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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. On 10/20/2014 at 3:10 PM, staff knew what to do, but there was holes in the bottom of the curtain and it took staff about 30 seconds to accomplish closing off of the corridor wall. 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). A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014. On October 20, 2014, staff H confirmed by observation.

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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). A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014.

Waiver Granted

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:


2) On 1/28/2014 at 3:00 PM, and on 10/20/2014 at 4:00 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). A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014. The observation was done by staff H on October 20, 2014 visit.

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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:

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. On October 20, 2014, the fluor scope blocked the sprinkler. This was observed by staff H on 10/20/2014. 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). A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014.

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:

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.

On October 20, 2014, the original extension cord was replace by a extension tap. with 4 outlets plugged into 2 outlet receptacle. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff H (construction liaison).

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). A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014.
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