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Based on observation and interview, the facility failed to provide and maintain the fire rated 2-hour 'common' separation wall. This deficiency occurred in 1 of the 2 smoke compartments, and would affect 5 of the patients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1-North smoke compartment in the G1700-Vestibule that penetration(s) were not sealed according to approved UL designs. Penetrations included a flexible 1/2 inch conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 10:30 AM on February 8, 2010.

2. It was observed in the 1-North smoke compartment in the G1704-Corridor that penetration(s) were not sealed according to approved UL designs. Penetrations included several metal pipes and sleeves. The facility Life Safety Plan showed this wall as 2-hour fire rated hospital separation assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 10:45 AM on February 8, 2010.

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Based on observation and interview, the facility failed to provide and maintain the fire-rated structure including columns, beams and floors system for the type of construction, Type I (3,3,2), used and as required by the code. This deficiency occurred in 1 of the 2 smoke compartments, and would affect 12 of the patients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1-West smoke compartment in the G1548-Soiled Utility Room that fire proofing was missing from the structural steel at two locations above the ceiling totaling about 4 linear feet.. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 3:30 PM on February 8, 2010.

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Based on observation and interview, the facility failed to provide and maintain corridor walls that meet code requirements for protecting the corridor from non-corridor spaces.This deficiency occurred in 1 of the 2 smoke compartments, and would affect 5 of the patients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1-North smoke compartment in the G1635 and G1638-Corridor Storage Alcoves that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included clean and sterile linen and supply packages stored on open carts, partially wrapped carts, open shelves and on support equipment. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 3:02 PM on February 9, 2010.

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Based on observation and interview, the facility failed to provide and maintain corridor door assemblies that meet code-requirements for protecting the corridor from non-corridor spaces. This deficiency occurred in 2 of the 2 smoke compartments, and would affect 14 of the inpatients (average daily census) including the babies in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1-West smoke compartment in the G1502 to G1524-LDRP Rooms that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This was observed at 11 out of the 12 LDRP Rooms in the West Wing. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 4. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:15 PM on February 8, 2010.

2. It was observed in the 1-North smoke compartment in the G1618, G1620, G1624, G1626, G1628-LDRP Rooms that the room had double corridor doors with a gap 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 edition), 18.2.3.5-exception 4. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 2:30 PM on February 9, 2010.

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Based on observation and interview, the facility failed to provide protection of the facility from the contents of hazardous room by using construction methods required by the code. This deficiency occurred in 2 of the 2 smoke compartments, and would affect 14 of the patients including the babies (average daily census) in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1-North smoke compartment in the G1526-Clean Supply Room that the door would not self-close because no door closer was installed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:15 PM on February 9, 2010.

2. It was observed in the 1-North smoke compartment in the G1643-Male Locker Room that penetration(s) were not sealed according to approved UL designs. Penetration(s) included several metal pipes. The facility Life Safety Plan showed this wall as 1-hour fire rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:32 PM on February 9, 2010.

3. It was observed in the 1-North smoke compartment in the G1645-Staff Toilet that penetration(s) were not sealed according to approved UL designs. Penetration(s) included sprinkler metal pipe. The facility Life Safety Plan showed this wall as 1-hour fire rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:46 PM on February 9, 2010.

4. It was observed in the 1-North smoke compartment in the G1645-Staff Toilet that penetration(s) were not sealed according to approved UL designs. Penetration(s) included medical gas pipe. The facility Life Safety Plan showed this wall as 1-hour fire rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:52 PM on February 9, 2010.

5. It was observed in the 1-North smoke compartment in the G1677-Trash Chute Collection Room that penetration(s) were not sealed according to approved UL designs. Penetration(s) included duct and metal pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 10:50 AM on February 8, 2010.

6. It was observed in the 1-North smoke compartment in the G1655-Clean Supply Room that penetration(s) were not sealed according to approved UL designs. Penetration(s) included two metal pipes in the northeast corner of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 2:13 PM on February 9, 2010.

7. It was observed in the 1-North smoke compartment in the G1648-Anesthesia Workroom that penetration(s) were not sealed according to approved UL designs. Penetration(s) included Medical Vacuum pipe. The facility Life Safety Plan showed this wall as 1-hour fire rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 2:23 PM on February 9, 2010.

8. It was observed in the 1-North smoke compartment in the G1676-Linen Chute Collection Room that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had screws that were not covered with joint compound. The room was considered hazardous because it exceeded 100 sq ft and contained seven (7) large bags of stored combustible soiled linen materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 10:55 AM on February 8, 2010.

9. It was observed in the 1-West smoke compartment in the G1536-Soiled Utility Room that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a 2 inch hole located above the bio-hazardous refrigerator above the ceiling. The room was considered hazardous because it exceeded 100 sq ft and contained several filled soiled material carts and multiple bags of soiled linen considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 2:30 PM on February 8, 2010.

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Based on observation and interview, the facility failed to ensure that all means of egress were readily available at all times. This deficiency occurred in 1 of the 2 smoke compartments, and would affect 5 of the inpatients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1-North smoke compartment in the G1651-EDIF Room that a portion of the path of egress had an abrupt change in elevation of 3/8th of an inch depression in the walk path at the door with a crack. inches. Changes in elevation that are 1/4"to 1/2" must be beveled at a rate of 1 to 2. Changes in elevation over 1/2" must meet the requirements of a ramp. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:28 PM on February 9, 2010.

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Based on observation and interview, the facility failed to ensure that all means of egress were readily available at all times. This deficiency occurred in 2 of the 2 smoke compartments, and would affect 16 inpatients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed during the record review that no fire drills were recorded held at unexpected times under varying conditions, at least quarterly on each shift. Surveyor 18107 was informed of this condition during the end-of-day interview and daily exit. This situation occurred after Columbia-St. Mary's - Ozaukee Campus (CSM-OC) changed their Security Contract. Security coordinates and manages the fire drills throughout the multiple hospital buildings. Since Columbia Center purchases this security service from CSM-OC, this service stopped being done at the areas occupied by Columbia Center at the Garden Level over a year ago. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.1.2. This deficiency was observed and verified by Surveyor 18107, Staff E (Plant Operations & Facilities Manager) and Staff A (CEO) with Surveyor 18816 present at approximately 4:30 PM on February 9, 2010.

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Based on observation and interview, the facility failed to provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, including the exceptions for not sprinkling a space. Full sprinkler protection is required to satisfy the exceptions permitted when a building is fully sprinkled, such as for the reduced rating of corridor walls doors and frames, reduced rating of corridor windows, reduced ratings of interior finishes, rooms open to corridors, storing recycle containers in non-rated rooms, and eliminating smoke dampers in smoke barriers. This deficiency occurred in 1 of the 2 smoke compartments, and would affect 5 of the inpatients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1-North smoke compartment in the G1563-Electrical Information Data Files (EIDF) Room that was not sprinkler protected. The facility took advantage of a construction 'exception' in the 1999 NFPA 13: 5-13.1 Electrical Equipment (sprinkler code) that requires all spaces to be sprinkled. Alternative protection in the form of 2-hour fire-rated construction separation from all other spaces was not provided to permit non-sprinklering. The EIDF room was enclosed with 2-hour fire-rated construction, but two (2) doors to this room were propped open, compromising the fire protection. The doors were propped open to avoid over-heating in the adjacent Information Data Files (IDF) Room where the cooling system was not operational during repairs to the refrigerant system. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1 (exception). This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 11:30 AM on February 8, 2010.

2. It was observed in the 1-North smoke compartment in the G1672A-Main Heating Pipe Chase within the Bed Storage Room that sprinkler pipes were located in a area subject to freezing without installation as an anti-freeze or dry-pipe system.The vents located in the double doors to this chase where blocked by display boards and prevented heat from entering the un-heated space with an outside surface. This observed situation was not compliant with NFPA 13 (1999 edition), 5-14.3.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 11:00 AM on February 8, 2010.

3. It was observed in the 1-North smoke compartment in the G1600-Lobby that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. Above the ceiling is a concealed space and contained 4 feet of a 1 by 4 inch pine board. All concealed spaces containing combustibles must be encapsulated or sprinkled or removed, per NFPA 13 (1999 edition), 5-13.1.4. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4 and 7.2.1.6.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 10:40 AM on February 8, 2010.

4. It was observed in the 1-North smoke compartment in the G1612-Sterile Processing Room that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. Above the ceiling is a concealed space and contained plastic sheeting. All concealed spaces containing combustibles must be encapsulated or sprinkled or removed, per NFPA 13 (1999 edition), 5-13.1.4. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4 and 7.2.1.6.1. This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 3:15 PM on February 9, 2010.

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Based on observation and interview and a review of documents, the facility failed to maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. This deficiency occurred in 1 of the 2 smoke compartments, and would affect 12 of the inpatients including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1-West smoke compartment in the G1542-Nursery Equipment Room that there was one or more unsealed holes near the ceiling. The hole(s) included a missing ceiling tile due to repairs of the variable air volume unit 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 edition), 1-11.1 . This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 3:00 PM on February 8, 2010.

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Based upon observation the facility failed to provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code. This deficiency occurred in 2 of the 2 smoke compartments, and would affect 14 inpatients (based on average daily census) including babies in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1-West smoke compartment in the G1549-Staff Lounge that an electrical outlet located adjacent to a sink was not provided with a ground fault interrupter device. The duplex outlet was approximately 3 feet from the sink. This observed situation was not compliant with NFPA 70 (1999 edition). This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:05 PM on February 8, 2010.

2. It was observed in the 1-North smoke compartment in the G1525-Circumsicion that an electrical outlet located adjacent to a sink was not provided with a ground fault interrupter device. This observed situation was not compliant with NFPA 70 (1999 edition). This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 1:22 PM on February 9, 2010.

3. It was observed in the 1-North smoke compartment in the G1681-On-Call Lounge that an electrical outlet located adjacent to a sink was not provided with a ground fault interrupter device. Surveyor 18107 observed a duplex electrical outlet approximately 2'-0" from the sink/lavatory. Plugged into this outlet was a microwave and toaster. This observed situation was not compliant with NFPA 70 (1999 edition). This deficiency was observed and verified by Surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 11:15 AM on February 8, 2010.

4. It was observed in the 1-North smoke compartment in the G1641-Labor and Deliver Equipment Room that temporary construction lighting was not operational and was left in the area. All abandoned utilities are required to be removed. This temporary electrical wire and lighting was above the ceiling. This observed situation was not compliant with NFPA 70 (1999 edition). This deficiency was observed and verified by surveyor 18107, Staff E (Plant Operations & Facilities Manager), Staff F (Maintenance Mechanic) and Staff G (Maintenance Mechanic) at 2:56 PM on February 9, 2010.

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