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Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and taped joints on rated walls . This deficiency occurred in 8 of the 10 smoke compartments, and had the potential to affect 12 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 12/6/2012 at 9:06 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the corrdor near dry storage, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating based on the installed rubber gasket. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 11:15 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the corridor outside of medical records storage, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating based on the installed rubber gasket. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

3. On 12/6/2012 at 10:30 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the exam room at fire barrier wall, that penetration(s) were not sealed according to an approved method. The deficiency included two conduit sleeves that were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:39 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the wall between rehab gym and board room, that penetration(s) were not sealed according to an approved method. The deficiency included conduit pipe and gypsum board not taped or plastered. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:03 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the office clinic corridor, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 10:48 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the corridor at medical office building separation, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 12" x 12" gypsum board patch over an existing hole that was not fire caulked. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:30 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the medical waste room, that penetration(s) were not sealed according to an approved method. Penetrations included (4) pipe penetrations. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 9:39 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the soiled linen storage, that penetration(s) were not sealed according to an approved method. Penetrations included conduit pipe and gypsum board not taped or plastered. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges, and positive-latching hardware. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 9:33 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the loading dock, 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:54 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 10:03 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the ambulance garage doors, 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:09 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:21 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the dining room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

6. On 12/6/2012 at 10:18 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at corridor, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

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 2 of the 10 smoke compartments, and had the potential to affect 20 of the 100 staff that were working.

FINDINGS INCLUDE:
On 12/6/2012 at 9:00 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the clinic corridor, 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with observable exit signs. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 12/6/2012 at 11:35 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the exit stair near ultrasound, that an exit sign was obstructed from view. An exit sign was obstructed by the lintel of the framed opening leading to the exterior door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 8 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 9:12 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the kitchen dry storage, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:18 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the fitness center and storage room, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 12:35 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the storage room off corridor #2703, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:00 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department storage room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included two (2) telecommunication sleeves that were not fire caulked as well as the gypsum board joint at the underside of the floor deck above. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 10:15 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the soiled utility room near nurse station, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included 1 1/2" diameter pipe penetration, an hvac duct penetration, telecommunication penetrations not sealed and the joint between the top of wall and deck above. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

6. On 12/6/2012 at 9:51 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the soiled utility room in recovery area, that penetration(s) were not sealed according to an approved method. The deficiency included gypsum board construction joints that were not taped or plastered as well as any existing plaster was failing. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

7. On 12/6/2012 at 10:12 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the soiled utility room, that penetration(s) were not sealed according toaccording to an approved method. The deficiency included an unprotected duct penetration. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

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 all rooms sprinkled when the code required full sprinkling, and unobstructed water distribution. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect 9 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 12/6/2012 at 9:15 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the kitchen, that the freezer and cooler was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:47 pm surveyor #28616 observed in the SC3-2 smoke compartment on the 3rd floor in the equipment room #3405, 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 large foam mattress. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, 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 and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 7 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 9:48 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the sterilizer room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 6" x 12" ceiling tile gap. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:42 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the med room at nurse station off corridor #2702, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12" x 24" hole in the ceiling where a tile had been removed above the exhaust hood. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 1:15 pm surveyor #28616 observed in the SC4-2 smoke compartment on the 4th floor in the ICU storage closet, that there was one or more unsealed holes near the ceiling. The hole(s) included 6" x 12", 6" x 24" and 6" x 8" holes in the ceiling tile. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 1:19 pm surveyor #28616 observed in the SC4-2 smoke compartment on the 4th floor in the data closet, that there was one or more unsealed holes near the ceiling. The hole(s) included two 12" x 24" and one 6" x 8" holes in the ceiling tile. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 11:31 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the closet near staff lounge, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 2" hole. 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 T (Maintenance Technician).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with a missing fire damper and non-plenum rated materials. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 10:36 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department exam room, that a fire/smoke damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:45 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the air handler room, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store boxes and equipment. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on record review and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. The kitchen exhaust hood fire suppression system was not inspected semi-annually and the kitchen exhaust hood was not cleaned semi-annually. This deficiency occurred in 10 of the 10 smoke compartments, and had the potential to affect all 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 12/5/2012 at 2:35 pm surveyor #28616 observed that the kitchen hood suppression system was not compliant. Review of facility documents did not provide confirmation or documentation regarding fire suppression inspection prior to the last inspection on October 29, 2012. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/5/2012 at 2:30 pm surveyor #28616 observed that during a review of documents it was discovered that the range hood and ducts were not inspected and cleaned of grease contamination semi-annually, as required for systems serving moderate-volume cooking operations. Cleaning records indicated no specific date regarding the last cleaning. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6; 9.2.3; and NFPA 96 (1998 edition), 8-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on interview and a review of documents, the facility did not provide a generator with a remote stop. This deficiency occurred in 10 of the 10 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 12/6/2012 at 11:21 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the outside at generator, that the emergency generator was not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

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, fixed wiring rather than extension cords, hospital grade outlets where medical device are used, and closed electrical raceways. This deficiency occurred in 4 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 9:42 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the electrical room, that access to electrical panel was less than 3'-0" clearance. The obstructions included two 2' x 2' boxes filled with copper tube and gages as well as two storage carts. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:40 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the office #212, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a portable fan, a radio and other equipment that was not directly related to the computer equipment. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 9:57 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department clean storage room, that a ground fault circuit interupt receptacle was not installed near the sink. This observed situation was not compliant with NFPA 70 (1999 edition), 517-18(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:06 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department exam room, that a ground fault circuit interupt receptacle was not installed near the sink. This observed situation was not compliant with NFPA 70 (1999 edition), 517-18(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:27 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the elevator equipment room, that a 4" x 4" 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not provide a common separation wall with rated doors, sealed wall penetrations, and taped joints on rated walls . This deficiency occurred in 8 of the 10 smoke compartments, and had the potential to affect 12 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 12/6/2012 at 9:06 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the corrdor near dry storage, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating based on the installed rubber gasket. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 11:15 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the corridor outside of medical records storage, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating based on the installed rubber gasket. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

3. On 12/6/2012 at 10:30 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the exam room at fire barrier wall, that penetration(s) were not sealed according to an approved method. The deficiency included two conduit sleeves that were not fire caulked. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:39 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the wall between rehab gym and board room, that penetration(s) were not sealed according to an approved method. The deficiency included conduit pipe and gypsum board not taped or plastered. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:03 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the office clinic corridor, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 3 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 10:48 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the corridor at medical office building separation, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 12" x 12" gypsum board patch over an existing hole that was not fire caulked. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:30 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the medical waste room, that penetration(s) were not sealed according to an approved method. Penetrations included (4) pipe penetrations. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 9:39 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the soiled linen storage, that penetration(s) were not sealed according to an approved method. Penetrations included conduit pipe and gypsum board not taped or plastered. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges, and positive-latching hardware. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 9:33 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the loading dock, 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:54 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 10:03 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the ambulance garage doors, 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:09 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:21 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the dining room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

6. On 12/6/2012 at 10:18 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department suite doors at corridor, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

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 2 of the 10 smoke compartments, and had the potential to affect 20 of the 100 staff that were working.

FINDINGS INCLUDE:
On 12/6/2012 at 9:00 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the clinic corridor, 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with observable exit signs. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 12/6/2012 at 11:35 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the exit stair near ultrasound, that an exit sign was obstructed from view. An exit sign was obstructed by the lintel of the framed opening leading to the exterior door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 8 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 9:12 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the kitchen dry storage, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:18 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the fitness center and storage room, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 12:35 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the storage room off corridor #2703, that the door would not self-close because the door did not have a closer installed. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:00 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department storage room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included two (2) telecommunication sleeves that were not fire caulked as well as the gypsum board joint at the underside of the floor deck above. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 10:15 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the soiled utility room near nurse station, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included 1 1/2" diameter pipe penetration, an hvac duct penetration, telecommunication penetrations not sealed and the joint between the top of wall and deck above. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

6. On 12/6/2012 at 9:51 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the soiled utility room in recovery area, that penetration(s) were not sealed according to an approved method. The deficiency included gypsum board construction joints that were not taped or plastered as well as any existing plaster was failing. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

7. On 12/6/2012 at 10:12 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the soiled utility room, that penetration(s) were not sealed according toaccording to an approved method. The deficiency included an unprotected duct penetration. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

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 all rooms sprinkled when the code required full sprinkling, and unobstructed water distribution. This deficiency occurred in 5 of the 10 smoke compartments, and had the potential to affect 9 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 12/6/2012 at 9:15 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the kitchen, that the freezer and cooler was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:47 pm surveyor #28616 observed in the SC3-2 smoke compartment on the 3rd floor in the equipment room #3405, 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 large foam mattress. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on observation and interview, 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 and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 7 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 9:48 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the sterilizer room, that there was one or more unsealed holes near the ceiling. The hole(s) included a 6" x 12" ceiling tile gap. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:42 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the med room at nurse station off corridor #2702, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12" x 24" hole in the ceiling where a tile had been removed above the exhaust hood. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 1:15 pm surveyor #28616 observed in the SC4-2 smoke compartment on the 4th floor in the ICU storage closet, that there was one or more unsealed holes near the ceiling. The hole(s) included 6" x 12", 6" x 24" and 6" x 8" holes in the ceiling tile. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 1:19 pm surveyor #28616 observed in the SC4-2 smoke compartment on the 4th floor in the data closet, that there was one or more unsealed holes near the ceiling. The hole(s) included two 12" x 24" and one 6" x 8" holes in the ceiling tile. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 11:31 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the closet near staff lounge, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 2" hole. 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 T (Maintenance Technician).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with a missing fire damper and non-plenum rated materials. This deficiency occurred in 2 of the 10 smoke compartments, and had the potential to affect all 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 12/6/2012 at 10:36 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department exam room, that a fire/smoke damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 9:45 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the air handler room, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store boxes and equipment. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on record review and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. The kitchen exhaust hood fire suppression system was not inspected semi-annually and the kitchen exhaust hood was not cleaned semi-annually. This deficiency occurred in 10 of the 10 smoke compartments, and had the potential to affect all 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 12/5/2012 at 2:35 pm surveyor #28616 observed that the kitchen hood suppression system was not compliant. Review of facility documents did not provide confirmation or documentation regarding fire suppression inspection prior to the last inspection on October 29, 2012. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/5/2012 at 2:30 pm surveyor #28616 observed that during a review of documents it was discovered that the range hood and ducts were not inspected and cleaned of grease contamination semi-annually, as required for systems serving moderate-volume cooking operations. Cleaning records indicated no specific date regarding the last cleaning. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6; 9.2.3; and NFPA 96 (1998 edition), 8-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

Based on interview and a review of documents, the facility did not provide a generator with a remote stop. This deficiency occurred in 10 of the 10 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 12/6/2012 at 11:21 am surveyor #28616 observed in the SC1-1 smoke compartment on the 1st floor in the outside at generator, that the emergency generator was not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Maintenance Technician).

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, fixed wiring rather than extension cords, hospital grade outlets where medical device are used, and closed electrical raceways. This deficiency occurred in 4 of the 10 smoke compartments, and had the potential to affect 20 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 12/6/2012 at 9:42 am surveyor #28616 observed in the G-2 smoke compartment on the ground floor in the electrical room, that access to electrical panel was less than 3'-0" clearance. The obstructions included two 2' x 2' boxes filled with copper tube and gages as well as two storage carts. 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 S (Dir. of Support Services) and staff T (Maintenance Technician).

2. On 12/6/2012 at 12:40 pm surveyor #28616 observed in the SC2-1 smoke compartment on the 2nd floor in the office #212, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a portable fan, a radio and other equipment that was not directly related to the computer equipment. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

3. On 12/6/2012 at 9:57 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department clean storage room, that a ground fault circuit interupt receptacle was not installed near the sink. This observed situation was not compliant with NFPA 70 (1999 edition), 517-18(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

4. On 12/6/2012 at 10:06 am surveyor #28616 observed in the SC1-2 smoke compartment on the 1st floor in the emergency department exam room, that a ground fault circuit interupt receptacle was not installed near the sink. This observed situation was not compliant with NFPA 70 (1999 edition), 517-18(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).

5. On 12/6/2012 at 9:27 am surveyor #28616 observed in the G-1 smoke compartment on the ground floor in the elevator equipment room, that a 4" x 4" 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff S (Dir. of Support Services) and staff T (Maintenance Technician).