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Based on observation and staff interviews between 4/9/2013-4/12/2013 for this verification visit, the facility failed to construct and maintain the building systems to ensure a safe Physical Environment due to the cumulative effects of the environment deficiencies and resulted in the hospital's inability to ensure a safe environment for patients, which is a Condition of Participation. The following deficiencies occurred in 30 of the 80 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101- Life Safety Code was NOT MET.

FINDINGS INCLUDE:
It was observed that the facilities had the following remaining life safety deficiencies.
K12: Class of Construction did not meet non-combustible standards of a Type I & II(protected)
K18: Positive latching and smoke-tight openings into the corridor.
K20: Vertical shafts and floor penetrations were not constructed to the proper hourly rating.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke-tight with ratings.
K29: Reliable enclosure of hazardous areas were lacking at specific locations in the building.
K33: Exit enclosure is open to an unoccupied space.
K36: Travel distances exceeded code minimums.
K38: Access to exits was not accessible due to a dead-end.
K42: Suite configuration not at code minimums.
K51: Fire alarm strobes were not installed in all common areas.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen Hood & Exhaust Duct System were not properly protected per NFPA 96.
K76: Medical gas storage was not protected per NFPA 99.
K77: Piped medical gas and valves were not installed properly.
K130: Miscellaneous provisions not found in other K-tags.
K160: Existing elevators were not in accordance with ANSI A17.3

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report. This observed situation was not compliant with 42 CFR 482.41.

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18107

Based on observation and staff interviews between 4/9/2013-4/12/2013 for this verification visit, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of the environment deficiencies and resulted in the hospital's inability to ensure a safe environment for patients, which is a condition of participation. The following deficiencies occurred in 30 of the 80 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Waukesha Memorial Hospital is licensed for 400 beds, with a census of 150-175 average inpatients on the days of the survey. The facility contained 6 multi-story inpatient care wings. The ProHealth Care Organization had 8 off-site satellite clinics of which only 3 were surveyed. The main hospital was surveyed under the 2000 Life Safety Code, Chapter 19 for an existing health care occupancy.

FINDINGS INCLUDE:
It was observed that the facility had the following remaining life safety deficiencies.
K12: Class of Construction did not meet non-combustible standards of a Type I & II(protected)
K18: Positive latching and smoke-tight openings into the corridor.
K20: Vertical shafts and floor penetrations were not constructed to the proper hourly rating.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke-tight with ratings.
K29: Reliable enclosure of hazardous areas were lacking at locations through-out the building.
K33: Exit enclosure is open to an unoccupied space.
K36: Travel distances exceeded code minimums.
K38: Access to exits were not always accessible due to corridor/aisle/passage blockage or dead-end.
K42: Suite configuration not at code minimums.
K51: Fire alarm strobes were not installed in all common areas.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen Hood and Exhaust Duct System was not properly protected per NFPA 96.
K76: Medical gas storage was not protected per NFPA 99.
K77: Piped medical gas and valves were not installed properly.
K130: Miscellaneous provisions not found in other K-tags.
K160: Existing elevators were not in accordance with ANSI A17.3

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report. These observed situations were not compliant with 42 CFR 482.41.

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