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Based upon observation during the survey walk-through, not all building components are protected to afford the required fire rating. Failure to provide protection can result in premature failure of the building components during a fire condition.

The finding is:

On 9/28/2016 at 11:30am while in the company of the DF exposed expanded polystyrene (EPS) was observed along the length of the 2-hour barrier between the 1981 building and the Medical Office Building (MOB). This barrier does not comply with the requirements of 19.1.2.3 as being constructed of materials that conform to a 2-hour fire resistant rating.

Example locations observed, above the finished ceiling on the second and third floors at the corridor leading to the MOB.

Based upon observation during the survey walk-through, not all building components are protected to maintain the building's construction type. Failure to provide protection can result in premature failure of the building components during a fire condition.

The findings are:

A. On 9/28/2016 at 11:30am while accompanied by the DF exposed expanded polystyrene (EPS) was observed along the full length of an exterior wall. This wall installation does not comply with 19.1.6.2 as being constructed of materials that conform to the requirements for a noncombustible healthcare building.

Example locations observed, second and third floor means of egress corridor, above the finished ceiling at the east exterior wall. Based on example locations, the surveyor believes that the same condition exists on the remainder of the building's envelope.

B. On 9/28/2016 at 3:10 pm while accompanied by the DF an unprotected metal floor deck was observed which does not comply with a type I (332) building per 19.1.6 and NFPA 220.

Location observed basement level mechanical room #0020 (per small scale life safety drawings).

Based on observation during the survey walk through, it was determined that the facility failed to maintain the closure of means of egress doors. This deficient practice could affect patient, staff and visitors if a fire were to occur in this smoke zone and improper door latching allowed smoke from patient rooms or support areas to fill the exit access corridor.

Findings include:

A. On 09/28/16 at 11:25 AM, while in the company of the OR supervisor, the surveyor observed the corridor door to the OR - Scrub Room 231A, Second Floor is being equipped with a plunger-type throw bolt at the floor level. This does not comply with 19.3.6.3.3.

B. On 09/29/16 at 9:30 AM, while in the company of the DF, and POSE, the surveyors observed the corridor double doors to the Kitchen Room LL18. One of the doors is equipped with a surface mounted throw bolt. This does not comply with 7.2.1.5.4.


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C. On 9/28/2016 while accompanied by the DF doors was observed which lack proper egress hardware to comply with 19.2.2.2.4.

Example locations include:

1. 2:00 pm First floor Outpatient Pharmacy the door which opens to the room titled Pharmacy (as shown on the Life Safety floor plan) lacks a thumbturn on the egress side.

2. 2:10 pm First floor Cath Lab contains a hook and eye door lock on the egress side.

Based on observation the facility failed to provide properly operating doors within the means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising a person's access to an exit.

Findings include:

A. On 9/28/2016 at 12:00pm while accompanied by the DF patient room doors was observed which lacked proper egress hardware to comply with 19.2.2.2.4.
Example location observed:

1. Third floor Behavioral bathroom door of patient room # 333 lacks any type of mechanism to unlock and release the door from the egress side if it is locked from the room side. This condition is to be investigated in the remaining patient rooms.

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

A. On 9/28/2016 at 1:30 PM while accompanied by the DF an access panel was observed within the third floor Activity room closet. The panel installation does not comply with 19.3.1 and 8.2.5.2 for a complete 2-hour fire rated shaft wall due to the following:

1. The access panel is not labeled as to its fire resistance rating.

2. The framed-in opening is incomplete allowing the cavity of the 2-hour wall to be exposed. This condition does not comply as a continuous enclosure for a shaft wall.

Based on direct observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

The finding is:

On 09/28/16 at 2:20 PM, while in the company of the DAS, the Furnace Room was observed to lack a self-closing door to comply with 39.3.2.1 and 8.4.

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 exit access corridors.

Findings include:

A. On 9/28/2016 at 2:40pm in the basement, while accompanied by the DF a pair of doors were observed to lack a label indicating the fire resistance rating of the installation to comply with 19.3.2.1. Location observed: entry doors to Fire Pump room

B. On 9/28/2016 at 2:45pm in the basement, while accompanied by the DF a large junction box (approximately 18"x 18") was observed without a cover to comply with 19.3.2.1 for separation requirements. Location observed: Fire Pump room.

C. On 9/28/2016 at 2:20 pm in the basement, while accompanied by the DF the entry door to the main switch gear room (across from room 067C) was observed to lack a label indicating the fire resistance rating to comply with 19.3.2.1.

D. On 9/28/2016 at 3:10 pm in the basement, while accompanied by the DF the perimeter wall cavity (in two locations) of a hazardous room is open to adjacent areas. This condition does not comply with the fire resistance rating of the room and separation requirements from adjacent areas.
Location observed: Data Center Main Distribution Room/Closet.

Based on observation, 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 exit access corridors.

Findings include:

A. On 9/29/2016 at 9:20am while accompanied by the DF and POSE perimeter walls were observed which were not smoke tight. The observed condition is of a servery freezer unit that is not separated from the kitchen due to a large continuous wall opening surrounding the unit. This does not comply with 19.3.2.1 for a smoke tight wall enclosure.

B. On 9/28/2016 at 9:50 am while accompanied by the DF on the Third floor Behavioral unit a egress door was observed to lack a self closing mechanism. Location observed: Clean Linen storage room.

C. On 9/29/2016 at 2:10am while accompanied by the DF on the third floor behavioral unit an electrical closet located across from room # 332 lacks a fire resistant separation from other floors and a smoke tight separation from the surrounding spaces due to open junction boxes and open conduits.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

A. 9/27/2016 at 2:30pm, 5th floor Exit Stair "B", while accompanied by the DF and POSE utilities which do not serve the stair were observed to penetrate the designated 2-hour fire rated stair enclosure. This does not comply with 19.3.2 and 7.1.3.2.1 (e). The noncompliant utilities observed were low voltage wiring and two exhaust pipes.

B. 9/27/2016 at 3:15pm 6th floor Exit Stair "A" while accompanied by the DF and POSE utilities which do not serve the stair were observed to penetrate the designated 2-hour fire rated stair enclosure. This does not comply with 19.3.2 and 7.1.3.2.1 (e). The noncompliant utilities observed were what appeared to be steam or hot water pipes.

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.

The finding is:

On 9/28/2016 at 9:35am while while accompanied by DF, third floor behavioral unit patient rooms were observed which were provided with keyed-one side locks with thumbturn on bathroom side. However a number of units lacked the thumbturn on the bathroom egress side of the door which can prevent exiting. The locks do not comply with NFPA 101-2000, 7.2.1.5.1 because they require a key to operate from the egress side when locked.

Based on observation the facility failed to provide exit discharge locations with adequate illumination. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

The finding is:

On 9/29/2016 at 9: 45am while accompanied by the DF an exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness to comply with 19.2.8.
Location observed: exterior exit from basement level dining room.

Based on observation during the survey walk-through and staff interview, the testing and maintenance of the battery-powered emergency lighting is not conducted on a regular basis. This deficiency could affect all patients within the areas of the facility, as well as any staff and visitors present, from readily identifying the exit path, when the required emergency lighting equipment fails.

Findings include:

On 09/28/16 at 2:15 PM, while accompanied by the DAS, the surveyor observed battery-powered emergency lights at the corridor. Based on document review the lights were not periodically tested, based on the last testing date of 01/15. This does not comply with 7.9.3 and NFPA 99-1999, 3-3.2.1.2.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 09/28/16 at 2:20 PM, while accompanied by the DAS, exit sign were observed located in the back corridor. These signs incorrectly direct occupants into the adjacent tenant space. This does not comply with 39.2.10 and 7.10.

B. On 09/28/16 at 2:20 PM, while in the company of the DAS, exit signs were observed in the corridor that were not illuminated to comply with 7.10.5.
.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

On 9/29/2016 at 9:10am in the basement, while accompanied by the DF and POSE exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. Stair "A" corridor entry lacks signage with directional arrow.
2. Corridor adjacent to Oncology, the Oncology sign blocks part of an existing exit sign.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. Exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. Basement level corridor # 0119 (room numbers per the facility's life safety floor plan) as viewed from Dining # 0312 which leads to Stair # 0102 and vestibule # 0101.

2. First floor level corridor containing ramp to shell space lacks directional signage as viewed toward the main entry vestibule.

3. First floor level corridor adjacent to Lab, lacks exit signage for both directions, as viewed from leaving the Lab waiting room.

4. Second floor level G. I. corridor east end

Based on document review and staff interview the location of smoke barriers is not known. This deficiency could result in a delayed evacuation from the smoke compartment of fire origin to an area of refuge during a fire emergency. This condition could affect patients, staff and visitors.

Findings include:

On 9/27/2016 during review of the facility's floor plan, and discussion with the DF it was determined that the location of the closest smoke barrier is not known due to the following:

A. The facility consultant responsible for the layout of the life safety floor plans wrote a note attached to the floor plans which read "Note for wall rating legend, There are no smoke barriers in this facility. This legend is a typical for all facilities in Illinois not all wall types apply". However this condition is not compliant due to the following:

1. Sixth floor, fifth floor and third floor all contain patient sleeping beds. Due to the number of beds on each floor the facility is in noncompliance with 19.3.7.1. The life safety drawings indicate fire resistant barriers on these floors, however, there is no indication that the walls, wall openings, the doors within the barriers operate and comply with 19.3.7.6 for a required smoke barrier.

2. The written facility "Fire Plan and Evacuation Procedures" refers to item 1 "all employees must be well oriented in regards to the various building exits, locations of area smoke barriers and locations of fire extinguishers". This does not coincide with information provided on the life safety floor plans used by staff. The plans do not indicate the location of any smoke barriers. Therefore, the staff do not appear familiar with the use of and purpose of a smoke barrier and smoke compartment locations which does not comply with 19.3.7.1, 19.3.7.3 and 19.7.2.2 (6).

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

On 09/27/16, at 2:00 PM, while in the company of the DF, and POSE, the surveyor observed a smoke detector installed too close to the supply air / exhaust diffusers. This does not comply with NFPA 72 1999 2-3.5.1.
Location observed: 6th Floor Med/Surg Unit behind the Nurse Station.

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

Findings include:

A. At 9:00am on 9/28/16 while in the company of POSE fire sprinkler protection was removed from the Penthouse elevator equipment machine room which does not comply with NFPA 13, 1999 5-1.1.

B. At 2:15pm on 9/28/16 while in the company of the DF complete sprinkler coverage of the loading dock when the overhead doors are in the open position was not provided to comply with NFPA 13, 1999, 5-5.5.3.1.

C. At 2:20pm on 9/28/16 while in the company of the DF sprinklers are not provided in the medical gas cylinder store room located adjacent to the Loading Dock.

D. At 3:00pm on 9/28/16 while in the company of the DF and POSE the freight elevator hydraulic machine room located in basement mechanical room 0008A.

E. At 9:30am on 9/29/16 while in the company of the DF and POSE the Sterile Processing Department clean and soiled elevator hydraulic machine room.


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F. On 09/28/16 at 11:15 AM, it was observed, while in the company of the OR supervisor, the Electrical Closet located in the Sub-Sterile Room.


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G. On 9/28/2016 at 2:45 pm while accompanied by the DF Stair "A" basement level

H. On 9/28/2016 at 2:35 pm while accompanied by the DF Freight elevator machine room basement level

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

Findings include:

A. At 3:00pm on 9/28/16 while in the company of the DF and POSE the freight elevator hydraulic machine room located in lower level mechanical room 0008A.

B. At 1:10pm on 9/28 while in the company of the DF the hydraulic machine room for the dietary and the construction elevators.


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C. At 1:15pm the second floor the electrical closet located between the Day Surgery waiting room and the exit stair.

D. At 2:10pm the third floor electrical closet located across from room # 332.

Based on direct observation the surveyor finds the facility failed to provide adequate maintenance of the sprinkler system. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

The finding is:

On 9/28/2016 at 2:30pm by direct observation while accompanied by the DF and POSE there is no stock of spare sprinkler heads to comply with NFPA 13, 1999, 3-2.9.

Based on direct observation the surveyor finds that the facility failed to provide a complete kitchen hood system. This deficient practice creates a high risk of fire and allows the spread of flames should a fire under the hood occur.

The findings are:

A. On 9/29/2016 at 10:30 am while accompanied by the DF and POSE the kitchen hood installation was observed to lack a metal container for grease collection from the kitchen hood's grease tray. This condition could allow for the grease collected by the grease filter to remain in the tray creating a high risk of fire should flames develop from the cooking procedures. This condition does not comply with NFPA 96, 1998, 3-2.6
Location observed: basement level kitchen

This deficient practice could allow for the grease collected by the grease filter to remain in the tray creating a high risk of fire should flames develop from the cooking procedures

B. On 9/29/2016 at 10:30 am while accompanied by the DF and POSE the kitchen hood installation was observed to lack a complete closure of the grease filters within the kitchen hood system. This condition does not allow for the capture of grease before entering the exhaust duct system which does not comply with NFPA 96, 1998, 3-2.6.
Location observed: basement level kitchen

Based on direct observation the facility failed to provide adequate protection from a chute installation. This deficient practice could allow fire within the chute or chute collection room to spread to adjacent spaces.

The finding is:

On 9/29/2016 at 9:25am while accompanied by the DF and POSE the linen chute door was observed to lack a fusible link which would allow the door to close upon a fire incident. The current condition does not comply with NFPA 82, 1999, 3-2.2.9.
Location observed: chute room located adjacent to the Loading Dock

Based on 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. This deficient practice may compromise the prompt care and movement of patients during a fire/smoke emergency.

On 9/28/2016 at 11:10am while accompanied by the POSE, a means of egress corridor was observed containing multiple boxes and equipment located adjacent to a pair of cross corridor doors. The material blocks part of the egress path which does not comply with 19.2.3.3.
Location observed: Surgery Department, semi restricted corridor

Based on direct observation the facility failed to provide ventilation to the outside for the medical gas manifolds and cylinder store room. This deficient practice could allow for a medical gas enriched atmosphere at a higher level and provide a fire.
The finding is:
On 9/28/2016 at 1:30pm while accompanied by the DF and POSE the surveyor observed that no ventilation is provided to the outside for the medical gas manifolds and cylinder store room. This condition does not comply with NFPA 99, 1999, 4-3.1.1.2 (b)4.

Based upon observations 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 code deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures (ILSM) 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 ILSM to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk through, the facility failed to provide emergency power that is properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

The finding is:

On 9/27/16 at 2:30 pm, while accompanied by the POSE, the surveyor observed that critical panel CP-BR in the boiler room was serving a fire alarm panel and equipment that should be served from the life safety branch and equipment branch of emergency power. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-32 through 517-34.

Based on observation during the survey walk-through, the facility failed to provide adequate space adjacent to electrical equipment. This deficient practice could affect patients in the facility, as well as any staff and visitors present, because the listed portion of the building electrical system is being compromised.

Findings include:

On 09/28/16, at 2:25 PM, while accompanied by the DAS, the electrical closet was observed to be obstructed with housekeeping supplies and cardboard boxes. The required minimum 3'-0" clear working space in front of the panel is not provided to comply with NFPA 70 1999 110-26(a).

Based on observation during the survey walk-through, the facility failed to provide portions of the building with a code compliant electrical system. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On 09/28/16 at 11:05, while in the company of the OR supervisor, the surveyor observed the Electrical Panels in the corridor of the OR Unit, Example panels CP-OR-S-1 and CP-OR-S-1, were either missing schedules or the directory panel schedules are not updated and or not properly labeled, to comply with NFPA-70, Section 110-22.


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B. On 9/27/16 at 1:00 pm, while accompanied by the POSE, the surveyor observed that the elevators 3 & 4 were not equipped with a lighting disconnects served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

C. On 9/28/16 at 11:15 am, while accompanied by the POSE, the surveyor observed that the operating rooms were using power strips that were not in compliance with the 1999 Edition of NFPA-99, Section 7-5.1.2.5.

D. On 9/28/16 at 11:20 am, while accompanied by the POSE, the surveyor observed that the panel schedules for the operating room isolation panels needed to be updated to comply with the 1999 Edition of NFPA-70, Section 384-13.

E. On 9/28/16 at 1:30 pm, while accompanied by the DF and POSE, the surveyor observed that the cath lab was not equipped with any battery lighting to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection in the elevator machine room. This deficient practice could cause an electrical hazard and or trap elevator passengers should water be applied to the elevator machinery.

Findings include:

On 9/29/2016 at 9:10am by direct observation while accompanied by the DF and POSE the machine room for elevator # 6 is provided with sprinkler fire protection but did not show evidence of electrical shunt trip.

Based upon observation during the survey walk-through, not all building components are protected to afford the required fire rating. Failure to provide protection can result in premature failure of the building components during a fire condition.

The finding is:

On 9/28/2016 at 11:30am while in the company of the DF exposed expanded polystyrene (EPS) was observed along the length of the 2-hour barrier between the 1981 building and the Medical Office Building (MOB). This barrier does not comply with the requirements of 19.1.2.3 as being constructed of materials that conform to a 2-hour fire resistant rating.

Example locations observed, above the finished ceiling on the second and third floors at the corridor leading to the MOB.

Based upon observation during the survey walk-through, not all building components are protected to maintain the building's construction type. Failure to provide protection can result in premature failure of the building components during a fire condition.

The findings are:

A. On 9/28/2016 at 11:30am while accompanied by the DF exposed expanded polystyrene (EPS) was observed along the full length of an exterior wall. This wall installation does not comply with 19.1.6.2 as being constructed of materials that conform to the requirements for a noncombustible healthcare building.

Example locations observed, second and third floor means of egress corridor, above the finished ceiling at the east exterior wall. Based on example locations, the surveyor believes that the same condition exists on the remainder of the building's envelope.

B. On 9/28/2016 at 3:10 pm while accompanied by the DF an unprotected metal floor deck was observed which does not comply with a type I (332) building per 19.1.6 and NFPA 220.

Location observed basement level mechanical room #0020 (per small scale life safety drawings).

Based on observation during the survey walk through, it was determined that the facility failed to maintain the closure of means of egress doors. This deficient practice could affect patient, staff and visitors if a fire were to occur in this smoke zone and improper door latching allowed smoke from patient rooms or support areas to fill the exit access corridor.

Findings include:

A. On 09/28/16 at 11:25 AM, while in the company of the OR supervisor, the surveyor observed the corridor door to the OR - Scrub Room 231A, Second Floor is being equipped with a plunger-type throw bolt at the floor level. This does not comply with 19.3.6.3.3.

B. On 09/29/16 at 9:30 AM, while in the company of the DF, and POSE, the surveyors observed the corridor double doors to the Kitchen Room LL18. One of the doors is equipped with a surface mounted throw bolt. This does not comply with 7.2.1.5.4.


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C. On 9/28/2016 while accompanied by the DF doors was observed which lack proper egress hardware to comply with 19.2.2.2.4.

Example locations include:

1. 2:00 pm First floor Outpatient Pharmacy the door which opens to the room titled Pharmacy (as shown on the Life Safety floor plan) lacks a thumbturn on the egress side.

2. 2:10 pm First floor Cath Lab contains a hook and eye door lock on the egress side.

Based on observation the facility failed to provide properly operating doors within the means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising a person's access to an exit.

Findings include:

A. On 9/28/2016 at 12:00pm while accompanied by the DF patient room doors was observed which lacked proper egress hardware to comply with 19.2.2.2.4.
Example location observed:

1. Third floor Behavioral bathroom door of patient room # 333 lacks any type of mechanism to unlock and release the door from the egress side if it is locked from the room side. This condition is to be investigated in the remaining patient rooms.

Based on observations the facility failed to maintain properly rated shaft enclosures. This deficient practice could affect patients, staff and visitor if smoke and fire were allowed to expand from other areas of the facility through deficient shaft enclosures.

Findings include:

A. On 9/28/2016 at 1:30 PM while accompanied by the DF an access panel was observed within the third floor Activity room closet. The panel installation does not comply with 19.3.1 and 8.2.5.2 for a complete 2-hour fire rated shaft wall due to the following:

1. The access panel is not labeled as to its fire resistance rating.

2. The framed-in opening is incomplete allowing the cavity of the 2-hour wall to be exposed. This condition does not comply as a continuous enclosure for a shaft wall.

Based on direct observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

The finding is:

On 09/28/16 at 2:20 PM, while in the company of the DAS, the Furnace Room was observed to lack a self-closing door to comply with 39.3.2.1 and 8.4.

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 exit access corridors.

Findings include:

A. On 9/28/2016 at 2:40pm in the basement, while accompanied by the DF a pair of doors were observed to lack a label indicating the fire resistance rating of the installation to comply with 19.3.2.1. Location observed: entry doors to Fire Pump room

B. On 9/28/2016 at 2:45pm in the basement, while accompanied by the DF a large junction box (approximately 18"x 18") was observed without a cover to comply with 19.3.2.1 for separation requirements. Location observed: Fire Pump room.

C. On 9/28/2016 at 2:20 pm in the basement, while accompanied by the DF the entry door to the main switch gear room (across from room 067C) was observed to lack a label indicating the fire resistance rating to comply with 19.3.2.1.

D. On 9/28/2016 at 3:10 pm in the basement, while accompanied by the DF the perimeter wall cavity (in two locations) of a hazardous room is open to adjacent areas. This condition does not comply with the fire resistance rating of the room and separation requirements from adjacent areas.
Location observed: Data Center Main Distribution Room/Closet.

Based on observation, 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 exit access corridors.

Findings include:

A. On 9/29/2016 at 9:20am while accompanied by the DF and POSE perimeter walls were observed which were not smoke tight. The observed condition is of a servery freezer unit that is not separated from the kitchen due to a large continuous wall opening surrounding the unit. This does not comply with 19.3.2.1 for a smoke tight wall enclosure.

B. On 9/28/2016 at 9:50 am while accompanied by the DF on the Third floor Behavioral unit a egress door was observed to lack a self closing mechanism. Location observed: Clean Linen storage room.

C. On 9/29/2016 at 2:10am while accompanied by the DF on the third floor behavioral unit an electrical closet located across from room # 332 lacks a fire resistant separation from other floors and a smoke tight separation from the surrounding spaces due to open junction boxes and open conduits.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

A. 9/27/2016 at 2:30pm, 5th floor Exit Stair "B", while accompanied by the DF and POSE utilities which do not serve the stair were observed to penetrate the designated 2-hour fire rated stair enclosure. This does not comply with 19.3.2 and 7.1.3.2.1 (e). The noncompliant utilities observed were low voltage wiring and two exhaust pipes.

B. 9/27/2016 at 3:15pm 6th floor Exit Stair "A" while accompanied by the DF and POSE utilities which do not serve the stair were observed to penetrate the designated 2-hour fire rated stair enclosure. This does not comply with 19.3.2 and 7.1.3.2.1 (e). The noncompliant utilities observed were what appeared to be steam or hot water pipes.

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.

The finding is:

On 9/28/2016 at 9:35am while while accompanied by DF, third floor behavioral unit patient rooms were observed which were provided with keyed-one side locks with thumbturn on bathroom side. However a number of units lacked the thumbturn on the bathroom egress side of the door which can prevent exiting. The locks do not comply with NFPA 101-2000, 7.2.1.5.1 because they require a key to operate from the egress side when locked.

Based on observation the facility failed to provide exit discharge locations with adequate illumination. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

The finding is:

On 9/29/2016 at 9: 45am while accompanied by the DF an exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness to comply with 19.2.8.
Location observed: exterior exit from basement level dining room.

Based on observation during the survey walk-through and staff interview, the testing and maintenance of the battery-powered emergency lighting is not conducted on a regular basis. This deficiency could affect all patients within the areas of the facility, as well as any staff and visitors present, from readily identifying the exit path, when the required emergency lighting equipment fails.

Findings include:

On 09/28/16 at 2:15 PM, while accompanied by the DAS, the surveyor observed battery-powered emergency lights at the corridor. Based on document review the lights were not periodically tested, based on the last testing date of 01/15. This does not comply with 7.9.3 and NFPA 99-1999, 3-3.2.1.2.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 09/28/16 at 2:20 PM, while accompanied by the DAS, exit sign were observed located in the back corridor. These signs incorrectly direct occupants into the adjacent tenant space. This does not comply with 39.2.10 and 7.10.

B. On 09/28/16 at 2:20 PM, while in the company of the DAS, exit signs were observed in the corridor that were not illuminated to comply with 7.10.5.
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Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

On 9/29/2016 at 9:10am in the basement, while accompanied by the DF and POSE exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. Stair "A" corridor entry lacks signage with directional arrow.
2. Corridor adjacent to Oncology, the Oncology sign blocks part of an existing exit sign.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. Exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. Basement level corridor # 0119 (room numbers per the facility's life safety floor plan) as viewed from Dining # 0312 which leads to Stair # 0102 and vestibule # 0101.

2. First floor level corridor containing ramp to shell space lacks directional signage as viewed toward the main entry vestibule.

3. First floor level corridor adjacent to Lab, lacks exit signage for both directions, as viewed from leaving the Lab waiting room.

4. Second floor level G. I. corridor east end

Based on document review and staff interview the location of smoke barriers is not known. This deficiency could result in a delayed evacuation from the smoke compartment of fire origin to an area of refuge during a fire emergency. This condition could affect patients, staff and visitors.

Findings include:

On 9/27/2016 during review of the facility's floor plan, and discussion with the DF it was determined that the location of the closest smoke barrier is not known due to the following:

A. The facility consultant responsible for the layout of the life safety floor plans wrote a note attached to the floor plans which read "Note for wall rating legend, There are no smoke barriers in this facility. This legend is a typical for all facilities in Illinois not all wall types apply". However this condition is not compliant due to the following:

1. Sixth floor, fifth floor and third floor all contain patient sleeping beds. Due to the number of beds on each floor the facility is in noncompliance with 19.3.7.1. The life safety drawings indicate fire resistant barriers on these floors, however, there is no indication that the walls, wall openings, the doors within the barriers operate and comply with 19.3.7.6 for a required smoke barrier.

2. The written facility "Fire Plan and Evacuation Procedures" refers to item 1 "all employees must be well oriented in regards to the various building exits, locations of area smoke barriers and locations of fire extinguishers". This does not coincide with information provided on the life safety floor plans used by staff. The plans do not indicate the location of any smoke barriers. Therefore, the staff do not appear familiar with the use of and purpose of a smoke barrier and smoke compartment locations which does not comply with 19.3.7.1, 19.3.7.3 and 19.7.2.2 (6).

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

On 09/27/16, at 2:00 PM, while in the company of the DF, and POSE, the surveyor observed a smoke detector installed too close to the supply air / exhaust diffusers. This does not comply with NFPA 72 1999 2-3.5.1.
Location observed: 6th Floor Med/Surg Unit behind the Nurse Station.

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

Findings include:

A. At 9:00am on 9/28/16 while in the company of POSE fire sprinkler protection was removed from the Penthouse elevator equipment machine room which does not comply with NFPA 13, 1999 5-1.1.

B. At 2:15pm on 9/28/16 while in the company of the DF complete sprinkler coverage of the loading dock when the overhead doors are in the open position was not provided to comply with NFPA 13, 1999, 5-5.5.3.1.

C. At 2:20pm on 9/28/16 while in the company of the DF sprinklers are not provided in the medical gas cylinder store room located adjacent to the Loading Dock.

D. At 3:00pm on 9/28/16 while in the company of the DF and POSE the freight elevator hydraulic machine room located in basement mechanical room 0008A.

E. At 9:30am on 9/29/16 while in the company of the DF and POSE the Sterile Processing Department clean and soiled elevator hydraulic machine room.


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F. On 09/28/16 at 11:15 AM, it was observed, while in the company of the OR supervisor, the Electrical Closet located in the Sub-Sterile Room.


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G. On 9/28/2016 at 2:45 pm while accompanied by the DF Stair "A" basement level

H. On 9/28/2016 at 2:35 pm while accompanied by the DF Freight elevator machine room basement level

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

Findings include:

A. At 3:00pm on 9/28/16 while in the company of the DF and POSE the freight elevator hydraulic machine room located in lower level mechanical room 0008A.

B. At 1:10pm on 9/28 while in the company of the DF the hydraulic machine room for the dietary and the construction elevators.


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C. At 1:15pm the second floor the electrical closet located between the Day Surgery waiting room and the exit stair.

D. At 2:10pm the third floor electrical closet located across from room # 332.

Based on direct observation the surveyor finds the facility failed to provide adequate maintenance of the sprinkler system. This deficient practice provides a higher level of hazard than normal affecting all building occupants.

The finding is:

On 9/28/2016 at 2:30pm by direct observation while accompanied by the DF and POSE there is no stock of spare sprinkler heads to comply with NFPA 13, 1999, 3-2.9.

Based on direct observation the surveyor finds that the facility failed to provide a complete kitchen hood system. This deficient practice creates a high risk of fire and allows the spread of flames should a fire under the hood occur.

The findings are:

A. On 9/29/2016 at 10:30 am while accompanied by the DF and POSE the kitchen hood installation was observed to lack a metal container for grease collection from the kitchen hood's grease tray. This condition could allow for the grease collected by the grease filter to remain in the tray creating a high risk of fire should flames develop from the cooking procedures. This condition does not comply with NFPA 96, 1998, 3-2.6
Location observed: basement level kitchen

This deficient practice could allow for the grease collected by the grease filter to remain in the tray creating a high risk of fire should flames develop from the cooking procedures

B. On 9/29/2016 at 10:30 am while accompanied by the DF and POSE the kitchen hood installation was observed to lack a complete closure of the grease filters within the kitchen hood system. This condition does not allow for the capture of grease before entering the exhaust duct system which does not comply with NFPA 96, 1998, 3-2.6.
Location observed: basement level kitchen

Based on direct observation the facility failed to provide adequate protection from a chute installation. This deficient practice could allow fire within the chute or chute collection room to spread to adjacent spaces.

The finding is:

On 9/29/2016 at 9:25am while accompanied by the DF and POSE the linen chute door was observed to lack a fusible link which would allow the door to close upon a fire incident. The current condition does not comply with NFPA 82, 1999, 3-2.2.9.
Location observed: chute room located adjacent to the Loading Dock

Based on 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. This deficient practice may compromise the prompt care and movement of patients during a fire/smoke emergency.

On 9/28/2016 at 11:10am while accompanied by the POSE, a means of egress corridor was observed containing multiple boxes and equipment located adjacent to a pair of cross corridor doors. The material blocks part of the egress path which does not comply with 19.2.3.3.
Location observed: Surgery Department, semi restricted corridor

Based on direct observation the facility failed to provide ventilation to the outside for the medical gas manifolds and cylinder store room. This deficient practice could allow for a medical gas enriched atmosphere at a higher level and provide a fire.
The finding is:
On 9/28/2016 at 1:30pm while accompanied by the DF and POSE the surveyor observed that no ventilation is provided to the outside for the medical gas manifolds and cylinder store room. This condition does not comply with NFPA 99, 1999, 4-3.1.1.2 (b)4.

Based upon observations 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 code deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures (ILSM) 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 ILSM to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk through, the facility failed to provide emergency power that is properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

The finding is:

On 9/27/16 at 2:30 pm, while accompanied by the POSE, the surveyor observed that critical panel CP-BR in the boiler room was serving a fire alarm panel and equipment that should be served from the life safety branch and equipment branch of emergency power. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-32 through 517-34.

Based on observation during the survey walk-through, the facility failed to provide adequate space adjacent to electrical equipment. This deficient practice could affect patients in the facility, as well as any staff and visitors present, because the listed portion of the building electrical system is being compromised.

Findings include:

On 09/28/16, at 2:25 PM, while accompanied by the DAS, the electrical closet was observed to be obstructed with housekeeping supplies and cardboard boxes. The required minimum 3'-0" clear working space in front of the panel is not provided to comply with NFPA 70 1999 110-26(a).

Based on observation during the survey walk-through, the facility failed to provide portions of the building with a code compliant electrical system. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On 09/28/16 at 11:05, while in the company of the OR supervisor, the surveyor observed the Electrical Panels in the corridor of the OR Unit, Example panels CP-OR-S-1 and CP-OR-S-1, were either missing schedules or the directory panel schedules are not updated and or not properly labeled, to comply with NFPA-70, Section 110-22.


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B. On 9/27/16 at 1:00 pm, while accompanied by the POSE, the surveyor observed that the elevators 3 & 4 were not equipped with a lighting disconnects served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

C. On 9/28/16 at 11:15 am, while accompanied by the POSE, the surveyor observed that the operating rooms were using power strips that were not in compliance with the 1999 Edition of NFPA-99, Section 7-5.1.2.5.

D. On 9/28/16 at 11:20 am, while accompanied by the POSE, the surveyor observed that the panel schedules for the operating room isolation panels needed to be updated to comply with the 1999 Edition of NFPA-70, Section 384-13.

E. On 9/28/16 at 1:30 pm, while accompanied by the DF and POSE, the surveyor observed that the cath lab was not equipped with any battery lighting to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.

Based on direct observation the surveyor finds the facility failed to provide complete sprinkler protection in the elevator machine room. This deficient practice could cause an electrical hazard and or trap elevator passengers should water be applied to the elevator machinery.

Findings include:

On 9/29/2016 at 9:10am by direct observation while accompanied by the DF and POSE the machine room for elevator # 6 is provided with sprinkler fire protection but did not show evidence of electrical shunt trip.