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Based on observation and interview, the facility did not enclose hazardous rooms with a localized smoke detection device. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 9:45 am, observation revealed on the Basement floor in the Medical Records Room, that the door to this hazardous room was equipped with a magnetic hold-open device but no local system smoke detector was installed on either side for "door release" requirement. 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.), sections 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist)..

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Based on observation and interview, the facility did not protect the facility from the contents of the hazardous gift shop by using construction methods required by the code, with a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 10:45 am, observation revealed on the 1st floor in the Gift Shop, that the gift shop was sprinkled, but did not resist the passage of smoke because the door was not equipped with a automatic or self closing device. The gift shop contained a quantity of stored combustible products that was considered hazardous and did was not stored in a separately protected area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path, paths that were maintainable in all weather conditions, and a compliant egress path. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 3:10 PM, observation revealed on the Basement floor in the Storage Room, that the door was locked from the egress side. The old punch card storage enclosure door was locked with a pad lock. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/16/2014 at 3:30 PM, observation revealed on the Basement floor in the Exit stair near the storage rooms, that the exit discharge path was not compliant. The exterior landing right after exit discharge door was slippery with permanent water accumulation. Staff B stated that due to an increase in ground water table after recent rains, water always accumulates in this location. 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 A (Executive Director of Support Services) and staff B (Maintenance Person).

3. On 06/16/2014 at 3:45 PM, observation revealed on the Basement floor in the Exterior of exit stair near the storage room, that the egress path was not compliant. The upper exterior landing facing the exterior stair leading to the basement had a vertical drop of more than 30 inches and was not protected by a compliant guard rail. The gap between guard rails was 19-1/2 inches. Staff B stated that, the building was built in 1970 and the gap between guards was compliant with the code effective at that time. Per Life Safety Code (1967 edition) Section 5-3165(d)(1), guards shall be constructed with a sufficient number of intermediate rails so that the clear distance between rails measured at right angles to the run of rail does not exceed 10 inches. Per NFPA 101 (2000) 7.2.2.4.6(3), existing open guards, shall have intermediate rails or ornamental pattern such that a sphere 4 inch diameter shall not pass through any opening up to a height of 34 inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.2.4.6 (3)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

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Based on interview and record review, 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 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 2:00 PM, review of facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (3rd and 4th quarter) of 4 first-shift drills were held between 9:40 am to 10:35 am, and 2 (3rd & 4th quarter) of 4 third-shift drills were held at 1:30 am. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).


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Based on observation and interview, the facility did not provide a fire alarm system with alarm power accessible by authorized persons only. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 9:15 am, observation revealed on the Basement floor in the Soiled Holding Room, that the fire alarm power source was not locked and was accessible to more than facility authorized personnel. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with on-time inspections. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:30 am, during a review of facility documents, it was noted that the required semi-annual inspections were not performed on an every 6 month basis. Sealed lead acid type batteries for the Fire Alarm System were only tested once, on 12/04/2013 by Communications Engineering Company of Green Bay, within the last year. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

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Based on a review of maintenance documents, the facility did not performed the complete smoke detector sensitivity test in accordance with manufacturer's specifications. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:40 am, during a review of facility documents, it was noted that records were not available to verify that any smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 12.01.2013 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

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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 ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 2:30 PM, observation revealed on the 1st floor in the Scrub area in the OR suite, that there was one or more unsealed holes near the ceiling. The hole included a 4 inch diameter unsealed hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

Based on observation, interview, and record review, the facility did not provide a kitchen extinguishing system, range hoods cleaned annually, extinguisher identification, and instruction for manual operation as required by NFPA 96. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:40 am, during a review of documents it was discovered that the range hood and ducts were inspected semi-annually, and not cleaned if grease contamination was found, as required for systems serving moderate-volume cooking operations. Cleaning and Inspection records indicated that, Fire & Safety Equipment Inc. only inspected the kitchen hood & exhaust system on 1/7/2014 and 07/30/2013. The last time the kitchen hood and exhaust systems were cleaned was more than a year ago by Fire & Safety Equipment Inc. on 2/7/2013. During the Kitchen tour on 06/17/2014 at 9:00 AM, the kitchen hood and exhaust system surface was not found to be cleaned to bare metal. Staff F stated that, no grease laden vapor producing cooking operations are conducted in this kitchen. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/17/2014 at 10:15 am, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

3. On 06/17/2014 at 10:20 am, observation revealed on the Basement floor in the Kitchen, that Instruction for manually operating the fire extinguishing system was not posted conspicuously in the kitchen and reviewed periodically with the employees by the management. This observed situation was not compliant with NFPA 96 (1998 ed.), 8-1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on observation and interview, the facility used life support systems and did not provide a compliant Type I essential electrical system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 2:00 PM, observation revealed on the 1st floor in the OR room, that the facility admitted patients that depend on life support equipment and did not have a Type 1 emergency electrical system. The electrical system present failed to have two independent electrical systems in the critical patient care areas. There is no normal power or second source (back to the 2nd transfer switch) of emergency power via receptacles in the critical care patient area of the operating room. Similar situations were occurring in other critical areas in the Emergency Trauma and Recovery Room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.9.1 and NFPA 99 (1999 ed.), 3-3.2.1.2(a)1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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EGRESS PATH

Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion and paths that are maintainable in all weather conditions. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 11:45 am, observation revealed on the 1st floor in the Vestibule, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt in the door located at 3 feet above the floor. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff F (Life Safety Code Specialist).

2. On 06/17/2014 at 12:00 pm, observation revealed in the exterior of 1st floor rear exit door, that the exit discharge path was not compliant. The 30 feet long path from the exterior door landing to the public way was composed of a grassy surface. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff F (Life Safety Code Specialist).

I - HAZARDOUS SPACES

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors. This deficiency occurred in 1 of the 1 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 10:35 am, observation revealed on the 1st floor in the Medical Records Room, that the door would not self-close because the door was not equipped with an automatic or self closing device. 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.), 39.3.2.2 and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


II - SPRINKLER MAINTENANCE

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 a wrench in the spare sprinkler cabinet. This deficiency occurred in 1 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 06/17/2014 at 10:40 am, observation revealed on the Basement floor in the Sprinkler Riser Room, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


III - ELECTRICAL

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. On 06/17/2014 at 10:30 am, observation revealed on the 1st floor in the Lobby, 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 five pieces of equipment including a large aquarium. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

Based on observation and interview, the facility did not provide a code compliant environment with procedures for responding to spills. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 8:50 am, observation revealed on the Basement floor in the Microbiology Laboratory, that the facility did not have Microbiology Lab Emergency Procedures available and in place for immediate access by staff for controlling chemical spills. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and NFPA 99 (1999 ed.), 10.2.1.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on interview and observation, the facility did not test the emergency electrical generator in accordance with the codes with an acceptable type of starting battery, and derangement signals at a continuously monitored location. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 8:00 am, observation revealed on the Basement floor in the Boiler Room, that a maintenance-free battery was used to start the generator, which is not allowed in a Level I type generator. This observed situation was not compliant with NFPA 110 (1999 ed.), section 3-5.4.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

2. On 06/17/2014 at 8:10 am, observation revealed on the Basement floor in the Boiler Room, that a remote annunciator, storage battery powered, was not provided outside of the generating room in a location readily observed by operating personnel at regular work station. 1967 National Fire Code (vol. 5) Section 64 required a storage battery powered annunciator panel, outside of the generating room in a location readily observed by operating personnel at a regular work station. Additionally Staff B stated that the regular operating personnel work station was attended 24/7, and an audible and visual derangement signal, appropriately labeled, was not established at a continuously monitored location. This observed situation was not compliant with NFPA 99 (1999 ed.), section 3-4.1.1.15(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords and electrical panels with restricted access. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 3:20 PM, observation revealed on the Basement floor in the Storage 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 data and communications equipment and four pieces of equipment were plugged in. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/16/2014 at 4:00 PM, observation revealed on the Basement floor in the Mechanical Equipment Room, that access to the electrical panel was not restricted to authorized use only, because the panels G1 & G2 were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

3. On 06/17/2014 at 8:20 am, observation revealed on the Basement floor in the Boiler Room, that access to the electrical panel was not restricted to authorized use only, because panel EP, E, EL, O, F and N were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

4. On 06/17/2014 at 8:30 am, observation revealed on the Basement floor in the Corridor inside the Office Suite, that access to the electrical panel was not restricted to authorized use only, because panel K was unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with a localized smoke detection device. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 9:45 am, observation revealed on the Basement floor in the Medical Records Room, that the door to this hazardous room was equipped with a magnetic hold-open device but no local system smoke detector was installed on either side for "door release" requirement. 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.), sections 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist)..

______________________________________

Based on observation and interview, the facility did not protect the facility from the contents of the hazardous gift shop by using construction methods required by the code, with a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 10:45 am, observation revealed on the 1st floor in the Gift Shop, that the gift shop was sprinkled, but did not resist the passage of smoke because the door was not equipped with a automatic or self closing device. The gift shop contained a quantity of stored combustible products that was considered hazardous and did was not stored in a separately protected area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path, paths that were maintainable in all weather conditions, and a compliant egress path. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 3:10 PM, observation revealed on the Basement floor in the Storage Room, that the door was locked from the egress side. The old punch card storage enclosure door was locked with a pad lock. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/16/2014 at 3:30 PM, observation revealed on the Basement floor in the Exit stair near the storage rooms, that the exit discharge path was not compliant. The exterior landing right after exit discharge door was slippery with permanent water accumulation. Staff B stated that due to an increase in ground water table after recent rains, water always accumulates in this location. 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 A (Executive Director of Support Services) and staff B (Maintenance Person).

3. On 06/16/2014 at 3:45 PM, observation revealed on the Basement floor in the Exterior of exit stair near the storage room, that the egress path was not compliant. The upper exterior landing facing the exterior stair leading to the basement had a vertical drop of more than 30 inches and was not protected by a compliant guard rail. The gap between guard rails was 19-1/2 inches. Staff B stated that, the building was built in 1970 and the gap between guards was compliant with the code effective at that time. Per Life Safety Code (1967 edition) Section 5-3165(d)(1), guards shall be constructed with a sufficient number of intermediate rails so that the clear distance between rails measured at right angles to the run of rail does not exceed 10 inches. Per NFPA 101 (2000) 7.2.2.4.6(3), existing open guards, shall have intermediate rails or ornamental pattern such that a sphere 4 inch diameter shall not pass through any opening up to a height of 34 inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.2.4.6 (3)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

______________________________________

Based on interview and record review, 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 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 2:00 PM, review of facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. The facility's fire drill records from June 2013 to May 2014 indicated that, 2 (3rd and 4th quarter) of 4 first-shift drills were held between 9:40 am to 10:35 am, and 2 (3rd & 4th quarter) of 4 third-shift drills were held at 1:30 am. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).


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Based on observation and interview, the facility did not provide a fire alarm system with alarm power accessible by authorized persons only. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 9:15 am, observation revealed on the Basement floor in the Soiled Holding Room, that the fire alarm power source was not locked and was accessible to more than facility authorized personnel. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

_____________________________________

Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with on-time inspections. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:30 am, during a review of facility documents, it was noted that the required semi-annual inspections were not performed on an every 6 month basis. Sealed lead acid type batteries for the Fire Alarm System were only tested once, on 12/04/2013 by Communications Engineering Company of Green Bay, within the last year. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

______________________________________

Based on a review of maintenance documents, the facility did not performed the complete smoke detector sensitivity test in accordance with manufacturer's specifications. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:40 am, during a review of facility documents, it was noted that records were not available to verify that any smoke detector sensitivity tests were conducted according to NFPA 72 required frequencies. Print out of the Fire Alarm Test and Inspection performed by the Communication Engineering Company of Green Bay on 12.01.2013 did not show any smoke detector sensitivity test results. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7, and NFPA 72 (1999 ed.), 7-3.2.1. This condition was confirmed at the time of discovery by a concurrent interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

______________________________________

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 ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 2:30 PM, observation revealed on the 1st floor in the Scrub area in the OR suite, that there was one or more unsealed holes near the ceiling. The hole included a 4 inch diameter unsealed hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

Based on observation, interview, and record review, the facility did not provide a kitchen extinguishing system, range hoods cleaned annually, extinguisher identification, and instruction for manual operation as required by NFPA 96. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 10:40 am, during a review of documents it was discovered that the range hood and ducts were inspected semi-annually, and not cleaned if grease contamination was found, as required for systems serving moderate-volume cooking operations. Cleaning and Inspection records indicated that, Fire & Safety Equipment Inc. only inspected the kitchen hood & exhaust system on 1/7/2014 and 07/30/2013. The last time the kitchen hood and exhaust systems were cleaned was more than a year ago by Fire & Safety Equipment Inc. on 2/7/2013. During the Kitchen tour on 06/17/2014 at 9:00 AM, the kitchen hood and exhaust system surface was not found to be cleaned to bare metal. Staff F stated that, no grease laden vapor producing cooking operations are conducted in this kitchen. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.2.6; 9.2.3; and NFPA 96 (1998 ed.), 8-3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/17/2014 at 10:15 am, observation revealed on the Basement floor in the Kitchen, that a placard identification sign was not provided near the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 ed.), section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

3. On 06/17/2014 at 10:20 am, observation revealed on the Basement floor in the Kitchen, that Instruction for manually operating the fire extinguishing system was not posted conspicuously in the kitchen and reviewed periodically with the employees by the management. This observed situation was not compliant with NFPA 96 (1998 ed.), 8-1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on observation and interview, the facility used life support systems and did not provide a compliant Type I essential electrical system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 2:00 PM, observation revealed on the 1st floor in the OR room, that the facility admitted patients that depend on life support equipment and did not have a Type 1 emergency electrical system. The electrical system present failed to have two independent electrical systems in the critical patient care areas. There is no normal power or second source (back to the 2nd transfer switch) of emergency power via receptacles in the critical care patient area of the operating room. Similar situations were occurring in other critical areas in the Emergency Trauma and Recovery Room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.9.1 and NFPA 99 (1999 ed.), 3-3.2.1.2(a)1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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EGRESS PATH

Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion and paths that are maintainable in all weather conditions. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 11:45 am, observation revealed on the 1st floor in the Vestibule, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt in the door located at 3 feet above the floor. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff F (Life Safety Code Specialist).

2. On 06/17/2014 at 12:00 pm, observation revealed in the exterior of 1st floor rear exit door, that the exit discharge path was not compliant. The 30 feet long path from the exterior door landing to the public way was composed of a grassy surface. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff F (Life Safety Code Specialist).

I - HAZARDOUS SPACES

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors. This deficiency occurred in 1 of the 1 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 10:35 am, observation revealed on the 1st floor in the Medical Records Room, that the door would not self-close because the door was not equipped with an automatic or self closing device. 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.), 39.3.2.2 and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


II - SPRINKLER MAINTENANCE

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 a wrench in the spare sprinkler cabinet. This deficiency occurred in 1 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 06/17/2014 at 10:40 am, observation revealed on the Basement floor in the Sprinkler Riser Room, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-4.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).


III - ELECTRICAL

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. On 06/17/2014 at 10:30 am, observation revealed on the 1st floor in the Lobby, 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 five pieces of equipment including a large aquarium. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

Based on interview and observation, the facility did not test the emergency electrical generator in accordance with the codes with an acceptable type of starting battery, and derangement signals at a continuously monitored location. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/17/2014 at 8:00 am, observation revealed on the Basement floor in the Boiler Room, that a maintenance-free battery was used to start the generator, which is not allowed in a Level I type generator. This observed situation was not compliant with NFPA 110 (1999 ed.), section 3-5.4.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

2. On 06/17/2014 at 8:10 am, observation revealed on the Basement floor in the Boiler Room, that a remote annunciator, storage battery powered, was not provided outside of the generating room in a location readily observed by operating personnel at regular work station. 1967 National Fire Code (vol. 5) Section 64 required a storage battery powered annunciator panel, outside of the generating room in a location readily observed by operating personnel at a regular work station. Additionally Staff B stated that the regular operating personnel work station was attended 24/7, and an audible and visual derangement signal, appropriately labeled, was not established at a continuously monitored location. This observed situation was not compliant with NFPA 99 (1999 ed.), section 3-4.1.1.15(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords and electrical panels with restricted access. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/16/2014 at 3:20 PM, observation revealed on the Basement floor in the Storage 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 data and communications equipment and four pieces of equipment were plugged in. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

2. On 06/16/2014 at 4:00 PM, observation revealed on the Basement floor in the Mechanical Equipment Room, that access to the electrical panel was not restricted to authorized use only, because the panels G1 & G2 were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services) and staff B (Maintenance Person).

3. On 06/17/2014 at 8:20 am, observation revealed on the Basement floor in the Boiler Room, that access to the electrical panel was not restricted to authorized use only, because panel EP, E, EL, O, F and N were unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

4. On 06/17/2014 at 8:30 am, observation revealed on the Basement floor in the Corridor inside the Office Suite, that access to the electrical panel was not restricted to authorized use only, because panel K was unlocked. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-31(c). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Executive Director of Support Services), staff B (Maintenance Person) and staff F (Life Safety Code Specialist).

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