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Based on interview and documentation review, the facility did not provide the minimum construction type for a 4-story building. The floors were only fire-rated to 1-hour construction. This deficiency occurred in 5 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

At the time of monitoring visit conducted on October 1, 2015 the FSES submitted by the provider through the State of Wisconsin in response to this citation and subsequent finding had not yet been acted on by the CMS regional office. On 08/06/2015 at approximately 3:00 pm, a letter dated January 5, 2005 was given to surveyor #18107 by staff KK, identifying that building #01 is not fire-rated to the required Type II (222). The letter states it could only be classified as a TYPE II (111) or possibly a "hybrid - (221)" structure. The Center Wing flooring/ceiling system in Smoke Compartments - A6, 1F, 2F, 3F & 4G was not constructed to a 2-hour fire resistance rating. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 19.1.6.2 and 19.1.1.4. These conditions were confirmed at the time of discovery by a concurrent interview and documentation review with staff JJ (Maintenance Manager), staff LL (Director Project Mgmt.), staff KK (Power Plant Manager) and staff O (IP Product Specialist-RN).