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Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Fire Alarm System is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the fire alarm system was inoperable.

Findings include:

A. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, in accordance with NFPA 101, 2012 Edition, Section 9.6.1.6.

Examples of missing Key Directives:

1. Facility shall provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuate effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6.

2. The Illinois Department of Public Health, Springfield, (the AHJ) shall be notified.

3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104 which includes the following:

(1) The personnel conducting the fire watch have no other duties.
(2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(3) Identification of Staff performing the Fire Watch
(4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Fire Alarm System is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the fire alarm system was inoperable.

Findings include:

A. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, of the shutdown until the fire alarm system has been returned to service in accordance with NFPA 101, 2012 Edition, Section 9.6.1.8.

Examples of missing Key Directives:

1. Facility shall provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuate effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6.

2. The Illinois Department of Public Health, Springfield shall be notified.

3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104 which includes the following:

(1) The personnel conducting the fire watch have no other duties.
(2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(3) Identification of Staff performing the Fire Watch
(4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on document review the facility failed to maintain the sprinkler system. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the sprinkler system failed to operate during a fire emergency due to a lack of required maintenance.

Findings include:

A. On 08/25/25 at 1:15 PM, during review of the Sprinkler System Inspection Reports with E-1 and E-2, it was revealed that the facility failed to provide three (3) of the four (4) required quarterly sprinkler inspections within the past twelve (12) months in accordance with NFPA 25; 2011 Edition, Section 5.1.1.2 and Table 5.1.1.2.

Examples of missing inspections include:

1. 1st Quarter 2025
2. 4th Quarter 2024

B. On 08/25/25 at 1:15 PM, Document review with E-1 revealed the facility failed to provide records, for monthly inspections of the wet sprinkler pressure gauges in accordance with NFPA 25, 2011 Edition Section 5.2.4.1, Section 5.1.1.2 and Table 5.1.1.2.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Sprinkler System is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the sprinkler system was inoperable.

Findings include:

A. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, of the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6).

Examples of missing Key Directives:

1. Impairment Coordinator is established in accordance with NFPA 25, 2011 Edition Section 15.2.1

2. Impairment tags are posted at each fire department connection and control valves in accordance with NFPA 25, 2011 Edition Section 15.3.2

3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(4):

(1) Evacuation of the building or portion of the building affected by the service outage
(2) An approved Fire Watch

4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, and shall include the following:

(1) The personnel conducting the fire watch has no other duties
(2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(3) Identification of Staff performing the Fire Watch
(4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff.

5. When the sprinkler is out of service the facility shall notify the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(6):

(1) The insurance carrier
(2) The alarm company
(3) IDPH Regional Office
(4) All other authorities having jurisdiction

6. Restoring System to Service the following are provided:

(1) Supervisors are notified
(2) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified
(3) Impairment tags removed.

These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Sprinkler System is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the sprinkler system was inoperable.

Findings include:

A. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 08/25/25 at 12:55 PM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, of the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6).

Examples of missing Key Directives:

1. Impairment Coordinator is established in accordance with NFPA 25, 2011 Edition Section 15.2.1

2. Impairment tags are posted at each fire department connection and control valves in accordance with NFPA 25, 2011 Edition Section 15.3.2

3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(4):

(1) Evacuation of the building or portion of the building affected by the service outage
(2) An approved Fire Watch

4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, and shall include the following:

(1) The personnel conducting the fire watch has no other duties
(2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(3) Identification of Staff performing the Fire Watch
(4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff.

5. When the sprinkler is out of service the facility shall notify the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(6):

(1) The insurance carrier
(2) The alarm company
(3) IDPH Regional Office
(4) All other authorities having jurisdiction

6. Restoring System to Service the following are provided:

(1) Supervisors are notified
(2) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified
(3) Impairment tags removed.

These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on an observation, it was revealed that the facility failed to provide properly constructed smoke barrier walls to meet at least 30 minutes fire resistance rating. This deficiency to the smoke barrier could affect all patients in the building 0103 - Room 1013 - IT Closet, as well as an indeterminable number of staff and visitors, if smoke or fire was allowed to pass from one smoke compartment to another.

Findings include:

On 08/26/25 at 1:29 PM, while accompanied by E-1, an observation revealed that the building 0103 - Room 1013 - IT Closet Smoke Barrier Wall is deficient above the lay-in ceiling, as visible from the IT Closet side of the barrier. There was one (1) three-quarter inch (3/4-inch) plastic pipe penetrating the wall with one (1) wire running through it. The pipe was not fire-stopped with a system listed by Underwriters laboratory (UL) or any other recognized testing agency. There was one (1) three-inch hole in the wall with a bundle of network cables running through it. The opening was not fire-stopped with a system listed by Underwriters laboratory (UL) or any other recognized testing agency. These were not in accordance with NFPA 101; 2012 Edition, Sections 8.3.2; 8.3.6.1 and 19.3.7.3.


This finding was reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on document review it was revealed that the facility failed to conduct fire drills as required. Fire drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice could affect all patients, in all Smoke Zones, as well as an indeterminable number of staff and visitors if they do not know how to evacuate the building or smoke zone in a fire emergency due to the lack of training
Findings include:

On 08/25/25 at 2:43 PM, during review of the facility's Fire Drills it was revealed that the facility had no documentation that the Fire Alarm monitoring company was contacted after all the required fire drills to ensure a signal was sent. This did not meet the requirements of LSC; Section 19.7.1.4.

1. 07/30/25 - Day Shift
2. 06/30/25 - Night Shift
3. 05/30/25 - Evening Shift

This finding was reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on a document review and an interview, the facility failed to provide required documentation for the generators' operation. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the generators failed to operate as required due to the lack of routine maintenance.

Findings include:

A. On 08/25/25 at 3:23 PM, during review of the Generator Log and Maintenance Schedule and an interview with E-1, it was revealed that the facility failed to document and log the required transfer time of the load transfer to the Generator Sets, on the monthly Generator Exercise Logs and was not per NFPA 99, 2012 Edition, Section 6.5.3.1.

B. On 08/25/25 at 3:23 PM, during review of the Generator Log and Maintenance Schedule it was revealed that the facility failed to document and log the required 5-minute cool down time of the load transfer from the Generator Sets during the monthly Generator Exercise Logs and was not per NFPA 110, 2010 Edition, Section 8.4.5.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.

Based on observations the facility failed to install electrical wiring to ensure the safety of the staff and patients. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the electrical wiring started a fire from overloading electrical circuits or electrical shock occurred due to the failure.

Findings include:

A. On 08/26/25 at between 12:27 PM and 1:16 PM, while accompanied by E-1, observations revealed that offices throughout the facility were using surge-protected power strips, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strips were lying on the floor where they could pose tripping hazards and were not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CMS S & C Memo 14-46-LSC.

Examples of offices with surge-protected power strips include:

1. Building 0103 - Office 1016
2. Building 0103 - Office 1052
3. Building 0103 - Office 1037

B. On 08/26/25 at 12:55 PM, while accompanied by E-1, observation revealed that the Building 0103 - Room 1010 was using a surge-protected power strip and an extension cord to operate electronic equipment. Flexible cables (extensions cords) shall not be as a substitute for the fixed wiring of a structure in accordance with the NFPA 70; 2011 Edition, Section 400.8 and the CMS 100-7 State Operations Providers Certification.

C. On 08/26/25 at 12:56 PM, while accompanied by E-1, an observation revealed that the Building 0103 - Room 1052, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment including a refrigerator and a coffee maker and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CMS S & C Memo 14-46-LSC.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.