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Based on random observation during the survey walk-through, document review, and staff interview, smoke barriers are not provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients as required by 19.3.7.1.

Findings include:

A. The interstitial space above the occupied story of the building was observed to lack smoke barriers required by 19.3.7.1. and 8.3.2. Surveyor 14290 notes that:

1. Based on sketch floor plans for the building, it was determined that the maximum patient sleeping occupancy within the building exceeds 30. This determination was confirmed by the provider's Business/Support Services Administrator during an interview held in her office on the morning of March 16, 2004.

2. The drywall ceiling assemblies were observed to consist of drywall on metal hat channel/ceiling runner suspension systems and thus do not carry a minimum 1/2 hour fire resistance rating required by 19.3.7.3. and cannot be considered smoke barriers.

3. During an interview held in the Business/Support Services Administrator's Office on the morning of March 15, 2004, the provider's Chief Engineer stated that each pod constituted an approximate area slightly less than 22,500 square feet; refer to 19.3.7.1. It remains the provider's responsibility to determine the number of required smoke compartments.

NEW 07/28/06: Surveyor 14290 notes that, according to Department records, correspondence has occurred regarding potential solutions to the cited deficiencies. The Department does not currently have a record of drawings being submitted for a formal construction project for the correction of said deficiencies.

UPDATE 9/21/07: This tag will clear with the FSES conducted by the Illinois Department of Human Services on May 2005, once the deficiency indicated under K-036 have been corrected.

Based on random observation during the survey walk-through, not all travel distances within the building are in accordance with 7.6.

Findings include:

A. The common path of travel from remote points of the Mezzanine (walking surface within the interstitial space) was observed to be in excess of 150'-0" as prohibited by 7.12. Exception 2. Locations observed include:

1. Pod A.

2. The North (Rehab/Gymnasium) Wing.

3. Pod C.

NEW 07/28/06: Surveyor 14290 notes that, according to Department records, correspondence has occurred regarding potential solutions to the cited deficiencies. The Department does not currently have a record of drawings being submitted for a formal construction project for the correction of said deficiencies.

UPDATE 9/21/07: The egress paths for this building need to be corrected. Drawings of the proposed correction will need to be provided to this Department for review.

Based on document review, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, fire alarm audible/visual notification devices were observed to not be present in the building areas listed below, as required by [NFPA 72 1999 4-4.4.]. Locations observed include:

1. Corridor 105 (no device within 15'-0" of the south end of the Corridor).

2. Corridor 131 (no device within 15'-0" of the south end of the Corridor).

3. Multi-Purpose Room 157.

4. Multi-Purpose Room 158.

5. Corridor 130.

6. Break Room 129G.

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Based on document review, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, fire alarm audible/visual notification devices were observed to not be present in the building areas listed below, as required by [NFPA 72 1999 4-4.4.]. Locations observed include:

1. Mezzanine Access C.
2. Food Service Area C (device obstructed by boxes on cabinets).

3. Mechanical catwalk area.

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Based on document review, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Corrected 06/26/12.

.B. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, conduits were observed (above an access panel in Lobby 101) which were observed to be separated at an unknown type of linear connection point. The conduits were observed to be taped together and weighing down on conduits housing life safety conductors. The connections do not include raceways, cable armors, or cable sheaths between cabinets, boxes, fittings, or other enclosures as required by [NFPA 70 1999 300-12.

.

Based on document review, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Corrected 06/26/12.

B. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, each pod is supplied with a security subpanel, backed up by a point-of-use UPS at the Mezzanine area. These UPS's were observed to be bypassed as prohibited by [NFPA 70 1999 517-32] and/or beyond their usable service lives.

C. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, a 112.5 kVA transformer and panelboard were installed without an engineered design at the main intersection at the center of the Mezzanine.

1. There is no secondary overcurrent protection required by [NFPA 70 1999 240-3(f).

2. The panelboard on the secondary side of the transformer is not labeled with a current rating or AIC rating, and it appears to be much smaller than what is available from the transformer.

3. The tap conductors were observed to exceed the maximum 25 ft. allowed by [NFPA 70 1999 240-21].

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Based on random observation during the survey walk-through, document review, and staff interview, smoke barriers are not provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients as required by 19.3.7.1.

Findings include:

A. The interstitial space above the occupied story of the building was observed to lack smoke barriers required by 19.3.7.1. and 8.3.2. Surveyor 14290 notes that:

1. Based on sketch floor plans for the building, it was determined that the maximum patient sleeping occupancy within the building exceeds 30. This determination was confirmed by the provider's Business/Support Services Administrator during an interview held in her office on the morning of March 16, 2004.

2. The drywall ceiling assemblies were observed to consist of drywall on metal hat channel/ceiling runner suspension systems and thus do not carry a minimum 1/2 hour fire resistance rating required by 19.3.7.3. and cannot be considered smoke barriers.

3. During an interview held in the Business/Support Services Administrator's Office on the morning of March 15, 2004, the provider's Chief Engineer stated that each pod constituted an approximate area slightly less than 22,500 square feet; refer to 19.3.7.1. It remains the provider's responsibility to determine the number of required smoke compartments.

NEW 07/28/06: Surveyor 14290 notes that, according to Department records, correspondence has occurred regarding potential solutions to the cited deficiencies. The Department does not currently have a record of drawings being submitted for a formal construction project for the correction of said deficiencies.

UPDATE 9/21/07: This tag will clear with the FSES conducted by the Illinois Department of Human Services on May 2005, once the deficiency indicated under K-036 have been corrected.

Based on random observation during the survey walk-through, not all travel distances within the building are in accordance with 7.6.

Findings include:

A. The common path of travel from remote points of the Mezzanine (walking surface within the interstitial space) was observed to be in excess of 150'-0" as prohibited by 7.12. Exception 2. Locations observed include:

1. Pod A.

2. The North (Rehab/Gymnasium) Wing.

3. Pod C.

NEW 07/28/06: Surveyor 14290 notes that, according to Department records, correspondence has occurred regarding potential solutions to the cited deficiencies. The Department does not currently have a record of drawings being submitted for a formal construction project for the correction of said deficiencies.

UPDATE 9/21/07: The egress paths for this building need to be corrected. Drawings of the proposed correction will need to be provided to this Department for review.

Based on document review, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, fire alarm audible/visual notification devices were observed to not be present in the building areas listed below, as required by [NFPA 72 1999 4-4.4.]. Locations observed include:

1. Corridor 105 (no device within 15'-0" of the south end of the Corridor).

2. Corridor 131 (no device within 15'-0" of the south end of the Corridor).

3. Multi-Purpose Room 157.

4. Multi-Purpose Room 158.

5. Corridor 130.

6. Break Room 129G.

.

Based on document review, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Corrected 06/26/12.

.B. NEW ITEM: Based on a Deficiencies List prepared by the provider's Consultant, dated August 3, 2010, conduits were observed (above an access panel in Lobby 101) which were observed to be separated at an unknown type of linear connection point. The conduits were observed to be taped together and weighing down on conduits housing life safety conductors. The connections do not include raceways, cable armors, or cable sheaths between cabinets, boxes, fittings, or other enclosures as required by [NFPA 70 1999 300-12.

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