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Based on observation during the survey walk-through not all doors in exit access corridors are installed to resist the passage of fire and smoke. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

On 12/01/15 at 12:52pm while in the company of DCC, the surveyor observed the 2nd floor patient room 226 corridor door lacked a strike plate mounted in the door frame to permit secure latching to comply with 19.3.6.3.2.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level tranferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

A. On 12/01/15 at 11:40am while in the company of DCC, the surveyor observed at the 3rd floor Morgue Cooler room that a floor penetration created by the removal of old equipment was not sealed to prevent the passage of heat and smoke through the floor to comply with 19.3.1.1 and 8.2.5.

B. On 12/01/15 at 11:45am while in the company of DCC, the surveyor observed at the 3rd floor east equipment room east of the Classroom that a steam pipe penetrated the floor through a sleeve which was not sealed to prevent the passage of heat and smoke to comply with 19.3.1.1 and 8.2.5.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level tranferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

On 12/01/15 at 12:45pm while in the company of DCC, the surveyor observed that the 2nd floor building separation/vertical opening separation fire rated doors located near the ED Addition elevator did not close to a latched condition to comply with 18.3.1.1, 8.2.3.2.1 and 8.2.5.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level transferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

On 12/01/15 at 4:30pm while in the company of DCC & LSS, it was observed that the basement level under the adjacent tenant space which is accessed from the Illini Xpress Clinic was not separated from the crawl space of the first floor Illini Xpress Clinic tenant space and the first floor Illini Xpress Clinic tenant space to comply with 38.3.1.1 and 8.2.5. The basement area is utilized for incidental storage and gas fired furnace/water heater equipment and lacks minimum 1-hour separation from the first floor Illini Xpress Clinic tenant space both at the wall of the crawl space (where piping, etc. extends) and at the stair wall/door which separates the basement from the first floor. These conditions do not comply with 38.3.1.2, 8.2.5.4 and 8.2.5.7. (See K029 also)

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

A. On 12/01/15 at 11:35am while in the company of DCC, the surveyor observed that the fire resistance labeled door accessing the 3rd floor west attic mechanical equipment space was observed not to be self-closing to a latched condition to comply with 8.2.3.2.1.

B. On 12/01/15 at 11:50am while in the company of DCC, the surveyor observed that the sprinklered 3rd floor east attic Storage rooms (the Education storage room and the mechanical/storage room surrounding the classroom) were not provided with (3) doors which are self-closing to comply with 19.3.2.1 and 8.4.1.2.

C. On 12/01/15 at 12:50pm while in the company of DCC, the surveyor observed that the 2nd floor west Clean Utility room 3/4-hour rated door was not self-closing to a latched condition to comply with 19.3.2.1 and 8.2.3.2.1.

D. On 12/01/15 at 3:30pm while in the company of DCC & LSS, the surveyor observed that the sprinklered Ground floor Lab identified on the life safety reference plans as a hazardous area was not provided with separation from the corridor to comply with 19.3.2.1, 8.4.1.1, and 19.3.6. The by-passing pass-thru transaction window is provided with a fire shutter at the corridor wall which is activated only by fusible link which does not provide closure resistant to the passage of smoke. The transaction window room is provided with smoke detection but is not provided with a door in the frame to separate it from the Lab proper to permit the reception window room to otherwise comply with 19.3.6.1 Exception No. 1.

E. On 12/01/15 at 3:50pm while in the company of DCC & LSS, the surveyor observed that the Ground floor Medical Air Manifold room door near Stair 4 was not self-closing to comply with 19.3.2.1 and NFPA 99-1999, 4-3.1.1.2(a)2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

On 12/01/15 at 1:45pm while in the company of the DCC & LSS, the surveyor observed that the 1st floor Storage room east of the Casteel Center lacked a strike plate mounted in the door frame to permit secure latching to comply with 18.3.2.1 and 18.3.6.3.2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

On 12/01/15 at 4:15pm while in the company of DCC & LSS, the surveyor observed that the fuel fired furnace & water heater units located in the basement which is accessed from the Illini Xpress Clinic tenant space and the furnace unit above the finished ceiling of the Illini Xpress Clinic tenant space breakroom were not protected to comply with 38.3.2.1 and 8.4.1.1. The spaces are neither sprinklered or separated by 1-hour rated construction. (See K020 also)

At least two Exits are not identified for all portions of the building. Failure to provide access to two separate means of egress can compromise the safety of all occupants of the areas in the event of a fire emergency where the only exit is blocked.

Findings include:

At 3:15pm on 12/1/15 while in the company of DCC & LSS the surveyor observed that the 2-hour separated 1st floor Boiler/Laundry/Maintenance area identified only a single means of egress which does not comply with 40.2.4.1.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating as required. These deficiencies could affect any patients in the facility that must utilize the exit, as well as any staff and visitors present by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

On 12/01/15 at 3:00pm while in the company of DCC & LSS, the surveyor observed that Stair 8 was not enclosed to comply with 19.3.1.1 and 8.2.5.2 as evidenced by the following:

1. The 1st floor level door did not close to a latched condition to comply with 8.2.3.2.1.

2. The life safety reference plans did not indicate a fire rated separation at the Ground floor. The door from the Ground floor IS Server room was not fire resistance labeled and the wall at the Medical Records room had an unprotected opening accessing the underside of the stair. The underside of the stair was not otherwise confirmed to provide a rated separation.

Exit stairways are not constructed as required. Failure to provide properly constructed and maintained stairways can prevent occupants from safely reaching the the public way or area of refuge.

Findings include:

On 12/01/15 at 2:50pm while in the company of DCC & LSS, the surveyor observed that the exterior areaway stair at the discharge of Stair 8 was not provided with at least one handrail to comply with 19.2.2.3 and 7.2.2.4.2 Exception No. 3.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

On 12/01/15 at 4:20pm, while in the company of DCC & LSS, the surveyor observed that the rear exterior exit door from the tenant space was provided with a mortised thumb latch and a dead bolt lock. A second dead bolt lock was also provided but had the strike removed to make it non-functional. The thumb latch and dead bolt lock constitute two separate operations to release the door when engaged which does not comply with 7.2.1.5.4.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On 12/01/15 at 3:52pm while in the company of DCC & LSS, the surveyor observed that the lighting provided at the Stair 4 discharge and the access to the public way was a single HID type lamp not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 19.2.8, 7.8.1.2, 7.8.1.3, and 7.8.1.4. This lighting was not verified to be on the life safety branch of the emergency power system to comply with 7.9.

Based on observation and staff interview during the survey walk-through, fire alarm systems are not installed as required. This deficiency could affect any patients, staff, or visitors in the building because the lack of a fire alarm system can delay awareness and response to fire emergencies.

On 12/01/15 at 4:30pm while in the company of DCC & LSS, the surveyor observed and was informed by staff that this 3-story building is not provided with a fire alarm system to comply with 38.3.4.1(1) and 9.6. Only single station smoke alarms are provided at select locations within the tenant space.

Based on observation during the survey walk, while accompanied by facility staff, the sprinkler installation does not comply. Failure to install and maintain the sprinkler system could result in failure or delayed response of the sprinkler system to control a fire event, which could affect patients, staff and visitors.
Findings include:
On 12/01/15 at 1:55pm while in the company of DCC & LSS, the surveyor observed that the newly constructed walls of the Renal Dialysis office located east of the Surgery suite on the 1st floor level placed the wall closer than 4" to the existing sprinkler head and not in compliance with NFPA 13-1999, 5-6.3.3.

Based on observation during the survey walk-through, while accompanied by facility staff, the sprinkler installation does not comply. Failure to install and maintain the sprinkler system could result in failure or delayed response of the sprinkler system to control a fire event, which could affect patients, staff and visitors.
Findings include:
A. On 12/01/15 at 3:45pm while in the company of DCC & LSS, the surveyor observed that the Ground floor Radiology suite north duct room is provided with sprinkler protection but is not separated from the adjacent non-sprinklered above-ceiling space of the remainder of the suite to comply with NFPA 13-1999. This lack of containment of the room will delay the activation of the sprinkler protection. This room also contained a smoke detector which was not securely mounted in accordance with NFPA 72-1999, 2-3.4.3.1. Activation of the smoke detector is also compromised by the lack of separation from the above-ceiling space.

B. On 12/01/15 at 2:00pm while in the company of DCC & LSS, the surveyor observed that the 1st floor north air handler room is provided with sprinkler protection but is not separated from the adjacent non-sprinklered above-ceiling space of the remainder of the suite to comply with NFPA 13-1999. This lack of containment of the room will delay the activation of the sprinkler protection.

Ventilation systems are not maintained in accordance with applicable standards. Failure to maintain the integrity of protective features within the ventilation system can result in building occupant's exposure to harmful fire and smoke conditions.

Findings include:

On 12/01/15 at 11:15am in the company of the DCC & LSS, the surveyor observed from document review of the most current (11/25/15) 6 year fire/smoke damper inspection and maintenance record that not all dampers are accessible to comply with NFPA 90A-1999, 3-4.7.

Electrical wiring and equipment is not installed according to Code. Failure to install and maintain the electrical system could result in failure of the system to operate when needed.

Findings include:

A. On 12/01/15 at 1:30pm while in the company of DCC & LSS, the surveyor observed that the 1st floor Casteel Center Exam rooms #1, #2, #4 and the nurse station had receptacles closer than 6' to the sinks which were not GFCI protected to comply with NFPA 70-1999, 210-8(b).

B. On 12/01/15 at 1:55pm while in the company of DCC & LSS, the surveyor observed that receptacle coverplates were missing at the newly installed receptacles for the 1st floor future Renal Dialysis office east of the Surgery suite to comply with NFPA 70-1999, 370-25.

Based on observation during the survey walk-through not all doors in exit access corridors are installed to resist the passage of fire and smoke. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

On 12/01/15 at 12:52pm while in the company of DCC, the surveyor observed the 2nd floor patient room 226 corridor door lacked a strike plate mounted in the door frame to permit secure latching to comply with 19.3.6.3.2.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level tranferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

A. On 12/01/15 at 11:40am while in the company of DCC, the surveyor observed at the 3rd floor Morgue Cooler room that a floor penetration created by the removal of old equipment was not sealed to prevent the passage of heat and smoke through the floor to comply with 19.3.1.1 and 8.2.5.

B. On 12/01/15 at 11:45am while in the company of DCC, the surveyor observed at the 3rd floor east equipment room east of the Classroom that a steam pipe penetrated the floor through a sleeve which was not sealed to prevent the passage of heat and smoke to comply with 19.3.1.1 and 8.2.5.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level tranferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

On 12/01/15 at 12:45pm while in the company of DCC, the surveyor observed that the 2nd floor building separation/vertical opening separation fire rated doors located near the ED Addition elevator did not close to a latched condition to comply with 18.3.1.1, 8.2.3.2.1 and 8.2.5.

Based on observation during the survey walk-through, vertical openings between floors are not protected. These deficiencies could result in the effects of fire and smoke on one floor level transferring to another floor level and compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

On 12/01/15 at 4:30pm while in the company of DCC & LSS, it was observed that the basement level under the adjacent tenant space which is accessed from the Illini Xpress Clinic was not separated from the crawl space of the first floor Illini Xpress Clinic tenant space and the first floor Illini Xpress Clinic tenant space to comply with 38.3.1.1 and 8.2.5. The basement area is utilized for incidental storage and gas fired furnace/water heater equipment and lacks minimum 1-hour separation from the first floor Illini Xpress Clinic tenant space both at the wall of the crawl space (where piping, etc. extends) and at the stair wall/door which separates the basement from the first floor. These conditions do not comply with 38.3.1.2, 8.2.5.4 and 8.2.5.7. (See K029 also)

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

A. On 12/01/15 at 11:35am while in the company of DCC, the surveyor observed that the fire resistance labeled door accessing the 3rd floor west attic mechanical equipment space was observed not to be self-closing to a latched condition to comply with 8.2.3.2.1.

B. On 12/01/15 at 11:50am while in the company of DCC, the surveyor observed that the sprinklered 3rd floor east attic Storage rooms (the Education storage room and the mechanical/storage room surrounding the classroom) were not provided with (3) doors which are self-closing to comply with 19.3.2.1 and 8.4.1.2.

C. On 12/01/15 at 12:50pm while in the company of DCC, the surveyor observed that the 2nd floor west Clean Utility room 3/4-hour rated door was not self-closing to a latched condition to comply with 19.3.2.1 and 8.2.3.2.1.

D. On 12/01/15 at 3:30pm while in the company of DCC & LSS, the surveyor observed that the sprinklered Ground floor Lab identified on the life safety reference plans as a hazardous area was not provided with separation from the corridor to comply with 19.3.2.1, 8.4.1.1, and 19.3.6. The by-passing pass-thru transaction window is provided with a fire shutter at the corridor wall which is activated only by fusible link which does not provide closure resistant to the passage of smoke. The transaction window room is provided with smoke detection but is not provided with a door in the frame to separate it from the Lab proper to permit the reception window room to otherwise comply with 19.3.6.1 Exception No. 1.

E. On 12/01/15 at 3:50pm while in the company of DCC & LSS, the surveyor observed that the Ground floor Medical Air Manifold room door near Stair 4 was not self-closing to comply with 19.3.2.1 and NFPA 99-1999, 4-3.1.1.2(a)2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

On 12/01/15 at 1:45pm while in the company of the DCC & LSS, the surveyor observed that the 1st floor Storage room east of the Casteel Center lacked a strike plate mounted in the door frame to permit secure latching to comply with 18.3.2.1 and 18.3.6.3.2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's means of egress.

Findings include:

On 12/01/15 at 4:15pm while in the company of DCC & LSS, the surveyor observed that the fuel fired furnace & water heater units located in the basement which is accessed from the Illini Xpress Clinic tenant space and the furnace unit above the finished ceiling of the Illini Xpress Clinic tenant space breakroom were not protected to comply with 38.3.2.1 and 8.4.1.1. The spaces are neither sprinklered or separated by 1-hour rated construction. (See K020 also)

At least two Exits are not identified for all portions of the building. Failure to provide access to two separate means of egress can compromise the safety of all occupants of the areas in the event of a fire emergency where the only exit is blocked.

Findings include:

At 3:15pm on 12/1/15 while in the company of DCC & LSS the surveyor observed that the 2-hour separated 1st floor Boiler/Laundry/Maintenance area identified only a single means of egress which does not comply with 40.2.4.1.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating as required. These deficiencies could affect any patients in the facility that must utilize the exit, as well as any staff and visitors present by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

On 12/01/15 at 3:00pm while in the company of DCC & LSS, the surveyor observed that Stair 8 was not enclosed to comply with 19.3.1.1 and 8.2.5.2 as evidenced by the following:

1. The 1st floor level door did not close to a latched condition to comply with 8.2.3.2.1.

2. The life safety reference plans did not indicate a fire rated separation at the Ground floor. The door from the Ground floor IS Server room was not fire resistance labeled and the wall at the Medical Records room had an unprotected opening accessing the underside of the stair. The underside of the stair was not otherwise confirmed to provide a rated separation.

Exit stairways are not constructed as required. Failure to provide properly constructed and maintained stairways can prevent occupants from safely reaching the the public way or area of refuge.

Findings include:

On 12/01/15 at 2:50pm while in the company of DCC & LSS, the surveyor observed that the exterior areaway stair at the discharge of Stair 8 was not provided with at least one handrail to comply with 19.2.2.3 and 7.2.2.4.2 Exception No. 3.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

On 12/01/15 at 4:20pm, while in the company of DCC & LSS, the surveyor observed that the rear exterior exit door from the tenant space was provided with a mortised thumb latch and a dead bolt lock. A second dead bolt lock was also provided but had the strike removed to make it non-functional. The thumb latch and dead bolt lock constitute two separate operations to release the door when engaged which does not comply with 7.2.1.5.4.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On 12/01/15 at 3:52pm while in the company of DCC & LSS, the surveyor observed that the lighting provided at the Stair 4 discharge and the access to the public way was a single HID type lamp not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 19.2.8, 7.8.1.2, 7.8.1.3, and 7.8.1.4. This lighting was not verified to be on the life safety branch of the emergency power system to comply with 7.9.

Based on observation and staff interview during the survey walk-through, fire alarm systems are not installed as required. This deficiency could affect any patients, staff, or visitors in the building because the lack of a fire alarm system can delay awareness and response to fire emergencies.

On 12/01/15 at 4:30pm while in the company of DCC & LSS, the surveyor observed and was informed by staff that this 3-story building is not provided with a fire alarm system to comply with 38.3.4.1(1) and 9.6. Only single station smoke alarms are provided at select locations within the tenant space.

Based on observation during the survey walk, while accompanied by facility staff, the sprinkler installation does not comply. Failure to install and maintain the sprinkler system could result in failure or delayed response of the sprinkler system to control a fire event, which could affect patients, staff and visitors.
Findings include:
On 12/01/15 at 1:55pm while in the company of DCC & LSS, the surveyor observed that the newly constructed walls of the Renal Dialysis office located east of the Surgery suite on the 1st floor level placed the wall closer than 4" to the existing sprinkler head and not in compliance with NFPA 13-1999, 5-6.3.3.

Based on observation during the survey walk-through, while accompanied by facility staff, the sprinkler installation does not comply. Failure to install and maintain the sprinkler system could result in failure or delayed response of the sprinkler system to control a fire event, which could affect patients, staff and visitors.
Findings include:
A. On 12/01/15 at 3:45pm while in the company of DCC & LSS, the surveyor observed that the Ground floor Radiology suite north duct room is provided with sprinkler protection but is not separated from the adjacent non-sprinklered above-ceiling space of the remainder of the suite to comply with NFPA 13-1999. This lack of containment of the room will delay the activation of the sprinkler protection. This room also contained a smoke detector which was not securely mounted in accordance with NFPA 72-1999, 2-3.4.3.1. Activation of the smoke detector is also compromised by the lack of separation from the above-ceiling space.

B. On 12/01/15 at 2:00pm while in the company of DCC & LSS, the surveyor observed that the 1st floor north air handler room is provided with sprinkler protection but is not separated from the adjacent non-sprinklered above-ceiling space of the remainder of the suite to comply with NFPA 13-1999. This lack of containment of the room will delay the activation of the sprinkler protection.

Ventilation systems are not maintained in accordance with applicable standards. Failure to maintain the integrity of protective features within the ventilation system can result in building occupant's exposure to harmful fire and smoke conditions.

Findings include:

On 12/01/15 at 11:15am in the company of the DCC & LSS, the surveyor observed from document review of the most current (11/25/15) 6 year fire/smoke damper inspection and maintenance record that not all dampers are accessible to comply with NFPA 90A-1999, 3-4.7.

Based on observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

Electrical wiring and equipment is not installed according to Code. Failure to install and maintain the electrical system could result in failure of the system to operate when needed.

Findings include:

A. On 12/01/15 at 1:30pm while in the company of DCC & LSS, the surveyor observed that the 1st floor Casteel Center Exam rooms #1, #2, #4 and the nurse station had receptacles closer than 6' to the sinks which were not GFCI protected to comply with NFPA 70-1999, 210-8(b).

B. On 12/01/15 at 1:55pm while in the company of DCC & LSS, the surveyor observed that receptacle coverplates were missing at the newly installed receptacles for the 1st floor future Renal Dialysis office east of the Surgery suite to comply with NFPA 70-1999, 370-25.