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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 4 of the 5 smoke compartments, and had the potential to affect 14 inpatients, 15 outpatients, and an unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 3:05 pm, observation revealed on the 1st floor in the Bariatric Inpatient Rooms 301, 310, 201 & 220, that fire proofing was missing from beam clamps that were attached to the structural steel beams. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2.

2. On 02/25/2013 at 11:40 am, observation revealed on the 1st floor in the Inpatient Gymnasium Room, that fire proofing was missing from multiple beam clamps that were attached to the structural steel beams. A new patient lift system was installed after final construction review on 08/22/2008. Surveyor #18107 was not aware of this installation and associated construction completion for compliance to Federal and State codes. Plans, specifications and calculation documentation could not be produced at time of survey exit on February 27, 2013 to validate its acceptance by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2.

3. On 02/25/2013 at 2:40 pm, observation revealed on the 1st floor in the Main Clean Linen & Utility, that fire proofing was missing from a beam clamp that was attached to the structural steel beam. The clamp was from a HVAC duct hanger. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2.

4. On 02/25/2013 at 4:16 pm, observation revealed on the Lower Level floor in the AHU Room #2, that fire proofing was missing from a beam clamp that was attached to the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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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 with sealed wall penetrations. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 20 inpatients and a unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 02/25/2013 at 1:55 pm, observation revealed on the 1st floor of smoke compartment SC-2, in the Electrical Room, that a penetration was not sealed. The deficiency included a 3/4 inch diameter pipe penetration. The corridor wall was required to resist the passage of smoke because the corridor ceiling did not qualify to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 20 inpatients, 3 outpatients, and a unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 12:02 pm, observation revealed on the 1st floor of smoke compartment CS-1, in the Dishwashing Room within Kitchen Suite, that a vertical rolling type shutter was installed that would not positively self-latch. There was a metal tray rack blocking it from closing and latching to the frame. This condition would not resist the passage of smoke. The Dining Room was considered open to the adjoining corridors. The wall this vertical rolling shutter was in was smoke-tight according to the Life Safety Plans. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2.

2. On 02/25/2013 at 11:58 am, observation revealed on the 1st floor of smoke compartment CS-1, in the Inpatient Gymnasium Room, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers, but the combination of devices prevented the doors from fully and automatically closing and latching. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2.

3. On 02/25/2013 at 4:30 pm, observation revealed on the Lower Level floor of smoke compartment SC-4, in the Rehabilitation Pool Room, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers, but the combination of devices prevented the doors from fully and automatically closing and latching. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, doors with positive-latching hardware, and taped joints on rated walls. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 20 inpatients, 5 outpatients and a unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 5:16 pm, observation revealed on the Lower Level floor of smoke compartment CS-5, in the Information Technology (IT) Room, that the door would not self-close because it was missing a door closer. This room was considered hazardous due to all the combustibles from plastics, cardboard boxes, wiring stored in this room as well as two walls covered with plywood panels of at least 5/8 inches thick that did not meet the limited combustibility requirements per (2000 ed.) NFPA 101, section 3.3.118. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.

2. On 02/25/2013 at 9:20 am, observation revealed on the Lower Level floorof smoke compartment CS-5, in the Loading Dock Room, that the door would not positively self-latch when released because the door was observed held open by a cart and cardboard boxes. Observed no one working in area at time door was wedged open. Observed many boxes in corridor against wall. In interview with staff A, at 9:30 AM, this is the only location supplies can be placed since the loading dock room is too small and supplies exceed the size of the loading dock room. Observed 9 boxes on floor in corridor outside loading dock room at 9:20 AM. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.3.2.

3. On 02/25/2013 at 11:51 am, observation revealed on the 1st floor of smoke compartment CS-1, in the Clean Utility Room within the Gymnasium Suite, that the enclosing wall was not constructed to a 1-hour fire resistance rating as required at time of occupancy because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for fire rated walls. Observed 6 screws not doubled mudded. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 02/25/2013 at 11:53 am, observation revealed on the 1st floor of smoke compartment CS-1, in the Soiled Utility Room within the Gymnasium Suite, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for fire rated walls. Observed 2 screws not doubled mudded. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide egress paths at all times with compliant egress path, no obstructions in the path of egress, and doors that were unlockable in the egress path. This deficiency occurred in 3 of the 5 smoke compartments, and had the potential to affect 30 inpatients, 10 outpatients and a unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 2:50 pm, observation revealed on the 1st floor of smoke compartment SC-3, in the Activities of Daily Living Bedroom, that the egress path was not compliant. The door between the ADL Bedroom and the ADL Living Room is not 41.5 inches in clear width. Per NFPA 101, section 18.2.3.5 the minimum clear width for doors in the means of egress from treatment areas, such as physical therapy, which this is a form of, requires hospitals to have 41.5 inches in clear width. Exception No. 1 does not apply. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5, 18.2.7 and 7.7.

2. On 02/25/2013 at 2:20 pm, observation revealed on the 1st floor of smoke compartment CS-2, in the Patient Room 209, that the exit path was not readily accessible because a cart used to hold infection control materials projected into the egress path coming out of the inpatient sleeping room and projected out into the corridor greater than 7 inches. Both of these conditions were in violation of exit egress minimum width (41.5" door opening clearance per section 18.3.7.5) through a inpatient door opening, and into the corridor (8'-0" minimum corridor width clearance per section 18.2.3.3). This observed situation was not compliant with NFPA 101 (2000 ed.), sections 7.5.1.1 & 18.2.3.3.

3. On 02/25/2013 at 1:44 pm, observation revealed on the 1st floor of smoke compartment CS-1, in the Kitchen Room, that the door was locked from the egress side. The door between the production kitchen area and Servery had a dead-bolt on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.2.2.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This included egress lighting fed by emergency power and adequate egress lighting. This deficiency occurred outside at 3 of the 5 smoke compartments, and had the potential to affect 30 inpatients and outpatients, and a unknown number of staff and visitors.


FINDINGS INCLUDE:

1. On 02/25/2013 at 2:25 pm, observation at the exterior of the building at the West Exit Discharge, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This same condition was present at the other exit discharges after reviewing this exit discharge situation. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

2. On 02/25/2013 at 5:08 pm, observation revealed on the Lower Level floor in the Emergency Electrical Power Room, that the path of egress to the public way was not illuminated to at least 1 foot-candle. One of the two light bulbs on emergency power were burnt out. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.4 Required Illumination & 7.9.2.5 Emergency Lighting System.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on interview and record review, the facility did not maintain a written evacuation plan that contained all the elements with an evacuation plan with all required elements. This deficiency could affect all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients and all staff and visitors within these smoke compartments.

FINDINGS INCLUDED:

On 02/26/2013 at 2:45 pm, records observation revealed that during a review of documents, it was discovered that the facility written fire safety plan did not address all of the elements required by the 2000 edition of the Life Safety Code. Missing were items; (1) complete documentation of information on the transmission of alarm to the local fire department (from Central Station in Minneapolis, to the local Police Department, to the local Fire Department), and (2) staff required response to fire alarms in the facility. These observed situations were not compliant with NFPA 101 (2000 ed.), section 18.7.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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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 the required quantity of drills, fire drills that fully test the staff's ability to respond to fire emergencies, and fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/26/2013 at 2:30 pm, observation revealed that during a review of facility documents the fire drill reports showed that fire drills were not conducted quarterly on every shift. Missing fire drill for third shift in the 3rd Quarter of year 2012. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 02/26/2013 at 2:35 pm, observation revealed that the facility fire drill record for the past 12 months revealed that fire drills were not conducted at varied locations. More than two drills were conducted in the same location on the same shift. Three of the 12 fire drills were tested in the Harbor Hallway, three of the 12 fire drills were tested in the Northwood's Hallway, and three of the 12 fire drills were tested in the Dining Room. This is not enough variable locations to meet the code intent. They should be occurring over the building at different locations in all five smoke compartments. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

3. On 02/26/2013 at 2:40 pm, observation revealed that the facility fire drill record 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. All of the drill times in the 1st shift are occurring between 1:25 pm and 2:20 pm; all 2nd shift drill times are occurring between 4:05 pm and 5:10 pm and 3rd shift drill times are occurring between 11:35 am and 12;25 pm with only one time out side the normal range. These times should be varied with at least 2-hour spread between the past shift time so the staff cannot anticipate when they will occur and you truly test the staff in all varying conditions. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 and with smoke detectors at required locations, complete inspection documentation, complete smoke detector sensitivity test records. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in a new 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 healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in 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 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 compliant fire alarm. This deficiency had the potential to affect all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 2:13 pm, observation revealed on the 1st floor of smoke compartment CS-1, in the South Corridor, that the smoke detector was not located in accordance with NFPA 72 requirements. Observed both sides of the cross corridor wall depth exceeded 24 inches, therefore requiring smoke detectors on both sides of the smoke barrier in the corridor. Both sides of cross corridor wall were measured to the ceiling from the door header and found to be in excess of 24 inches from the bottom of the smoke barrier door header to the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), section 2-2 & section 2-10.6.5.1.2.

2. On 02/25/2013 at 2:30 pm, observation revealed on the 1st floor of smoke compartment CS-2, in the Brain Injury Unit at Far West Wing, that the fire alarm installation was not compliant. The Brain Injury Unit installed smoke detection throughout the spaces of this area located in a portion of the SC-2. During the walk-thru it was observed by surveyor #18107 that some of the smoke detectors were installed greater than 33'-0" on center. Per NFPA 72 (1999 edition), section 2-3.4.5.1.1 spot type detectors on smooth ceilings are allowed up to 30'-0" on-center. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), sections 1-5.2.5.2 & 2-3.4.5.1.

3. On 02/26/2013 at 10:45 am, observation revealed that during a review of documents it was discovered that the quarterly visual inspections and performance tests of the fire alarm system were not conducted as required by the code. The 3 In-house (quarterly) Reports of 2012 (4/25, 9/17 & 12/19) and one Cintas Co. (quarterly) Report of (1/22/2013) were missing language of visually inspecting the Control Valve Tamper devices per (1999 ed.) NFPA 72, section 7-3.1. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

4. On 02/26/2013 at 11:00 am, observation revealed that during a review of documents it was discovered that records of smoke detector sensitivity tests did not contain all the required information. The Annual 2012 & 2013 Fire Alarm Testing Reports by Cintas Company were missing the full display of the manufacturer (detector) acceptable range and the tested current reading per the (1999 ed.) NFPA 72, section 7-5.2.2. Cintas Company stated in a conference call about this time, they were completing all detector testing within the two years, and the Report was missing some of the readings for all the detectors. The dates of the Annual Fire Alarm Reports were 1/22/2013 & 9/11/2012. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations).
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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 sprinkler coverage throughout the building. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 10 inpatients and a unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 02/25/2013 at 2:47 pm, observation revealed on the 1st floor of smoke compartment CS-3, in the Activities of Daily Living Washer & Dryer Closet, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation, interview and a review of documents, 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 complete annual inspection, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint, all required sprinkler system inspections, and verification of all quarterly tests. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/26/2013 at 10:15 am, observation revealed that during a review of documents it was discovered that an annual sprinkler inspection did not include all the necessary information. The Annual Sprinkler Inspection Report was completed by Tom Barlow of Cintas Company, N56 W13605 Silver Spring Drive, Menomonee Falls, WI 53051 on July 11, 2012. The annual report was missing the following: need to review the hydraulic nameplate per section 2-2.7, identify the 'type and number' of different sprinkler head (spares) within the facility per sections 2-2.1.3 & 2-4.1, and visually check for damage and check for loose sprinkler hangers per section 2-2.3. This observed situation was not compliant with NFPA 25 (998 ed.), section 2-2, and Table 2-1 Summary.

2. On 02/25/2013 at 11:21 am, observation revealed on the 1st floor in the Main Lobby off corridor, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 02/25/2013 at 11:33 am, observation revealed on the 1st floor in the Electrical Closet next to Employee Entrance, that there was one unsealed hole near the ceiling. The hole included a 1 inch hole in a shared corridor wall near 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.

4. On 02/25/2013 at 2:49 pm, observation revealed on the 1st floor in the Activities of Daily Living Washer & Dryer Closet, that there was one unsealed hole near the ceiling. The hole included a 4 inch diameter exhaust duct from the dryer that penetrated the ceiling and was not sealed around the exhaust duct to the ceiling to stop the spread of smoke. This hole would reduce the response time of the future 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.

5. On 02/25/2013 at 1:35 pm, observation revealed on the 1st floor in the Kitchen Cooler, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

6. On 02/26/2013 at 9:50 am, observation revealed that during a review of facility documents the monthly wet sprinkler inspections were not performed as required by the code. The In-house Monthly Sprinkler System Inspection Report(s), as reviewed and documented by staff A & staff B, were missing identification that the gauges, control valves and backflow were being reviewed for normal position, accessibility, no leaks, and valve position per (1998 ed.) NFPA 25, sections 2-2.4.1. & 9-6.1.1 with Monthly Exception. The same for Table 2-1: Summary of Sprinkler System Inspection, Testing, and Maintenance. These observed situations were not compliant with NFPA 25 (1998 ed.), section 2-2, and Table 2-1 Summary.

7. On 02/26/2013 at 10:00 am, observation revealed that during a review of documents it was discovered that a quarterly sprinkler inspection was not conducted correctly. All four (Quarterly) visual inspections were missing language to check the Fire Department 'gasket connections' and verify the ID sign was present. The four (Quarterly) tests were missing language to review the Main Drain per (1998 ed.) NFPA 25, section 9-1. Per interview with staff A during the review of the documents, these quarterly main drain tests were done at separate times to the visual quarterly's. This observed situation was not compliant with NFPA 25 (998 ed.), 2-2. and Table 2-1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation, interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 15 inpatients and an unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDED:

On 02/26/2013 at 1:05 pm, observation revealed that during a review of facility maintenance documents and subsequence inspection of three (3) randum fire/smoke dampers, it was discovered that all required observation and maintenance procedures were not performed. A small sample of duct inspections by surveyor #18107, revealed that the electrical outlet box attached to the fire/smoke damper (FS-11) above the ceiling in the Case Manager's Office, was not closed. The last Annual (Fire/Smoke) Duct Inspection on September 11, 2012 should have noticed this condition. Need to re-check all fire/smoke dampers to identify any deficiencies. The Life Safety Code, section 9.2.1 permits ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). CMS directs their inspectors to use NFPA 90A as the guideline that should be followed in all facilities. Thus, the Life Safety Code supersedes NFPA 90A (1999 ed.) 1-3.3, which notes that the Code is not normally intended to be applied retroactively. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96, to have the range hood cleaned semi-annually. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients and an unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/26/2013 at 11:45 am, observation revealed that during a review of documents it was discovered that the range hood and ducts were not inspected semi-annually, and cleaned if grease contamination is found, as required for systems serving moderate-volume cooking operations. Cleaning records indicated nothing what was cleaned in the semi-annual report. Only a invoice for 9/6/2012 was available from; Hood Cleaning, Inc., PO Box 180014, Delafield, WI 53018. This documentation did not meet the requirements of (1998 ed.) NFPA 96, section 8-3.1. This observed situation was not compliant with NFPA 101 (2000 ed.), 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 (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide and implement a policy on the use of portable space heating devices with space heaters that comply with code requirements. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/26/2013 at 4:07 pm, observation revealed that the facility did not have a policy that prohibited the use of space heaters in patient areas and permitted them only in non-sleeping areas when elements do not exceed 212 degrees Fahrenheit. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the appropriate codes for weekly inspections of the emergency generator. This deficiency could affect all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/26/2013 at 1:30 pm, observation revealed that during a review of facility documents on weekly visual inspections of the generator, the checks of all fluids and general conditions were not recorded, as recommended by the manufacturer or Figure A-6.3.1 of NFPA 110. The weekly generator inspection consisted of; fuel level, float switches, hoses, lube oil heater operation, water pump, water pump hoses, exhaust system and the general housekeeping around the generator. The following was missing in the weekly generator inspection report; Lube Oil Level, Coolant level, and Radiator Cleanliness. The batteries are automatically replaced every two years. This observed situation was not compliant with NFPA 110 (1999 ed.), 6-4.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation and interview, the facility did not provide a Type I essential electrical system that was divided with electrical branches in accordance with the Codes inforce at the time of design and contruction for a hospital with a compliant Type 1, emergency electrical system. This deficiency had the potential to affect all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/26/2013 at 1:45 pm, observation revealed that the ATS transfer is not showing the exact time of power transfer. The monthly reports only note less than 10 seconds, questioning the reliability of this notation. There is always a variance of time over the life of the Automatic Transfer System (ATS). This ATS System was installed in 2008 and has been in constant operation for about 5 years. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-4.2.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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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 working clearances at electrical panels, electrical panels with complete directories, and emergency electrical outlets labeled back to emergency panels. This deficiency occurred in 3 of the 5 smoke compartments, and had the potential to affect 30 inpatients, 15 outpatients, and about 61 staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 9:20 am, observation revealed on the Lower Level floor of smoke compartment SC-5, in the Loading Dock Room, that clearance in front of electrical equipment was less than 3'-0". Electrical panel on the East wall was blocked by a cart and boxes. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On 02/25/2013 at 1:59 pm, observation revealed on the 1st floor of smoke compartment SC-2, in the Electrical Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Electrical panel #RILSA, fire alarm breaker, was not uniquely identified per code requirement. Black peeling tape was placed over the fire alarm breaker. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

3. On 02/25/2013 at 5:04 pm, observation revealed on the Lower Level floor of smoke compartment SC-5, in the Main Electrical Power Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Several panels lists were incomplete. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

4. On 02/25/2013 at 5:12 pm, observation revealed on the Lower Level floor of smoke compartment SC-5, in the Loading Dock & Receiving Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. The electrical 'SNOW PANEL' was not identified correctly. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

5. On 02/25/2013 at 11:34 am, observation revealed on the 1st floor of the smoke compartment CS-1, in the Employees Entrance Hallway, that emergency electrical outlet(s) were not labeled to identify where the load was fed. Several emergency electrical outlets in the Employees Lounge and Entrance did not have the proper identification on the outlet plate, identifying back to the electrical panel were it was feed from. This observed situation was not compliant with NFPA 70 (1999 ed.), Critical Branch of the Emergency System meeting requirements of Article 517-33(a, b & c) Critical Branch & Article 700.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on interview and record review, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to sprinkler outages. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/26/2013 at 3:00 pm, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the Wisconsin Department of Health Services (WDHS). The policy only acknowledged contacting the local Fire Department. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.6.1 sprinkler system.

2. On 02/26/2013 at 3:31 pm, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy did not include staff dedicated to the fire watch for sprinkler outage. The policy did not identify the time limit for re-inspection of the effected area(s) during the course of the outage. The fire watch policy was missing a standard interval (example 30 minutes) rotating continuously until the fire watch was stopped. The fire watch was also missing the 'designated staff' shall cover all areas including opening up closets and spaces isolated to seeing and smelling of all elements within the building space. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.6.1 sprinkler system.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on interview and record review, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to fire alarm outages. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/26/2013 at 3:16 pm, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the fire alarm system of more than 4 hours in a 24 hour period. The facility policy did not include notification of the Wisconsin Department of Health Services (WDHS). The policy only acknowledged contacting the local Fire Department. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.8.

2. On 02/26/2013 at 3:31 pm, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the fire alarm system of more than 4 hours in a 24 hour period. The facility policy did not include staff dedicated to the fire watch for fire alarm outage. The policy did not identify the time limit for re-inspection of the effected area(s) during the course of the outage. The fire watch policy was missing a standard rotation (example 30 minutes) rotating continuously until the fire watch was stopped. The fire watch was also missing the 'designated staff' shall cover all areas including opening up closets and spaces isolated to seeing and smelling of all elements within the building space. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.8 fire alarm system.


This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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