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Based on observation and interview, the facility did not provide and maintain the required building construction type and support structure with rated construction. This deficiency occurred in 1 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 11:15 AM, observation revealed on the 1st floor in the wellness gym air handler room, that roof structural support members were not enclosed with rated construction. The roof is not rated because no fire protection is present on the deck. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

2. On 1/28/2014 at 11:30 AM, observation revealed on the 1st floor floor in the wellness gym , that a structural support member was not enclosed with rated construction. The rated ceiling tile is penetrated with 12 eye bolts and holes which eliminates the rating of the ceiling tile protecting the roof structure. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces and rooms open to the corridor with the required safe-guards. This deficiency occurred in 2 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:35 PM, observation revealed on the Lower Level floor in the PT/OT reception area, that a drop down shutter was installed in the corridor wall. However, there is a wood piece that fits into a hole at the desk that staff BB did not install when asked what she would do if a fire alarm sounded. She stated that management told her not to put it in. With this hole in the corridor wall, this area did not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

2. On 1/29/2014 at 9:50 AM, observation revealed on the 2nd floor floor in the food service of ambulatory care area, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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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 4 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:25 AM, observation revealed on the Lower Level in the x-ray storage room and disaster storage room (AHU room), that the rooms have 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 ed.), 19.3.6.3.1.

2. On 1/28/2014 at 1:40 PM, observation revealed on the 1st floor floor in the radiology waiting 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 ed.), 19.3.6.3.2.

3. On 1/28/2014 at 2:15 PM, observation revealed on the 1st floor floor in the Emergency Department waiting 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 ed.), 19.3.6.3.2.

4. On 1/29/2014 at 10:00 AM, observation revealed on the 2nd floor in Rooms 203, 204, 205, 206, and 207, 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. There is no latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/29/2014 at 11:45 AM, observation revealed on the 2nd floor floor in the smoke barrier by a data room, that penetrations were not sealed according to an approved method. The deficiency included a 4" conduit pipe full of data cables. 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 G (plant operations manager), staff H (construction liaison) and staff I (construction liaison).
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Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, and doors with positive-latching hardware. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:35 AM, observation revealed on the lower level floor in the biohazard room, that penetrations were not sealed according to an approved method. The deficiency included a 6 inch polyvinyl chloride (PVC) pipe that did not have a fire rated collar. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2. On 1/29/2014 at 8:35 AM, observation revealed on the 2nd floor floor in the clean supply storage of the OR, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The clean supply room includes OR supplies wrapped in plastic. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

3. On 1/28/2014 at 10:15 AM, observation revealed on the 1st floor floor in the purchasing (material storage room), that penetrations were not sealed according to an approved method. The deficiency included the electrical box was recessed into the 1 hour wall and was 140 square inches which is greater than the 100 square inches in a hundred square that is allowed for electrical boxes. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:20 PM, observation revealed on the lower level floor in the exit passage way, that an opening in an exit enclosure was from an unoccupied space. The soiled utility room opened directly into the exit passage. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain all stairs with door assemblies, to meet code requirements with exits free of storage. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:40 PM, observation revealed on the lower Level floor in the Southwest stair near the exit door, that a portion of the stair enclosure was being used as usable space. Storage was found including a rolled rug, garbage containers, and masks. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfere with egress". This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.3 and 7.2.2.5.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide egress paths at all times with snow cleared from the egress path, doors that were unlockable in the egress path, and travel interruption at stairs that go below the level of exit discharge. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:55 PM, observation revealed on the lower level floor in the administrative stair area, there was an accumulation of snow in the exit discharge path outside of the building. Snow, approximately 6 inches deep, blocks the exit out the administration stair area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.10.1.

2. On 1/28/2014 at 2:16 PM, observation revealed on the 1st floor floor in the Emergency Department waiting room, that the door was locked from the egress side. At night, the door to the corridor was locked. It has an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

3. On 1/28/2014 at 3:20 PM, observation revealed on the 1st floor in the stair by the ER and serving the OR, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation, record review, and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with manual pull stations at required locations and to inform people of fire information through the fire alarm system. This deficiency occurred in all of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On 1/28/2014 at 8:05 AM, observation revealed on the lower level floor in the exit stairs out of the laundry and boiler rooms, that the manual pull station was not located in accordance with NFPA 72 requirements. No manual pull station was located at these exits. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.).

2) On 1/28/2014 at 3:00 PM, during a record review and interview, it was determined that an overhead speaker system, that is not part of the fire alarm system, was used to inform staff, visitors and patients of fire conditions. After the speaker system announcement, then a separation action would activate the fire alarm system. Relocation or partial evacuation voice communication shall be through the fire alarm system per NFPA 72, 1999 edition, sections 3-8.4.3, 3-8.4.1.3.5 and 3-8.4.1. In addition, the system shall be protected per 3-.8.4.1.1.4 from the point at which the circuits exit the control unit until the point that they enter the notification zone.

These conditions were confirmed at the time of discovery by a concurrent observation, record review, and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers located with the appropriate separation distance, sprinklers free of obstructions near the ceiling, and unobstructed water distribution. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 8:50 AM, observation revealed on the lower level floor in the Maintenance/ ER stairs, that a sprinkler was not provided under the bottom of the stairs, leaving floor space that was not protected. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.3.2.

2. On 1/28/2014 at 10:50 AM, observation revealed on the 1st floor floor in the Yoga 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 ductwork. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

3. On 1/28/2014 at 11:55 AM, observation revealed on the 1st floor floor in the speech therapy, Little kids room, that a sprinkler was located approximately 5-1/2 feet between sprinklers. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.3.

4. On 1/28/2014 at 1:05 PM, observation revealed on the 1st floor floor in the CT 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 a privacy curtain that has holes at the top of the curtain that is 1/4 inch in diameter that would limit the amount of water passing through the curtain. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On 1/28/2014 at 1:22 PM, observation revealed on the 1st floor floor in the Fluor Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included an x-ray machine which was located on a ceiling track beneath the sprinkler. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

6. On 1/28/2014 at 2:40 PM, observation revealed on the 1st floor in Exam room 2 of the emergency department, that items were stored on a shelf within 18" below a sprinkler deflector. Storage of items is located on shelving directly underneath the sprinkler. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.6.

7. On 1/29/2014 at 7:45 AM, observation revealed on the 2nd floor in shower Room 270 and shower of OB on call sleep 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 the bulkhead above the shower/tub. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

8. On 1/29/2014 at 10:37 AM, observation revealed on the 2nd floor floor in the data room by Room 210, 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 black box under the sprinkler. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, compliant fire dampers, and corridor used as a plenum. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:50 PM, observation revealed on the Lower Level floor in the Dietetic Office, that airflow between the corridor and this room was not neutral. There is only a supply duct in the room. There is no return or exhaust duct. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1 and 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

2. On 1/28/2014 at 11:40 AM, observation revealed on the 1st floor in the wellness gym air handler room, that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.2.

3. On 1/29/2014 at 9:25 AM, observation revealed on the 2nd floor in the ambulatory care mechanical room, that the ventilation system used the corridor as a plenum for air returning to the air handling unit. Air flow is from the ambulatory care corridor into the mechanical room. From the mechanical room, the air is exhausted outside. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.11.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not maintain an egress path that was free of obstructions, and corridors free of materials that obstruct egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:30 AM, observation revealed on the lower level in the corridor leading to the exit passage way to the receiving area, that items were stored in the exit access pathway, including a large wooden crate, approximately 4' x 5' x 3' tall. The item was still there the next day at 3 pm on 1/29/14. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

2. On 1/28/2014 at 10:35 AM, observation revealed on the 1st floor in the corridor by the Wellness elevator entrance, that items were stored in the exit access pathway, including waiting room chairs. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

3. On 1/29/2014 at 8:05 AM, observation revealed on the 2nd floor in the back corridor by surgery, that items were stored in the exit access pathway, including radiology equipment. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

4. On 1/29/2014 at 8:30 AM, observation revealed on the 2nd floor in the back hall inside the OR suite, that items were stored in the exit access pathway, including general OR equipment and supplies on carts. The aisle was less than 44 inches wide. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

5. On 1/29/2014 at 8:50 AM, observation revealed on the 2nd floor in the front OR corridor, that items were stored in the exit access pathway, including trash containers. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6), and 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with verification of rated hanging materials.

FINDINGS INCLUDE:

1. On 1/28/2014 at 12:05 PM, record review revealed on the 1st floor in Eunice's old office, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

This condition was confirmed at the time of discovery by concurrent record review, and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/29/2014 at 8:12 AM, observation revealed on the 2nd floor in the OR suite hallways, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A cart 2' x 4' by 2.5' to store dirty linen was located in the hallways of the OR. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On 1/29/2014 at 8:13 AM, observation revealed on the 2nd floor in the bathroom of the women's locker room of the OR, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There was a 32 gallon linen container next to a 15 gallon trash container. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:42 PM, observation revealed on the lower level floor in the PT/OT area, that combustible materials were stored within 5 ft. of the storage site of cylinders of oxygen. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Item #1
NFPA 99 Health Care Facilities, 1999 edition 3-4.1.1.15(b)(4) states: "The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows..... Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following ... Low fuel --- when the main fuel storage tank contains less than a 3-hour operating supply."

NFPA 76A, Standard for Essential Electrical System for Health Care Facilities 1977 edition, 3-3.7(b) states "A remote annuciator, storage battery powered shall be provided to operate outside of the generating room in a location readily observable by operating personal at a regular work station. ... Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:..Low fuel --- when the main fuel storage tank contains less than a three-hour operating supply."

Based on observation and interview, the facility failed to properly a low fuel alarm for the 1994 generator set. This deficient practice could affect all patients, staff, and visitors in all of the 18 smoke compartments.

FINDINGS INCLUDE:

1. On 01/29/2014 at 1:30 PM, observation revealed that the emergency generator annunciator panel did not have a low fuel alarm. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant Operations Manager), staff H (Construction Liaison) and staff I (Construction Supervisor).

Item #2
NFPA 50 Bulk Oxygen System at Consumers Sites, 2001 edition section 2.2.7 states: "The minimum distance from any bulk oxygen system to solid materials that burn rapidly, such as excelsior or paper, shall be 50 feet. Section 2.2.8 states: "The minimum distance from any bulk oxygen system to solid materials that burn slowly, such as coal and heavy timber, shall be 25 feet."

Based on observation and interview, the facility failed to locate combustible that burn rapidly at least 50 feet from the oxygen bulk tanks. This deficient practice could affect all patients.

FINDINGS INCLUDE:

1. On 01/28/2014 at 11:30 AM, observation revealed that the bulk oxygen storage tanks were adjacent to open large (approximately 30' x 8' x 5') trash containers containing combustibles such as cardboard. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant Operations Manager), staff H (Construction Liaison) and staff I (Construction Supervisor).

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, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:40 PM, observation revealed on the lower level floor in the pool storage room, that access to an electrical panel was less than 3'-0" clearance. Items for the pool were stored in front of the panel. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On 1/27/2014 at 2:55 PM, observation revealed on the lower level floor in the pool water room, that access to an electrical panel was less than 3'-0" clearance. Items for the pool were stored in front of the disconnects for the jet pump and circulation pump. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On 1/28/2014 at 7:20 AM, observation revealed on the lower level floor in the dirty laundry room, that access to an electrical panel was less than 3'-0" clearance. Dirty laundry carts blocked access to 2 disconnects. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On 1/28/2014 at 7:30 AM, observation revealed on the lower level floor in the washing machine room, 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 the washing machines. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain the required building construction type and support structure with rated construction. This deficiency occurred in 1 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 11:15 AM, observation revealed on the 1st floor in the wellness gym air handler room, that roof structural support members were not enclosed with rated construction. The roof is not rated because no fire protection is present on the deck. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

2. On 1/28/2014 at 11:30 AM, observation revealed on the 1st floor floor in the wellness gym , that a structural support member was not enclosed with rated construction. The rated ceiling tile is penetrated with 12 eye bolts and holes which eliminates the rating of the ceiling tile protecting the roof structure. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces and rooms open to the corridor with the required safe-guards. This deficiency occurred in 2 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:35 PM, observation revealed on the Lower Level floor in the PT/OT reception area, that a drop down shutter was installed in the corridor wall. However, there is a wood piece that fits into a hole at the desk that staff BB did not install when asked what she would do if a fire alarm sounded. She stated that management told her not to put it in. With this hole in the corridor wall, this area did not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

2. On 1/29/2014 at 9:50 AM, observation revealed on the 2nd floor floor in the food service of ambulatory care area, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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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 4 of the 18 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:25 AM, observation revealed on the Lower Level in the x-ray storage room and disaster storage room (AHU room), that the rooms have 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 ed.), 19.3.6.3.1.

2. On 1/28/2014 at 1:40 PM, observation revealed on the 1st floor floor in the radiology waiting 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 ed.), 19.3.6.3.2.

3. On 1/28/2014 at 2:15 PM, observation revealed on the 1st floor floor in the Emergency Department waiting 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 ed.), 19.3.6.3.2.

4. On 1/29/2014 at 10:00 AM, observation revealed on the 2nd floor in Rooms 203, 204, 205, 206, and 207, 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. There is no latch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/29/2014 at 11:45 AM, observation revealed on the 2nd floor floor in the smoke barrier by a data room, that penetrations were not sealed according to an approved method. The deficiency included a 4" conduit pipe full of data cables. 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 G (plant operations manager), staff H (construction liaison) and staff I (construction liaison).
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Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations, and doors with positive-latching hardware. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:35 AM, observation revealed on the lower level floor in the biohazard room, that penetrations were not sealed according to an approved method. The deficiency included a 6 inch polyvinyl chloride (PVC) pipe that did not have a fire rated collar. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2. On 1/29/2014 at 8:35 AM, observation revealed on the 2nd floor floor in the clean supply storage of the OR, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The clean supply room includes OR supplies wrapped in plastic. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

3. On 1/28/2014 at 10:15 AM, observation revealed on the 1st floor floor in the purchasing (material storage room), that penetrations were not sealed according to an approved method. The deficiency included the electrical box was recessed into the 1 hour wall and was 140 square inches which is greater than the 100 square inches in a hundred square that is allowed for electrical boxes. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:20 PM, observation revealed on the lower level floor in the exit passage way, that an opening in an exit enclosure was from an unoccupied space. The soiled utility room opened directly into the exit passage. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain all stairs with door assemblies, to meet code requirements with exits free of storage. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:40 PM, observation revealed on the lower Level floor in the Southwest stair near the exit door, that a portion of the stair enclosure was being used as usable space. Storage was found including a rolled rug, garbage containers, and masks. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfere with egress". This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.3 and 7.2.2.5.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide egress paths at all times with snow cleared from the egress path, doors that were unlockable in the egress path, and travel interruption at stairs that go below the level of exit discharge. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:55 PM, observation revealed on the lower level floor in the administrative stair area, there was an accumulation of snow in the exit discharge path outside of the building. Snow, approximately 6 inches deep, blocks the exit out the administration stair area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.10.1.

2. On 1/28/2014 at 2:16 PM, observation revealed on the 1st floor floor in the Emergency Department waiting room, that the door was locked from the egress side. At night, the door to the corridor was locked. It has an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

3. On 1/28/2014 at 3:20 PM, observation revealed on the 1st floor in the stair by the ER and serving the OR, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation, record review, and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with manual pull stations at required locations and to inform people of fire information through the fire alarm system. This deficiency occurred in all of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On 1/28/2014 at 8:05 AM, observation revealed on the lower level floor in the exit stairs out of the laundry and boiler rooms, that the manual pull station was not located in accordance with NFPA 72 requirements. No manual pull station was located at these exits. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.).

2) On 1/28/2014 at 3:00 PM, during a record review and interview, it was determined that an overhead speaker system, that is not part of the fire alarm system, was used to inform staff, visitors and patients of fire conditions. After the speaker system announcement, then a separation action would activate the fire alarm system. Relocation or partial evacuation voice communication shall be through the fire alarm system per NFPA 72, 1999 edition, sections 3-8.4.3, 3-8.4.1.3.5 and 3-8.4.1. In addition, the system shall be protected per 3-.8.4.1.1.4 from the point at which the circuits exit the control unit until the point that they enter the notification zone.

These conditions were confirmed at the time of discovery by a concurrent observation, record review, and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers located with the appropriate separation distance, sprinklers free of obstructions near the ceiling, and unobstructed water distribution. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 8:50 AM, observation revealed on the lower level floor in the Maintenance/ ER stairs, that a sprinkler was not provided under the bottom of the stairs, leaving floor space that was not protected. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.3.2.

2. On 1/28/2014 at 10:50 AM, observation revealed on the 1st floor floor in the Yoga 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 ductwork. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

3. On 1/28/2014 at 11:55 AM, observation revealed on the 1st floor floor in the speech therapy, Little kids room, that a sprinkler was located approximately 5-1/2 feet between sprinklers. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.3.

4. On 1/28/2014 at 1:05 PM, observation revealed on the 1st floor floor in the CT 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 a privacy curtain that has holes at the top of the curtain that is 1/4 inch in diameter that would limit the amount of water passing through the curtain. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On 1/28/2014 at 1:22 PM, observation revealed on the 1st floor floor in the Fluor Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included an x-ray machine which was located on a ceiling track beneath the sprinkler. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

6. On 1/28/2014 at 2:40 PM, observation revealed on the 1st floor in Exam room 2 of the emergency department, that items were stored on a shelf within 18" below a sprinkler deflector. Storage of items is located on shelving directly underneath the sprinkler. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.6.

7. On 1/29/2014 at 7:45 AM, observation revealed on the 2nd floor in shower Room 270 and shower of OB on call sleep 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 the bulkhead above the shower/tub. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

8. On 1/29/2014 at 10:37 AM, observation revealed on the 2nd floor floor in the data room by Room 210, 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 black box under the sprinkler. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, compliant fire dampers, and corridor used as a plenum. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 3:50 PM, observation revealed on the Lower Level floor in the Dietetic Office, that airflow between the corridor and this room was not neutral. There is only a supply duct in the room. There is no return or exhaust duct. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.5.2.1 and 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

2. On 1/28/2014 at 11:40 AM, observation revealed on the 1st floor in the wellness gym air handler room, that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.2.

3. On 1/29/2014 at 9:25 AM, observation revealed on the 2nd floor in the ambulatory care mechanical room, that the ventilation system used the corridor as a plenum for air returning to the air handling unit. Air flow is from the ambulatory care corridor into the mechanical room. From the mechanical room, the air is exhausted outside. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.11.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not maintain an egress path that was free of obstructions, and corridors free of materials that obstruct egress. This deficiency occurred in 5 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/28/2014 at 9:30 AM, observation revealed on the lower level in the corridor leading to the exit passage way to the receiving area, that items were stored in the exit access pathway, including a large wooden crate, approximately 4' x 5' x 3' tall. The item was still there the next day at 3 pm on 1/29/14. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

2. On 1/28/2014 at 10:35 AM, observation revealed on the 1st floor in the corridor by the Wellness elevator entrance, that items were stored in the exit access pathway, including waiting room chairs. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

3. On 1/29/2014 at 8:05 AM, observation revealed on the 2nd floor in the back corridor by surgery, that items were stored in the exit access pathway, including radiology equipment. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

4. On 1/29/2014 at 8:30 AM, observation revealed on the 2nd floor in the back hall inside the OR suite, that items were stored in the exit access pathway, including general OR equipment and supplies on carts. The aisle was less than 44 inches wide. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

5. On 1/29/2014 at 8:50 AM, observation revealed on the 2nd floor in the front OR corridor, that items were stored in the exit access pathway, including trash containers. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6), and 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with verification of rated hanging materials.

FINDINGS INCLUDE:

1. On 1/28/2014 at 12:05 PM, record review revealed on the 1st floor in Eunice's old office, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

This condition was confirmed at the time of discovery by concurrent record review, and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/29/2014 at 8:12 AM, observation revealed on the 2nd floor in the OR suite hallways, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A cart 2' x 4' by 2.5' to store dirty linen was located in the hallways of the OR. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On 1/29/2014 at 8:13 AM, observation revealed on the 2nd floor in the bathroom of the women's locker room of the OR, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There was a 32 gallon linen container next to a 15 gallon trash container. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:42 PM, observation revealed on the lower level floor in the PT/OT area, that combustible materials were stored within 5 ft. of the storage site of cylinders of oxygen. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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Item #1
NFPA 99 Health Care Facilities, 1999 edition 3-4.1.1.15(b)(4) states: "The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows..... Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following ... Low fuel --- when the main fuel storage tank contains less than a 3-hour operating supply."

NFPA 76A, Standard for Essential Electrical System for Health Care Facilities 1977 edition, 3-3.7(b) states "A remote annuciator, storage battery powered shall be provided to operate outside of the generating room in a location readily observable by operating personal at a regular work station. ... Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:..Low fuel --- when the main fuel storage tank contains less than a three-hour operating supply."

Based on observation and interview, the facility failed to properly a low fuel alarm for the 1994 generator set. This deficient practice could affect all patients, staff, and visitors in all of the 18 smoke compartments.

FINDINGS INCLUDE:

1. On 01/29/2014 at 1:30 PM, observation revealed that the emergency generator annunciator panel did not have a low fuel alarm. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (Plant Operations Manager), staff H (Construction Liaison) and staff I (Construction Supervisor).

Item #2
NFPA 50 Bulk Oxygen System at Consumers Sites, 2001 edition section 2.2.7 states: "The minimum distance from any bulk oxygen system to solid materials that burn rapidly, such as excelsior or paper, shall be 50 feet. Section 2.2.8 states: "The minimum distance from any bulk oxygen system to solid materials that burn slowly, such as coal and heavy timber, shall be 25 feet."

Based on observation and interview, the facility failed to locate combustible that burn rapidly at least 50 feet from the oxygen bulk tanks. This deficient practice could affect all patients.

FINDINGS INCLUDE:

1. On 01/28/2014 at 11:30 AM, observation revealed that the bulk oxygen storage tanks were adjacent to open large (approximately 30' x 8' x 5') trash containers containing combustibles such as cardboard. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (plant Operations Manager), staff H (Construction Liaison) and staff I (Construction Supervisor).

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, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 18 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 1/27/2014 at 2:40 PM, observation revealed on the lower level floor in the pool storage room, that access to an electrical panel was less than 3'-0" clearance. Items for the pool were stored in front of the panel. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On 1/27/2014 at 2:55 PM, observation revealed on the lower level floor in the pool water room, that access to an electrical panel was less than 3'-0" clearance. Items for the pool were stored in front of the disconnects for the jet pump and circulation pump. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On 1/28/2014 at 7:20 AM, observation revealed on the lower level floor in the dirty laundry room, that access to an electrical panel was less than 3'-0" clearance. Dirty laundry carts blocked access to 2 disconnects. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On 1/28/2014 at 7:30 AM, observation revealed on the lower level floor in the washing machine room, 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 the washing machines. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff G (plant operations manager), staff H (construction liaison) and staff I (construction supervisor).
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