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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
2. On 7/25/2012 (5-7-2013) at 7:15am surveyor observed that the north side of the two-hour fire barrier had ¾" hole, a cable tray was open and a junction box that was not fire caulked. [Third Level /I-2 occupancy] This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

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, sealed floor penetrations. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

12. On 7/25/2012 at 10:02 am surveyor observed that the Mechanical shaft in Lab 3-47D did not have a 12" x 12" hole in the deck sealed to maintain the rating of this floor [3rd Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/18/2012 at 2:25 pm surveyor observed on the 4th floor in the room 2-55, Chapel, that the door to the corridor was held open with a electrical system that did not release when pulled. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

17. On 7/24/2012 at 11:57 am surveyor observed on the 2nd floor in the room 2-61, Chapel, that the door to the corridor was held open with a electrical system that did not release when pulled. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview the facility did not provide reliable corridor doors due to a lack of an astragal or latching hardware. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

3. On 7/23/2012 at 7:34 am surveyor observed that the paired set of doors from OR #2 did not positively latch, and no astragal was provided to maintain the smoke-tight quality Corridor 300-6 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/23/2012 at 7:58 am surveyor observed that the paired set of doors from OR#1, #3, #4, #5, #6, #7, #9 and #10 were not provided with astragals to maintain the smoke-tight quality in Corridor 300-5 and Corridor 300-6 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/23/2012 at 8:03 am surveyor observed that the paired set of doors from Supply 3-46 had a rubber astragal that was partially missing; this did not provide a smoke-tight quality for Corridor 300-12 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/23/2012 at 8:22 am surveyor observed that the Dutch doors from Workroom 3-07 did not positively latch independently, and no astragal was provided at the meeting edge of the upper and lower door to maintain the smoke-tight quality for Corridor 3-07 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/23/2012 at 8:45 am surveyor observed that the three sets of paired doors from Recovery and Passage into Corridor 300-10 and Corridor 300-6 did not have astragals. This did not provide a smoke-tight quality for Corridor 300-10 or 300-6. None of these sets of doors had positive latching [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/23/2012 at 8:48 am surveyor observed that the set of paired doors from Passage near Nurse Desk 3-24E into Corridor 300-10 did not have any latching hardware [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

11. On 7/23/2012 at 11:37 am surveyor observed that a hole about 8 " square was present in the south wall of Closet 6-68B into Stair 6. This did not maintain the one-hour rating of this vertical shaft. [6th Floor/I-2 occupancy]. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

27. On 7/25/2012 at 9:48 am surveyor observed within Electrical Closet 3-48F a hole in the floor above created a shaft which did not have any fire rating. [3rd /I-2 occupancy]. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

28. On 7/25/2012 at 10:02 am surveyor observed the Mechanical shaft in Lab 3-47D had clay tile missing and penetrations not fire caulked to maintain the hourly rating of the shaft. Pipes were installed within an abandoned air duct. [3rd Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

35. On 7/19/2012 at 4:00 pm surveyor observed on the penthouse in the penthouse east side, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. The duct served the exhaust system. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

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 could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

6. On 7/25/2012 at 10:50 am surveyor observed on the 3rd floor in the connector to ST Anna, 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 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency could affect 75 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/18/2012 at 2:10 pm surveyor observed on the 5th floor in the room 5-44 and 5-42A, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included 2 holes and a 3/4" conduit. 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 YY (Admin. Support services) and staff CCC (Safety Officer).

Based on observation and interview, the facility did not enclose hazardous rooms with closer's on all doors, doors with positive-latching hardware, closer's on all doors, sealed wall penetrations, closer's on all doors, rated doors, and rated walls in a non-sprinkled hazardous room. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 11:58 am surveyor observed that all of the perimeter walls of Housekeeping L-113 did not have all of the tape fully embedded in joint compound to a one-hour standard [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 1:48 pm surveyor observed within Electrical L-116 that the one-hour fire resistant walls did not have all of the penetrations sealed to a one-hour rating at the wood panel, 24x24 duct, and the beam at the west wall. The door did not have a fire label and no door closer was installed [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/18/2012 at 2:24 pm surveyor observed that all of the perimeter walls of Soiled Utility L-68 and Clean Utility L-70 did not have all of the screw heads covered with joint compound to a one-hour standard for all of these walls [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/18/2012 at 3:15 pm surveyor observed that Shell Space L-64 was greater than 100 square feet and used for storage of combustible materials. The wall from this space into Corridor 07 had only one layer of gypsum wallboard on one side of metal studs (not a one-hour assembly) [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 7:15 am surveyor observed that one (1) ¾" and one (1) 1" electrical conduits were not fire caulked in the south wall of Storage L-29 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).


7. On 7/19/2012 at 8:45 am surveyor observed that three (3) 3/4" conduits and one (1) 10" round duct were not fire caulked to a one-hour standard in Clean Utility 1-86 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/19/2012 at 8:49 am surveyor observed that a gypsum wallboard offset in this wall was not taped and mudded to a one-hour standard in the corridor for the west wall of Clean Utility 1-86 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

9. On 7/19/2012 at 8:58 am surveyor observed that two (2) penetrations in the west wall and one (1) penetration in the south wall were not fire caulked to a one-hour standard in Clean Utility 1-82 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/19/2012 at 9:01 am surveyor observed that one (1) penetration in the north wall and one (1) penetration in the south wall were not fire caulked to a one-hour standard in Soiled Utility 1-84 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

11. On 7/19/2012 at 9:44 am surveyor observed that the screw heads within the one-hour wall of Electrical 1-131 were not mudded [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

12. On 7/19/2012 at 10:12 am surveyor observed that a 12" x 12" opening was found in the south wall, a sprinkler pipe was not fire caulked to a one-hour and the door was not labeled at 45 minutes within Communications 1-138A [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

13. On 7/19/2012 at 10:55 am surveyor observed that one (1) penetration in the west wall and two (2) penetrations in the south wall were not fire caulked to a one-hour standard in Clean Utility 1-34 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

14. On 7/19/2012 at 11:24 am surveyor observed that a 2" x 3" hole in the north wall was not sealed to a one-hour standard in Soiled Utility 1-39 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

15. On 7/19/2012 at 1:31 pm surveyor observed that both doors into Communications 1-81 and Storage 1-83 were not 45-min labeled doors. Additionally, four (4) penetrations into the walls were not fire caulked [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

16. On 7/19/2012 at 7:49 am surveyor observed that six (6) holes in the north wall of Corridor 100-01 at the two-hour wall were not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

17. On 7/19/2012 at 2:39 pm surveyor observed that one (1) hole in the north wall of Workroom 1-03 at the two-hour wall was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

18. On 7/19/2012 at 2:52 pm surveyor observed that four (4) penetrations in the north wall of Office 1-03A at the two-hour wall was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

19. On 7/19/2012 at 2:53 pm surveyor observed that one (1) penetration in the north wall of Decontamination 1-01B was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

20. On 7/19/2012 at 2:56 pm surveyor observed that two (2) stub conduits and three (3) conduit penetrations in the north wall of LT 1-01A were not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

23. On 7/23/2012 at 8:39 am surveyor observed that the southeast and southwest corners were not taped and mudded to a one-hour rating in Soiled Utility 3-14C [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation, record review and interview, the facility did not enclose hazardous rooms with closers on all doors, doors with positive-latching hardware, closers on all doors, sealed wall penetrations, closers on all doors, rated doors, and rated walls in a non-sprinkled hazardous room. This deficiency could affect 125 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

3. On 7/19/2012 at 7:50 am surveyor observed on the basement floor in the large storage room B62, that the door would not self-close because there is no closer on the door. 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 YY (Admin. Support services) and staff CCC (Safety Officer).

5. On 7/19/2012 at 8:15 am surveyor observed on the basement floor in the room B52, that the door would not self-close because there was not 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 YY (Admin. Support services) and staff CCC (Safety Officer).


15. On 7/23/2012 at 10:20 am surveyor observed that Bio-Med 8-49A, Storage 8-50, Office 8-49C and an additional room were open to each other without doors. These rooms were being used as a suite arrangement. The amount of combustibles would require a one-hour fire barrier around this suite. No barrier was provided [8th Floor/I-2 occupancy]. 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 WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

21. On 7/23/2012 at 2:20 pm surveyor observed on the 1st floor in the room 117, that the fire barrier door could not be verified to have the one hour rating. The owner could not verity that the bolt lock retained the rating of the door frame. 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

23. On 7/24/2012 at 4:01 pm surveyor observed on the 2nd floor in Room 2-68, that the door would not self-close because there was no automatic 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 YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1) On 7/19/2012 at 10:00 am surveyor observed on the basement floor in the stairs 7, that there is an opening into an exit enclosure was from a mechanical room, which is an non habitable room. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).
for Life Safety walls and spaces ONLY.

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, doors that were unlockable in the egress path, doors that swing in the direction of egress, compliant egress path, doors that were unlockable in the egress path, and paths with sufficient headroom. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

7. On 7/23/2012 at 12:10 pm surveyor observed on the 1st floor in the former ED area, that the door was locked from the egress side. Magnetic locks prevented egress from the area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

10. On 7/23/2012 at 3:17 pm surveyor observed on the 1st floor in the corridor by stair 1, that the headroom was six feet. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).


14. On 7/25/2012 at 4:00 pm surveyor observed on the basement floor in the maintenance shop office suite, that the headroom was less than 6'-8". This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors installed per listing requirements, did not install notification devices in all public spaces, and did not install an evacuation paging system as an intergral part of the fire alarm. This deficiency could affect all patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

3. On 7/19/2012 at 7:10 am surveyor observed that the fire alarm installation was not compliant. The overhead paging system is used to direct and inform patients, visitors and staff after the initial fire alarm signal is initiated. The paging system is not part of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition) 9.6.1.4 and NFPA 72 (1999 edition) 1-5.2.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

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. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/25/2012 at 3:50 pm surveyor observed that the fire alarm maintenance was not compliant. Repair to the fire alarm system was identified within the fire alarm testing reports, yet there was no information that substantiated that the repair were completed. Examples of items not tested: 3 analog detectors; 1 chime, and 2 of 26 sealed lead acid batteries. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 7-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkle coverage. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 1:48 pm surveyor observed within Electrical L-116 that the sprinkler head was not located less than 22 inches below the exposed ceiling of this space [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).


4. On 7/18/2012 at 2:46 pm surveyor observed that a gap was present around the sprinkler head escutcheon in Storage L-80 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/18/2012 at 3:39 pm surveyor observed that storage obstructed the discharge of the sprinkler heads in Storage rooms L53 and L55 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/18/2012 at 3:47 pm surveyor observed that walls within Changing L-47 obstructed the discharge of the sprinkler heads [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/19/2012 at 7:29 am surveyor observed that openings were present within the ceiling system in UPS room L-11A and Data Center L-11. These openings will not allow the sprinkler systems to activate in the allotted time frame for these sprinklers [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

9. On 7/19/2012 at 7:37 am surveyor observed that one (1) 1" hole was found in the ceiling of Linen L-07 [Lower Level /I-2 occupancy]. Ceilings in all sprinkler spaces require reliable and continuous ceiling membrane to ensure prompt sprinkler response. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/19/2012 at 7:43 pm surveyor observed that a ceiling light and the rubbish chute door obstructed the discharge of the sprinkler head in Trash L-05 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

13. On 7/19/2012 at 10:55 am surveyor observed that holes within the ceiling of Clean Utility 1-34 are not sealed to a smoke-tight quality for timely sprinkler system discharge [First Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

14. On 7/19/2012 at 1:31 pm surveyor observed that the sprinkler head into Storage 1-83 was greater than 22" from the exposed deck [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

15. On 7/23/2012 at 8:05 am surveyor observed that storage obstructed the discharge of a sprinkler head in Supply 3-46 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

16. On 7/23/2012 at 8:38 am surveyor observed that ceiling tiles were missing in Clean Utility 3-14B [Third Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

17. On 7/23/2012 at 8:54 am surveyor observed that holes within the ceiling of Frozen Lab 3-40 are not sealed to a smoke-tight quality for timely sprinkler system discharge [Third Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). The Wisconsins Department of Health Services and Centers for Medicare Services directs inspectors to use NFPA 90A when evaluating the ventilation system in both new and existing facilties. Thus, the Life Safey Code supercedes NFPA 90A (1999 edition) 1-3.3. This deficiency could affect 75 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

5. On 7/19/2012 at 11:05 am surveyor observed on the basement floor in the rooms B 67 and B 69, that airflow between the corridor and this room was not neutral. The air flow was from the receiving room to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

8. On 7/25/2012 at 10:35 am surveyor observed on the 3rd floor in Room 3-20, that airflow between the corridor and this room was not neutral. The air flow was into the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview the facility did not provide rubbish and linen chute enclosures installed to minimum standards. This deficiency could affect 25 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/23/2012 at 11:08 am surveyor observed that the two-hour trash chute located in Passage 6-74 has several holes in the clay tile wall and the access panel was not labeled. The two-hour rating was not provided for this vertical opening [First Floor/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5 and 8.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials. This deficiency could affect 5 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/19/2012 at 7:30 am surveyor observed on the basement floor in the telephone operators room, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, including exit signs that are indicating to travel to nonconforming exits, and revolving doors that do not break open. This deficiency could affect all outpatients that the facility serves, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/25/2012 at 8:10 am surveyor observed on the 1st floor at the main entrance that the revolving door did not collapsed as required in NFPA 101, 2000 edition, 7.2.1.10.1(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide medical gas alarms as required by NFPA 99 with a medical gas panel in required locations. This deficiency could affect 5 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/23/2012 at 11:50 am surveyor observed on the 1st floor in the Former ED nurse station, that the facility had anesthetizing locations and did not have a compliant alarm panel for the medical gas system. There was no one near the alarm panel to hear it. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 4.3.1.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).