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A. Based on random observation during the survey walk-through, not all portions of the building are fire resistive construction in accordance with 19.1.6.2. Non-sprinklered portions of the building was observed to be Type II (000) containing open web steel joists that are not covered by fire proofing materials to comply with a designated UL Design. Location observed:

1. 1977 addition elevator penthouse lacks fire proofing. This penthouse is open to the Fourth floor mechanical room and the Fourth floor exit access to the patient elevator. The Elevator penthouse is not separated from the Fourth floor Mechanical room by a 2-hour fire rated barrier to comply with 19.1.6 due to the following:

a. An open unprotected stairway connecting the two spaces. Therefore the construction type for the mechanical room along with the heliport elevator area is the same construction type as the penthouse which does not comply with 19.1.6 for a healthcare building





B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010


2. CORRECTED 02/10/2010

A. Based on random observation uses in corridors do not comply with the exceptions under 19.3.6.1 Exception #1(a). The surveyor observed patient care areas that are open to the exit access corridors. Example locations include:

1. 2002 addition Second floor Recovery, Day Surgery Prep and Stage I Recovery.

2. 1977 addition First floor, Radiology Department, numerous use spaces open to exit access corridors.

3. CORRECTED 02/10/2010


B. The Facility representative during staff interview was unable to verify that these areas constitute a suite to comply with 19.2.5.2. Other similar locations observed:

1. Pain Clinic, Physical Therapy, and Occupational therapy. These areas all contained habitable room locations which lacked an exit access door leading directly to an exit access corridor to comply with 19.2.5.1.

A. Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.
Doors in exit access corridors were observed that are not positive latching. Example locations include:

1. 1977 addition First floor Radiology Dept (not indicated as a suite) contains numerous doors which are not positive latching.


2. 1977 addition Ground floor Occupational Health (not indicated as a suite) contains several doors which are not positive latching due to defective hardware.


B. 1977 addition First floor, The inactive leaf at the pair of doors to the Endo procedure room was observed to be disengaged, thus making the pair of doors not positive latching to comply with 19.3.6.3.2. The inactive leaf contains manual flush bolts, this condition was observed on numerous other pairs of corridor doors.


C. Surveyor noted numerous locations, within patient care areas, of corridor doors containing separate thumbturn mechanisms in addition to the latching hardware. This condition does not comply with 7.2.1.5.4 for one releasing operation. Example locations observed:

1. 1977 addition First floor Endo procedure room.

2. 1977 addition First floor Lab West door leading to Elevator Lobby


D. Surveyor noted numerous locations throughout the facility where corridor doors were found wedged open which does not comply with 7.2.1.8.1 for doors required to be part of the smoke tight corridor wall separation. Example locations observed:

1. 1963 addition Corridor door to Dishwashing was wedged open with a bag of garbage.

2. CORRECTED 02/09/2010

3. CORRECTED 02/09/2010.

A. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010

a. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010


C. Pipe penetration through 2 hour fire floors were observed throughout the facility which are not sealed with a U.L. listed design assembly to protect against the passage of fire to comply with 8.2.3.2.4.1. Example locations observed:

1. CORRECTED 02/09/2010

2. 1957 addition First floor Generator room PVC pipe penetrates the 2-hour floor above.

3. 1977 addition Ground floor Boiler room PVC pipe penetrates the 2-hour floor above.

4. 1977 addition Second floor Pathology room PVC pipe penetrates the 2-hour floor above.

5. CORRECTED 02/10/2010

A. CORRECTED 02/10/2010

1. CORRECTED 02/09/2010

2. CORRECTED 02/09/2010

3. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010

2. CORRECTED 02/10/2010


3. CORRECTED 02/09/2010

4. CORRECTED 02/09/2010


C. Hazardous areas were observed at which doors do not comply with 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include :

1. CORRECTED 02/09/2010

2. Ground floor Generator room entry door is not a fire resistant door due to the lack of a U.L. listed label for fire resistant rating.

3. Ground floor Boiler room corridor wood door has a U.L. label however it is not a solid core door.


D. Materials were observed being stored in the mechanical room which does not comply with 19.3.2.1.
Location observed: 1977 addition Fourth floor.


E. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010

2. CORRECTED 02/10/2010

3. CORRECTED 02/10/2010

F. CORRECTED 02/09/2010

A. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010



B. CORRECTED 02/10/2010

1. CORRECTED 02/09/2010



C Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way to comply with Chapter 7 of NFPA 101. Locations observed:

1. Stair #4 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. Two elevators open into the exit passageway. The elevator doors are not smoke tight and do not maintain the protected enclosure of the exit passageway from the elevator shaft.

b. The passageway lacks a continuous protected path to an exit discharge in accordance with 7.7.1 or 7.7.2. This passageway appears incomplete and does not extend to the exterior of the building. Surveyor noted that the passageway terminates to another corridor which does discharges to the exterior. However, this corridor contains ductwork, piping and other systems which do not serve the corridor.

c. An unoccupied mechanical
room opens into the exit passageway which does not comply with 7.1.3.2.1 (d).

2. Stair #5 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. The passageway lacks a continuous protected path to an exit discharge in accordance with 7.7.1 or 7.7.2. Surveyor noted that the passageway contains ductwork, piping and other systems which do not serve the passageway.

b. Numerous unoccupied rooms deemed hazardous open into the exit passageway which does not comply with 7.1.3.2.1 (d). The hazardous rooms are as follows - Generator room, Paint room, Linen chute room.



D. CORRECTED 02/09/2010

1. CORRECTED 02/09/2010

A. Based on random observation during the survey walk through not all corridors have two remote exits to comply with 19.2.5.5. Surveyor observed a corridor leading from the heliport to the exit stair and elevator passed through a mechanical room being used for storage. Corridor access through a hazardous area does not provide a compliant exit access path.

Location observed: 1977 Fourth floor mechanical room

A. Based on random observation during the survey walk-through, not all suites are constructed or configured in accordance with 19.2.5.
Location observed: The Second Floor Recovery Area(s), Day Surgery Recovery/Prep area were observed to house holding bays that are not separated from the exit access corridor. The unit is not indicated on the facility's Life Safety Master Plans as constituting a suite. Numerous patient care areas are not directly connected to an exit access corridor, however the facility's Life Safety Floor Plans do not indicate these areas as constituting suites. Example locations refer to K-Tag 017 for habitable rooms not directly connected to exit access corridors.

1. The unit constitutes a suite which is in excess of the area permitted by 19.2.5.7.

OR

2. The holding bays are open to an exit access corridor which does not comply with 19.3.6.1.

A. The surveyor finds that a fire barrier is not installed to comply with 8.2.1 (1) for construction type separations. There is a pair of cross corridor doors at the separation which contain U L Labels indicating that they are 1 1/2 hour fire rated doors and close upon activation of the fire alarm system. The connection of the elevated walkway to the facility does not comply with NFPA 80A 1996 and NFPA 221 5.1.1 (fire separations between buildings). due to the following:
Location observed: 1954 addition Third floor, Elevated walkway to the parking garage

1. The walkway is not sprinkler protected and appears to be Type II (000) construction. The facility construction type is Type I (332) sprinkler protected. The facility Life Safety floor plans do not indicate a continuous 2-hour barrier in this location.

2. 1954 addition Third floor, elevated bridge walkway: There is no additional protection provided for unprotected window openings which are less than 10'-0" clear distance surrounding the walkway.

A. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey and was not accurate as a Life Safety Code Master Plan.

The plans provided with colored lines indicating life safety features:

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. Fire barriers are identified with a red line. What type of fire barriers is not clear. The fire ratings for these barriers are not identified. Some of the barriers are clearly combination fire/smoke barriers but they are not identified as such. Other barriers enclose, shafts, exits and/or hazardous areas; however, not enough information is provided to evaluate such locations for compliance.

3. Smoke barriers are not identified as such. The fire ratings for each smoke barrier are not identified.

4. The size and boundary of each smoke compartment is not identified on plan.

5. The provider has no information identifying the locations, size and boundaries of suites. Travel distances in suites could not be evaluated. All areas have been evaluated in this survey as if there are no suites and all areas have exit access corridors, until such time that accurate information is provided. The surveyors expect to find additional deficiencies (for corridors) if accurate information regarding suites is not provided.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A. Based on direct observation, the facility failed to provide automatic smoke detection at the fire alarm control panel. Locations include but not limited to the Laboratory Waiting Room.
(NFPA 72, 1999, 1-5.6)

B. By direct observation the surveyor finds numerous smoke detectors located within 3 feet of supply air diffusers. (NFPA 72, 1999, 2-3.5.1).




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C. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed to comply with 19.3.4. During a test of the facility fire alarm system the following was observed

1. CORRECTED 02/10/2010


2 Fire alarm strobes (where three or more devices are visible) are not synchronized in accordance with NFPA 72 and the Illinois Accessibility Code. This includes the Second and Third MedSurg Floors.

A. Based on direct observation, the facility failed to provide automatic sprinkler protection for elevator machine rooms. (NFPA 13, 1999, 5-13.6)

B. Based on document review and staff interview the surveyor finds the facility does not conduct a from the floor inspection of the installed sprinkler system annually. (NFPA 25, 1998, 2-2.1.1)

.












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C. Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.
Surveyor noted through out the facility that ceiling tile has been removed, which compromises sprinkler coverage and does not comply with NFPA 13 1999 5-6.4.1.1. Example locations observed:

1. 1913 building, Fourth floor, corridor near 1963 West addition.

2. 1913, 1939 buildings Fourth floor, Abandoned Surgery area, multiple ceiling tile have been removed.

3. 1963 addition First floor, Kitchen

4. 1954 addition, Second floor, Administration corridor contains exposed horizontal run of data conduit with multiple broken ceiling tiles allowing openings.

5. CORRECTED 02/09/2010

6. CORRECTED 02/09/2010

7. 1977 addition Ground floor Boiler room, contains multiple holes in the finished ceiling system compromising sprinkler coverage.


D. CORRECTED 02/10/2010

1. CORRECTED 02/09/2010

2. CORRECTED 02/10/2010


E. The facility is designated as fully sprinkler protected, however, protection is not provided in accordance with NFPA 13 in numerous areas throughout the facility. Example locations observed:

1. 1977 addition Ground floor, room used for paper shredding. Sprinkler coverage appears inadequate for the amount of stored boxes located within this space. Refer to K-Tag 029.

2. 2002 addition Third floor medsurg patient room # 353 and 352 lack sprinkler coverage for the exclusive use of the wardrobes.

3. CORRECTED 02/10/2010

4. CORRECTED 02/10/2010

5. CORRECTED 02/10/2010.

6. CORRECTED 02/10/2010

Based on direct observation and document review, the facility failed to provide:

A. A remote alarm annunciator for the fire pump at a point of constant attendance. (NFPA 20, 1999, 7-4.7)

B. Indication that the annual fire pump flow test was conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)

C. Indication that alarm conditions were simulated at the time of the annual fire pump test. (NFPA 25, 1998, 5-3.3.3)

A. By document review and staff interview, evidence was not provided for the 4 year inspection and maintenance of fire and smoke dampers. NFPA 90A, 1999, 3-4.7

A. Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3.
The finding includes: Carts, beds, and mobile equipment were observed within designated exit access corridors that obstruct egress and does not comply with 19.2.3.3. Locations observed

1. 2002 addition Second floor Surgery (not a designated suite).

2. 2002 addition First floor E.D. (not a designated suite).

3. 2002 addition Ground floor east/west corridor between Chiller room and Central Sterile areas along with the corridor leading to the receiving area.


B Based on random observation the surveyor noted chairs and an end table which were located such that the path of egress within a non designated suite was diminished below the minimum required width. Location observed:

1. 1977 addition, Ground floor Physical therapy and Cardiac Rehab

A. By direct observation and staff interview the oxygen zone valve for ICU is supplied from the zone valve for the adjacent medical surgical nursing unit as prohibited by NFPA 99, 1999, 4-3.1.2.3 (d)


B. By direct observation the surveyor finds the facility failed to provide an intervening wall between the zone valves and the outlets they serve at the following locations:
(NFPA 99, 1999, 4-3.1.2.3 (d)

1. Emergency room triage stations

2. Stage 2 recovery - "Day Surgery" Bays 1 - 6



C. CORRECTED 02/10/2010



D. CORRECTED 02/09/2010



E. CORRECTED 02/10/2010

Based on direct observation and staff interview, the facility failed to provide:

A. Remote alarm annunciator for three of three emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

B. Remote manual emergency stop stations for three of three emergency generators.
(NFPA 110, 1999, 3-5.5.6)


C. Three required branches of the essential electrical system (life safety, critical & equipment) for the 1913 building and additions, 1939, 1957 & 1963. (Staff indicated there is one transfer switch for the from the generator located on the first floor of the 1957 addition, with a connected load less than 150 kVA)


D. A separate 2 hour enclosure for the emergency generator located in the 1957 addition. (NFPA 5-2.1)


E. Fire sprinkler protection for the emergency generator enclosure located within the boiler room of the 1977 building.


F. CORRECTED 02/10/2010

A. By direct observation and staff interview it could not be determined the function and purpose of the fans installed in the ceilings of stairwell # 1 & # 2. These fans are activated by the fire alarm although dampers did not open allowing purpose to be demonstrated.
.


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B. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. By direct observation the surveyor finds all elevators are not provided with the required Firefighter's Service elevator recall.

A. Based on random observation uses in corridors do not comply with the exceptions under 19.3.6.1 Exception #1(a). The surveyor observed patient care areas that are open to the exit access corridors. Example locations include:

1. 2002 addition Second floor Recovery, Day Surgery Prep and Stage I Recovery.

2. 1977 addition First floor, Radiology Department, numerous use spaces open to exit access corridors.

3. CORRECTED 02/10/2010


B. The Facility representative during staff interview was unable to verify that these areas constitute a suite to comply with 19.2.5.2. Other similar locations observed:

1. Pain Clinic, Physical Therapy, and Occupational therapy. These areas all contained habitable room locations which lacked an exit access door leading directly to an exit access corridor to comply with 19.2.5.1.

A. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010

a. CORRECTED 02/10/2010


B. CORRECTED 02/10/2010

1. CORRECTED 02/10/2010


C. Pipe penetration through 2 hour fire floors were observed throughout the facility which are not sealed with a U.L. listed design assembly to protect against the passage of fire to comply with 8.2.3.2.4.1. Example locations observed:

1. CORRECTED 02/09/2010

2. 1957 addition First floor Generator room PVC pipe penetrates the 2-hour floor above.

3. 1977 addition Ground floor Boiler room PVC pipe penetrates the 2-hour floor above.

4. 1977 addition Second floor Pathology room PVC pipe penetrates the 2-hour floor above.

5. CORRECTED 02/10/2010

A. Based on random observation during the survey walk-through, not all suites are constructed or configured in accordance with 19.2.5.
Location observed: The Second Floor Recovery Area(s), Day Surgery Recovery/Prep area were observed to house holding bays that are not separated from the exit access corridor. The unit is not indicated on the facility's Life Safety Master Plans as constituting a suite. Numerous patient care areas are not directly connected to an exit access corridor, however the facility's Life Safety Floor Plans do not indicate these areas as constituting suites. Example locations refer to K-Tag 017 for habitable rooms not directly connected to exit access corridors.

1. The unit constitutes a suite which is in excess of the area permitted by 19.2.5.7.

OR

2. The holding bays are open to an exit access corridor which does not comply with 19.3.6.1.

A. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey and was not accurate as a Life Safety Code Master Plan.

The plans provided with colored lines indicating life safety features:

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. Fire barriers are identified with a red line. What type of fire barriers is not clear. The fire ratings for these barriers are not identified. Some of the barriers are clearly combination fire/smoke barriers but they are not identified as such. Other barriers enclose, shafts, exits and/or hazardous areas; however, not enough information is provided to evaluate such locations for compliance.

3. Smoke barriers are not identified as such. The fire ratings for each smoke barrier are not identified.

4. The size and boundary of each smoke compartment is not identified on plan.

5. The provider has no information identifying the locations, size and boundaries of suites. Travel distances in suites could not be evaluated. All areas have been evaluated in this survey as if there are no suites and all areas have exit access corridors, until such time that accurate information is provided. The surveyors expect to find additional deficiencies (for corridors) if accurate information regarding suites is not provided.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A. Based on direct observation, the facility failed to provide automatic smoke detection at the fire alarm control panel. Locations include but not limited to the Laboratory Waiting Room.
(NFPA 72, 1999, 1-5.6)

B. By direct observation the surveyor finds numerous smoke detectors located within 3 feet of supply air diffusers. (NFPA 72, 1999, 2-3.5.1).




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C. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed to comply with 19.3.4. During a test of the facility fire alarm system the following was observed

1. CORRECTED 02/10/2010


2 Fire alarm strobes (where three or more devices are visible) are not synchronized in accordance with NFPA 72 and the Illinois Accessibility Code. This includes the Second and Third MedSurg Floors.

Based on direct observation and document review, the facility failed to provide:

A. A remote alarm annunciator for the fire pump at a point of constant attendance. (NFPA 20, 1999, 7-4.7)

B. Indication that the annual fire pump flow test was conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)

C. Indication that alarm conditions were simulated at the time of the annual fire pump test. (NFPA 25, 1998, 5-3.3.3)

A. By document review and staff interview, evidence was not provided for the 4 year inspection and maintenance of fire and smoke dampers. NFPA 90A, 1999, 3-4.7

Based on direct observation and staff interview, the facility failed to provide:

A. Remote alarm annunciator for three of three emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

B. Remote manual emergency stop stations for three of three emergency generators.
(NFPA 110, 1999, 3-5.5.6)


C. Three required branches of the essential electrical system (life safety, critical & equipment) for the 1913 building and additions, 1939, 1957 & 1963. (Staff indicated there is one transfer switch for the from the generator located on the first floor of the 1957 addition, with a connected load less than 150 kVA)


D. A separate 2 hour enclosure for the emergency generator located in the 1957 addition. (NFPA 5-2.1)


E. Fire sprinkler protection for the emergency generator enclosure located within the boiler room of the 1977 building.


F. CORRECTED 02/10/2010

A. By direct observation the surveyor finds all elevators are not provided with the required Firefighter's Service elevator recall.