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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 7:46 am surveyor #14105 observed in the south inpatient smoke compartment on the 2nd floor in the Corridor, that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space was used for physical therapy. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching hardware, and smoke-tight seals at meeting edges. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all of the 108 staff that were working.

FINDINGS INCLUDE:
1. On 08/16/10 at 11:29 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Radiology corridor, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:49 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the radiology aisle, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

3. On 08/16/10 at 1:18 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the physical therapy, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and walls. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect 4 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/16/10 at 9:52 am surveyor #14105 observed in the OR smoke compartment on the 1st floor in the Recovery Area, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The room contained five carts sized at 30" by 60" by 5 feet high which all contained combustible materials. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:45 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Soiled Utility room in ED, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

3. On 08/16/10 at 11:46 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Soiled Utility room in ED, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 7:43 am surveyor #14105 observed in the south inpatient smoke compartment on the 2nd floor in the Corridor, that the lamp within an internally illuminated exit sign is not operatational. The exit sign led to stair B. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.5.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system that had and notification devices at required locations. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 30 of the 108 staff that were working.

FINDINGS INCLUDE:
1. On 08/16/10 at 1:01 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the therapy office, that a visual notification appliance was not installed in this room, which was used by at least two people. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 1:08 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the therapy office, that a visual notification appliance was not installed in this room, which was used by at least two people. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

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 ceilings sealed above the sprinklers to collect heat, and intact escutcheon rings. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect 4 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/16/10 at 10:05 am surveyor #14105 observed in the OR smoke compartment on the 1st floor in the Clean Utility room 1150, that there was one or more unsealed holes near the ceiling. The hole(s) included three removed and displaced ceiling tiles 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:21 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Mammography room, 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant that had NFPA 70, National Electrical Code that had closed electrical raceways. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 10 of the 108 staff that were working.

FINDINGS INCLUDE:
On 08/16/10 at 1:07 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the electrical room L238, that a 12" x 12" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 7:46 am surveyor #14105 observed in the south inpatient smoke compartment on the 2nd floor in the Corridor, that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space was used for physical therapy. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching hardware, and smoke-tight seals at meeting edges. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all of the 108 staff that were working.

FINDINGS INCLUDE:
1. On 08/16/10 at 11:29 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Radiology corridor, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:49 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the radiology aisle, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

3. On 08/16/10 at 1:18 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the physical therapy, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and walls. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect 4 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/16/10 at 9:52 am surveyor #14105 observed in the OR smoke compartment on the 1st floor in the Recovery Area, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The room contained five carts sized at 30" by 60" by 5 feet high which all contained combustible materials. 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. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:45 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Soiled Utility room in ED, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

3. On 08/16/10 at 11:46 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Soiled Utility room in ED, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 7:43 am surveyor #14105 observed in the south inpatient smoke compartment on the 2nd floor in the Corridor, that the lamp within an internally illuminated exit sign is not operatational. The exit sign led to stair B. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.5.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system that had and notification devices at required locations. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 30 of the 108 staff that were working.

FINDINGS INCLUDE:
1. On 08/16/10 at 1:01 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the therapy office, that a visual notification appliance was not installed in this room, which was used by at least two people. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 1:08 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the therapy office, that a visual notification appliance was not installed in this room, which was used by at least two people. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

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 ceilings sealed above the sprinklers to collect heat, and intact escutcheon rings. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect 4 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/16/10 at 10:05 am surveyor #14105 observed in the OR smoke compartment on the 1st floor in the Clean Utility room 1150, that there was one or more unsealed holes near the ceiling. The hole(s) included three removed and displaced ceiling tiles 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

2. On 08/16/10 at 11:21 am surveyor #14105 observed in the ER-Rad smoke compartment on the 1st floor in the Mammography room, 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant that had NFPA 70, National Electrical Code that had closed electrical raceways. This deficiency occurred in 1 of the 10 smoke compartments, and had the potential to affect 10 of the 108 staff that were working.

FINDINGS INCLUDE:
On 08/16/10 at 1:07 pm surveyor #14105 observed in the pt/offices smoke compartment on the LL floor in the electrical room L238, that a 12" x 12" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director of Plant Operation), and staff K (Lead Engineer).