edition), 15.5.2. This deficient practice could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 07-18-2017 at 8:50 a.m., review of the facility policy titles "Failure of Fire Systems" dated "effective 3-2000" and "reviewed 2008; 2009; 2010; 2011; 2015; 2017" revealed that the policy did not address requirements if the fire sprinkler system is out of service for more than 10 hours in a 24-hour period, including arranging for evacuation of the building or portion of the building affected by the system, establishment of a temporary water supply, and establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire.

This deficiency was confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that transfer grilles are not used in corridor walls in accordance with NFPA 101 (2012 edition), 19.3.6.4.1. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 07-18-2017 at 1:16 p.m., observation in the oxygen cylinder storage room 449 revealed an approximate 8" x 8" transfer grille between the oxygen cylinder storage room and the adjacent corridor.

This deficiency was confirmed at the time of discovery by concurrent observation and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that the fire resistance rating and smoke tightness of smoke barrier walls, with sealed penetrations, were maintained in accordance with NFPA 101 (2012 edition), 19.3.7.3 and 8.5. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 07-18-2017 at 10:46 a.m., observation in the 1-hr. rated smoke barrier wall above the acoustical ceiling near the door to room 329 revealed an approximate 1/2" diameter electrical conduit penetration, a 1-1/2" diameter PVC low voltage sleeve penetration, a 1/2" diameter low voltage conduit sleeve penetration, and two individual low voltage wire penetrations that were not properly fire stopped.

2. On 07-18-2017 at 10:53 a.m., observation in the 1-hr. rated smoke barrier wall above the acoustical ceiling near the door to room 336 revealed an approximate 2" diameter metal sleeve penetration with low voltage wires passing through it that was not properly fire stopped around the sleeve and inside the sleeve.

3. On 07-18-2017 at 11:03 a.m., observation in the 1-hr. rated smoke barrier wall above the acoustical ceiling in the waiting room 359 revealed an approximate 1/2" diameter electrical conduit penetration that was not properly fire stopped.

4. On 07-18-2017 at 11:08 a.m., observation in the 1-hr. rated smoke barrier wall above the acoustical ceiling in room 361 revealed an approximate 1-1/2" diameter sprinkler pipe penetration that was not properly fire stopped.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that fire dampers were maintained in accordance with NFPA 101 (2012 edition), 19.5.2.1 and 9.2, and NFPA 105 (2010 edition), 6.5.2, and the facility did not ensure that HVAC systems were installed in accordance with NFPA 101 (2012 edition), 19.5.2.1 and 9.2, and NFPA 90A (2012 edition), 4.3.12 with a corridor used as a portion of a return air plenum. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings Include:

1. On 07-17-2017 at 1:50 p.m., records were requested for the most recent functional test of fire dampers. At the time of the request, Staff O indicated that he was unaware if there were any fire dampers within the facility and unaware of any records of damper testing. On 07-18-2017 at 12:57 p.m. a fire damper was observed in the north wall of mechanical room 447 and at 1:12 p.m. a second fire damper was observed in the oxygen storage room 449. A second record request of functional testing revealed that no records exist for the functional testing of fire dampers.

2. On 07-18-2017 at 10:05 a.m., observation in the oncology entrance corridor revealed that the ventilation system utilized the oncology entrance corridor, above the acoustical ceiling, as a return air plenum.

These deficiencies were confirmed at the time of discovery by concurrent observation and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that a written fire safety plan was provided that addressed all of the items required by NFPA 101 (2012 edition), 19.7.2.2. This deficient practice could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 07-18-2017 at 8:30 a.m., a review of the document titled "Fire Alarm" dated "effective 3/2011" and "reviewed 3/2017" revealed that the facility's written fire safety plan did not clearly address all nine elements required by code, specifically the transmission of alarms to the fire department, the emergency phone call to the fire department, and the extinguishment of the fire. The plan only stated that 911 shall be contacted in the event that the fire alarm system malfunctions.

This deficiency was confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that fire alarm signals were received by the monitoring company or that the fire drills were held once per each shift per quarter and under varying conditions as required per NFPA 101 (2012 edition), 19.7.1.4 and 19.7.1.6. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 07-18-2017 at 8:10 a.m., review of the facility form titled "Fire Drill Log" revealed that within the past calendar year fire drills were not conducted during the 2nd and 3rd shifts in the third quarter of 2016, during the 3rd shift in the fourth quarter of 2016, during the 3rd shift in the first quarter of 2017 and during the 2nd shift in the second quarter of 2017.

2. On 07-18-2017 at 8:15 a.m., review of the facility form titled "Fire Drill Log" revealed that the facility is not checking and recording that the fire alarm signal has been received by their monitoring company after completing a fire drill.

These deficiencies were confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on record review and staff interview, the facility did not ensure that the emergency generator is visually inspected and maintained weekly in accordance with NFPA 101 (2012 edition), 19.5.1, 9.1.3 and NFPA 110 (2010 edition), 8.4.1. This deficient practice could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 07-17-2017 at 2:45 p.m., review of the facility records for generator testing titled "Monthly Generator Log" revealed that the facility is testing the generator once monthly under load, however no record of a weekly inspection was available. Staff O indicated that the facility does not currently perform weekly inspections of the generator, only a monthly load test.

This deficiency was confirmed at the time of discovery by a concurrent record review and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that a remote stop for the emergency power generator is provided in accordance with NFPA 101 (2012 edition), 9.1.3.1 and NFPA 110 (2010 edition), 5.6.5.6, 5.6.5.6.1 and the facility did not ensure that a battery powered emergency light is provided in the transfer switch room in accordance with NFPA 110 (2010 edition), 7.3. These deficient practices could affect all 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 07-18-17 at 1:00 p.m., observation revealed that the emergency generator was located outside of the building and did not have a remote manual stop station elsewhere on the premises.

2. On 07-18-17 at 1:04 p.m., observation in the transfer switch electrical room 450 revealed that no battery powered emergency lighting was installed in the room with the transfer switch.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff O.

Based on observation and staff interview, the facility did not ensure that helium gas containers are properly stored and secured in accordance with NFPA 99 (2012 edition), 11.3.3.3 . This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 07-18-2017 at 11:44 a.m., observation in the MRI Equipment room 387 revealed that a single helium cylinder was leaning to the side and partially secured to a vertical piece of steel by means of a copper ground wire.

This deficiency was confirmed at the time of discovery by concurrent observation and interview with Staff O.