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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. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/24/16 at 10:00 am, observation revealed on the basement floor in the chiller room, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not provide corridor separation doors with all doors that would close when pushed or pulled, positive-latching hardware, and self-latching inactive doors. This deficiency occurred in 4 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:57 pm, observation revealed on the 2nd floor in tub room 2947, that the corridor door would not positively self-latch. When 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 ed.), 19.3.6.3.2.

2. On 02/23/16 at 1:15 pm, observation revealed on the 2nd floor in storage room 2952, that the door to the corridor was held open with a large quantity of equipment placed in the room, in front of the door, including fans, thermometers, and portable commodes. The door would not close with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

3. On 02/23/16 at 1:25 pm, observation revealed on the 2nd floor in therapy room 2920, that the corridor door would not positively self-latch. When 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 ed.), 19.3.6.3.2.

4. On 02/24/16 at 8:25 am, observation revealed on the 1st floor in the gift shop, room 103, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf was not positively latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

5. On 02/24/16 at 11:45 am, observation revealed on the basement floor in room L014, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of all smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 1:35 pm, observation revealed on the 2nd floor, above smoke doors 35, that a penetration was not sealed according to an approved method. The deficiency included a 1" conduit not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 02/23/16 at 1:45 pm, observation revealed on the 2nd floor above smoke doors 34, that penetrations were not sealed according to an approved method. This deficiency included a 1 1/2" conduit and a 1" conduit not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke doors held-open with the required safe guards. This deficiency occurred in 4 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 1:58 pm, observation revealed on the 2nd floor at door 36, that the smoke door was prevented from self-closing by the door rubbing on the door frame. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 02/24/16 at 9:10 am, observation revealed on the 1st floor at the corridor doors between corridor 1600 and corridor 1082, that the smoke door was prevented from self-closing by the latching hardware. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not enclose all hazardous rooms with operational closers on all doors and sealed wall penetrations. This deficiency occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:40 am, observation revealed on the 1st floor in room 1003, that the door would not self-close because of the latching hardware. 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 ed.), 19.3.2.1 and 8.4.1.

2. On 02/24/16 at 9:30 am, observation revealed on the basement floor in room L100, that the door would not self-close because the doors were not equipped with closers and automatic flush bolts. 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 ed.), 19.3.2.1 and 8.4.1.

3. On 02/24/16 at 9:30 am, observation revealed on the basement floor in the room L100, that penetrations were not sealed according to an approved method. This deficiency included penetrations sealed with non-rated spray foam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

4. On 02/24/16 at 9:50 am, observation revealed on the basement floor in the room L114, that the door would not self-close because the doors were not equipped with closers and automatic flush bolts. 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 ed.), 19.3.2.1 and 8.4.1.

5. On 02/24/16 at 10:02 am, observation revealed on the basement floor in the chiller room, that penetrations were not sealed according to an approved method. This deficiency included penetrations sealed with non-rated spray foam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not provide all egress paths that are maintainable in all weather conditions. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:50 am, observation revealed on the 1st floor in the exit path, by exit door 160, that the exit discharge path did not have a maintainable surface. The path was composed of a grass surface. Additionally there was a 6" PVC pipe laid across the exit path for down spout drainage. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.

2. On 02/24/16 at 10:05 am, observation revealed on the basement floor in the corridor exit near the generator room, that the exit discharge path did not have a maintainable surface. The path was composed of washed stone. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on record review and interview, the facility did not provide and maintain battery pack emergency illumination for at least 90 minutes after a power failure with adequate testing of emergency batteries. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:30 pm, it was noted during a review of facility documents, that there was no record of the facility testing the battery-powered emergency lights for 30 seconds each month and 90 minutes each year. Staff Z (Maintenance Manager) confirmed during an interview, that the facility had no record of monthly and annual testing of battery-powered emergency lights. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3.

This condition was confirmed at the time of discovery by interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not maintain a written fire safety plan that contained all required elements. This deficiency occurred in all of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:55 pm, observation revealed on the 2nd floor during the facility tour that there was no written fire safety plan located at the inpatient nurses station. An interview with staff WW (Health Unit Coordinator) confirmed that there was no written fire safety plan, however it was stated that everything was available online via the computer. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.2.2.

2. On 02/24/16 at 9:00 am, observation revealed on the 1st floor during the facility tour that there was no written fire safety plan located at the outpatient nurses station. An interview with staff OO(Assistant Head RN OR) confirmed that there was no written fire safety plan, however it was stated that everything was available online via the computer. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 10:55 am, it was noted that fire drills were conducted in a pattern so they were not always at unexpected times. Three of the four 3rd shift drills were held between 23:26 and 23:50, two of the four 2nd shift drills were held between 15:20 and 15:21, and two of the four 1st shift drills were held between 9:20 and 9:40. This situation is not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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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 and smoke detectors at required locations. This deficiency occurred in 7 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:48 pm, observation revealed on the 2nd floor in the in-patient smoke compartment rooms, that the resident room smoke detection was not compliant. The smoke detectors were tied into an annunciator panel at the nurse station, but not tied into the buildings fire alarm system. They are non-code required detectors, however since they are installed and used they must be inspected and tested as required by the codes and manufactures recommendations. Staff AA (Level 2 Engineer) stated in an interview that these smoke detectors and connected equipment are not regularly inspected and tested, with the code required fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 4.6.12.2.

2. On 02/23/16 at 12:58 pm, observation revealed on the 2nd floor in the corridor in front of room 2947, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #1001104 was located 12" from an air return. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

3. On 02/23/16 at 4:00 pm, observation revealed on the 1st floor in the corridor 1131A, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020106 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

4. On 02/23/16 at 4:30 pm, observation revealed on the 1st floor in the corridor by doors #22, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020187 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

5. On 02/23/16 at 4:45 pm, observation revealed on the 1st floor in the corridor 1524, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020173 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

6. On 02/24/16 at 8:35 am, observation revealed on the 1st floor in the corridor by doors #23, that the smoke detector was not located in accordance with NFPA 72 requirements. There was no smoke detector located within 5' of the cross corridor doors on the orthopedic side of the doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

7. On 02/24/16 at 9:15 am, observation revealed on the basement floor in the corridor L077, that the smoke detector was not located in accordance with NFPA 72 requirements. There was no smoke detector located within 5' of the cross corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

8. On 02/24/16 at 9:35 am, observation revealed on the basement floor in the corridors L107 and L131, that the smoke detector was not located in accordance with NFPA 72 requirements. There were no smoke detectors located within 5' of the cross corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

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Based on observation and interview, the facility did not provide and maintain the sprinkler system as required by the code, with all rooms sprinkled and unobstructed water distribution. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:45 pm, observation revealed on the 2nd floor in the 2nd floor nurse station, charting room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included printer cartridge boxes located on the top shelf. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On 02/24/16 at 9:12 am, observation revealed on the 1st floor in the basement stairwell off of corridor 1082, that the area was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

3. On 02/24/16 at 10:15 am, observation revealed on the basement floor in the stairwell from the air handler room to the 2nd floor in-patient wing, that the area was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

4. On 02/24/16 at 10:30 am, observation revealed on the basement floor in room L060, 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 cubical curtain installed that did not have a mesh top with 1/2" openings from the sprinkler deflector to 18" below, this would restrict the proper flow of sprinkler water. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview, with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

Based on observation and interview, the facility did not provide supervision of the control valves on the sprinkler system. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/24/16 at 10:16 am, observation revealed on the basement floor in the stairwell from the air handler room to the 2nd floor in-patient wing, the sprinkler control valve was not supervised by the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.2.1 and NFPA 72.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

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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 intact escutcheon rings, sprinklers free of damage, and sprinklers free of lint. This deficiency occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:10 am, observation revealed on the 1st floor in the corridor in front of roon 1540, that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1 .

2. On 02/24/16 at 8:12 am, observation revealed on the 1st floor in the room 1540, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 02/24/16 at 8:15 am, observation revealed on the 1st floor in the radeology break room, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

4. On 02/24/16 at 8:30 am, observation revealed on the 1st floor in the room 1541, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

5. On 02/24/16 at 8:45 am, observation revealed on the 1st floor in the corridor in front of room 1608, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

6. On 02/24/16 at 8:55 am, observation revealed on the 1st floor in the corridor 1604, that a sprinkler deflector was damaged. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

7. On 02/24/16 at 9:05 am, observation revealed on the 1st floor in the 1st floor out-patient nurses station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on record review and interview, the facility did not provide, and use, a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in all of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:23 pm, it was noted during a review of facility documents that the facility did not have an appropriate response to outages of the sprinkler system for more than 4 hours in a 24 hour period. The facility policy did not include contact information for the Superior Fire Department and The Wisconsin Department of Health. Instead it listed information for the Duluth Fire department and the Minnesota Fire Marshall. This situation was not compliant with NFPA 101 (2000 ed.), 9.7.6.1.

This condition was confirmed at the time of discovery by a concurrent review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to outages. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:23 pm, it was noted during a review of facility documents that the facility did not have an appropriate response to outages of the fire alarm system for more than 4 hours in a 24 hour period. The facility policy did not include contact information for the Superior Fire Department and The Wisconsin Department of Health. Instead it listed information for the Duluth Fire department and the Minnesota Fire Marshall. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.8.

This condition was confirmed at the time of discovery by a concurrent review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

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. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/24/16 at 10:00 am, observation revealed on the basement floor in the chiller room, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with all doors that would close when pushed or pulled, positive-latching hardware, and self-latching inactive doors. This deficiency occurred in 4 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:57 pm, observation revealed on the 2nd floor in tub room 2947, that the corridor door would not positively self-latch. When 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 ed.), 19.3.6.3.2.

2. On 02/23/16 at 1:15 pm, observation revealed on the 2nd floor in storage room 2952, that the door to the corridor was held open with a large quantity of equipment placed in the room, in front of the door, including fans, thermometers, and portable commodes. The door would not close with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

3. On 02/23/16 at 1:25 pm, observation revealed on the 2nd floor in therapy room 2920, that the corridor door would not positively self-latch. When 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 ed.), 19.3.6.3.2.

4. On 02/24/16 at 8:25 am, observation revealed on the 1st floor in the gift shop, room 103, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf was not positively latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

5. On 02/24/16 at 11:45 am, observation revealed on the basement floor in room L014, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of all smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 1:35 pm, observation revealed on the 2nd floor, above smoke doors 35, that a penetration was not sealed according to an approved method. The deficiency included a 1" conduit not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 02/23/16 at 1:45 pm, observation revealed on the 2nd floor above smoke doors 34, that penetrations were not sealed according to an approved method. This deficiency included a 1 1/2" conduit and a 1" conduit not sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke doors held-open with the required safe guards. This deficiency occurred in 4 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 1:58 pm, observation revealed on the 2nd floor at door 36, that the smoke door was prevented from self-closing by the door rubbing on the door frame. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 02/24/16 at 9:10 am, observation revealed on the 1st floor at the corridor doors between corridor 1600 and corridor 1082, that the smoke door was prevented from self-closing by the latching hardware. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not enclose all hazardous rooms with operational closers on all doors and sealed wall penetrations. This deficiency occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:40 am, observation revealed on the 1st floor in room 1003, that the door would not self-close because of the latching hardware. 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 ed.), 19.3.2.1 and 8.4.1.

2. On 02/24/16 at 9:30 am, observation revealed on the basement floor in room L100, that the door would not self-close because the doors were not equipped with closers and automatic flush bolts. 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 ed.), 19.3.2.1 and 8.4.1.

3. On 02/24/16 at 9:30 am, observation revealed on the basement floor in the room L100, that penetrations were not sealed according to an approved method. This deficiency included penetrations sealed with non-rated spray foam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

4. On 02/24/16 at 9:50 am, observation revealed on the basement floor in the room L114, that the door would not self-close because the doors were not equipped with closers and automatic flush bolts. 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 ed.), 19.3.2.1 and 8.4.1.

5. On 02/24/16 at 10:02 am, observation revealed on the basement floor in the chiller room, that penetrations were not sealed according to an approved method. This deficiency included penetrations sealed with non-rated spray foam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on observation and interview, the facility did not provide all egress paths that are maintainable in all weather conditions. This deficiency occurred in 2 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:50 am, observation revealed on the 1st floor in the exit path, by exit door 160, that the exit discharge path did not have a maintainable surface. The path was composed of a grass surface. Additionally there was a 6" PVC pipe laid across the exit path for down spout drainage. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.

2. On 02/24/16 at 10:05 am, observation revealed on the basement floor in the corridor exit near the generator room, that the exit discharge path did not have a maintainable surface. The path was composed of washed stone. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
______________________________________

Based on record review and interview, the facility did not provide and maintain battery pack emergency illumination for at least 90 minutes after a power failure with adequate testing of emergency batteries. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:30 pm, it was noted during a review of facility documents, that there was no record of the facility testing the battery-powered emergency lights for 30 seconds each month and 90 minutes each year. Staff Z (Maintenance Manager) confirmed during an interview, that the facility had no record of monthly and annual testing of battery-powered emergency lights. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3.

This condition was confirmed at the time of discovery by interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on observation and interview, the facility did not maintain a written fire safety plan that contained all required elements. This deficiency occurred in all of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:55 pm, observation revealed on the 2nd floor during the facility tour that there was no written fire safety plan located at the inpatient nurses station. An interview with staff WW (Health Unit Coordinator) confirmed that there was no written fire safety plan, however it was stated that everything was available online via the computer. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.2.2.

2. On 02/24/16 at 9:00 am, observation revealed on the 1st floor during the facility tour that there was no written fire safety plan located at the outpatient nurses station. An interview with staff OO(Assistant Head RN OR) confirmed that there was no written fire safety plan, however it was stated that everything was available online via the computer. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 10:55 am, it was noted that fire drills were conducted in a pattern so they were not always at unexpected times. Three of the four 3rd shift drills were held between 23:26 and 23:50, two of the four 2nd shift drills were held between 15:20 and 15:21, and two of the four 1st shift drills were held between 9:20 and 9:40. This situation is not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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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 and smoke detectors at required locations. This deficiency occurred in 7 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:48 pm, observation revealed on the 2nd floor in the in-patient smoke compartment rooms, that the resident room smoke detection was not compliant. The smoke detectors were tied into an annunciator panel at the nurse station, but not tied into the buildings fire alarm system. They are non-code required detectors, however since they are installed and used they must be inspected and tested as required by the codes and manufactures recommendations. Staff AA (Level 2 Engineer) stated in an interview that these smoke detectors and connected equipment are not regularly inspected and tested, with the code required fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 4.6.12.2.

2. On 02/23/16 at 12:58 pm, observation revealed on the 2nd floor in the corridor in front of room 2947, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #1001104 was located 12" from an air return. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

3. On 02/23/16 at 4:00 pm, observation revealed on the 1st floor in the corridor 1131A, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020106 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

4. On 02/23/16 at 4:30 pm, observation revealed on the 1st floor in the corridor by doors #22, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020187 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

5. On 02/23/16 at 4:45 pm, observation revealed on the 1st floor in the corridor 1524, that a smoke detector was installed near an adjacent air register that would prevent operation of the detector. The facility had no manufacturer's documentation to confirm that the detector was installed per its recommendations. Smoke detector #020173 was located 12" from an air supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.4 and 9.6 and NFPA 72 (1999 ed.), 2-3.5.1.

6. On 02/24/16 at 8:35 am, observation revealed on the 1st floor in the corridor by doors #23, that the smoke detector was not located in accordance with NFPA 72 requirements. There was no smoke detector located within 5' of the cross corridor doors on the orthopedic side of the doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

7. On 02/24/16 at 9:15 am, observation revealed on the basement floor in the corridor L077, that the smoke detector was not located in accordance with NFPA 72 requirements. There was no smoke detector located within 5' of the cross corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

8. On 02/24/16 at 9:35 am, observation revealed on the basement floor in the corridors L107 and L131, that the smoke detector was not located in accordance with NFPA 72 requirements. There were no smoke detectors located within 5' of the cross corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

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Based on observation and interview, the facility did not provide and maintain the sprinkler system as required by the code, with all rooms sprinkled and unobstructed water distribution. This deficiency occurred in 4 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/23/16 at 12:45 pm, observation revealed on the 2nd floor in the 2nd floor nurse station, charting room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included printer cartridge boxes located on the top shelf. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On 02/24/16 at 9:12 am, observation revealed on the 1st floor in the basement stairwell off of corridor 1082, that the area was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

3. On 02/24/16 at 10:15 am, observation revealed on the basement floor in the stairwell from the air handler room to the 2nd floor in-patient wing, that the area was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

4. On 02/24/16 at 10:30 am, observation revealed on the basement floor in room L060, 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 cubical curtain installed that did not have a mesh top with 1/2" openings from the sprinkler deflector to 18" below, this would restrict the proper flow of sprinkler water. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview, with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

Based on observation and interview, the facility did not provide supervision of the control valves on the sprinkler system. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/24/16 at 10:16 am, observation revealed on the basement floor in the stairwell from the air handler room to the 2nd floor in-patient wing, the sprinkler control valve was not supervised by the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.2.1 and NFPA 72.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

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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 intact escutcheon rings, sprinklers free of damage, and sprinklers free of lint. This deficiency occurred in 3 of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/24/16 at 8:10 am, observation revealed on the 1st floor in the corridor in front of roon 1540, that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1 .

2. On 02/24/16 at 8:12 am, observation revealed on the 1st floor in the room 1540, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 02/24/16 at 8:15 am, observation revealed on the 1st floor in the radeology break room, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

4. On 02/24/16 at 8:30 am, observation revealed on the 1st floor in the room 1541, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

5. On 02/24/16 at 8:45 am, observation revealed on the 1st floor in the corridor in front of room 1608, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

6. On 02/24/16 at 8:55 am, observation revealed on the 1st floor in the corridor 1604, that a sprinkler deflector was damaged. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

7. On 02/24/16 at 9:05 am, observation revealed on the 1st floor in the 1st floor out-patient nurses station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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Based on record review and interview, the facility did not provide, and use, a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in all of the 12 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:23 pm, it was noted during a review of facility documents that the facility did not have an appropriate response to outages of the sprinkler system for more than 4 hours in a 24 hour period. The facility policy did not include contact information for the Superior Fire Department and The Wisconsin Department of Health. Instead it listed information for the Duluth Fire department and the Minnesota Fire Marshall. This situation was not compliant with NFPA 101 (2000 ed.), 9.7.6.1.

This condition was confirmed at the time of discovery by a concurrent review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).

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Based on record review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to outages. This deficiency occurred in all of the 12 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/23/16 at 12:23 pm, it was noted during a review of facility documents that the facility did not have an appropriate response to outages of the fire alarm system for more than 4 hours in a 24 hour period. The facility policy did not include contact information for the Superior Fire Department and The Wisconsin Department of Health. Instead it listed information for the Duluth Fire department and the Minnesota Fire Marshall. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.8.

This condition was confirmed at the time of discovery by a concurrent review and interview with staff Z (Maintenance Manager), staff AA (Level 2 Engineer) and staff BB (Lead Engineer).
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