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Based on random observation during the survey walk-through, not all exit enclosures are constructed and maintained in accordance with 39.3.1.1.

Findings include:

A. The door to the Ground Floor landing of the Exit Stair adjacent to the Medical Records Storage Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.1.1., 8.2.5., and 7.2.1.8.2.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 18.3.7.5., 18.3.7.6., and 18.3.7.7.

Findings include:

A. One leaf of the smoke barrier doors at the Second Floor Med-Surg Unit was observed to be bound on the carpet and did not close upon activation of the building fire alarm system; the door is thus not self-closing as required by 18.3.7.6.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1.

Findings include:

A. An area of approximately 200 square feet of stored combustibles were observed, in the Lower Level Kitchen, which are not separated from the remainder of the building as required by 18.3.2.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. A series of hazardous areas were observed that are not separated from the remainder of the building by minimum 1 hour fire rated enclosures, as required by 39.3.2.1. and 8.4.1.1., because the walls and floor/ceiling assemblies do not carry fire ratings and because the rooms are not provided with minimum 3/4 hour fire rated doors. Locations observed include (all Ground Floor):

1. Medical Records Storage Room.

2. Shared Corridor, which is used for storage.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. The door to the Ground Floor Medical Records Storage Room was observed to not be self-closing as required by 39.3.2.1. and 8.4.1.1.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 18.3.1.1.

Findings include:

A. Lockers were observed being stored at the Lower Level landing of the Physical Plant Exit Stair as prohibited by 7.1.3.2.3.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1.

Findings include:

A. Combustible and other materials were observed being stored in the Ground Floor landing of the Exit Stair adjacent to the Medical Records Storage Room as prohibited by 39.3.1.1. and 7.1.3.2.3.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1.

Findings include:

A. The Exit Stair was observed to not be enclosed with minimum 1 hour fire rated construction as required by 39.3.1.1., 8.2.5., and 7.2.2.5.1.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 18.2.1.

Findings include:

A. The pair of doors from the First Floor Emergency Department to the Ambulance Bay Vestibule, which was observed to be equipped with a magnetic lock , was observed to not be provided with a sensor on the egress side of the doors required by Subpart (a) to 7.2.1.6.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. During the survey walk-through, it could not be determined that the common path of travel, as measured from the most remote point of the First Floor EAP/OCS Unit to the point near the Exit Stair at which building occupants have to egress paths, was less than 75'-0" as required by 39.2.5.3. Surveyor 14290 notes that both exits for the EAP/OCS Unit discharge into the same Corridor.

A. Doors were observed which are equipped with locking devices which require a key to exit as prohibited by 7.2.1.5.1. Locations observed include:

1. First Floor EAP/OCS Unit exit door.
2. Ground Floor Kishwaukee Cancer Care Center, exit door to Corridor.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 18.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. Second Floor OB Unit, egress path in the west North-South Corridor, toward the south.

2. First Floor:

a. Emergency Department Lobby, egress path toward the north (toward Administration.

b. Radiology Department, Light Room Passage, egress paths toward the east and west.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4.

Findings include:

A. The manual fire alarm pull station at the First Floor Emergency Department Ambulance Bay exit doors was observed to be in excess of 5'-0" of the door as prohibited by NFPA 72 1999 2-8.2.2.

Based on random observation during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. The manual pull station for the Lower Level Kitchen hood suppression system was observed to be obstructed by carts as prohibited by NFPA 96 1998 7-5.1.

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 in accordance with 18.2.3.3.

Findings include:

A. Stools and step stools were observed in exit access corridors, at standing height work counters, which obstruct egress as prohibited by 18.2.3.3. and 7.1.10.2.1. Locations observed include:

1. Second Floor:
a. Med-Surg Unit, 3 Corridors.

b. Intensive Care Unit Corridor.

2. First Floor:
a. Med-Surg Unit, 3 Corridors.

b. Surgical Corridor.

B. A portable X-Ray machine was observed being stored, in the First Floor Radiology Department Corridor, as prohibited by 18.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. Second Floor Intensive Care Unit Clean Utility Room.

2. First Floor Respiratory Therapy Storage/Work Room.

Based on random 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:

A. 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.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical receptacles served by the building emergency electrical system, located at the headwalls of Treatment Rooms in the First Floor Emergency Department, were observed to not be labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).

Based on random observation during the survey walk-through, not all exit enclosures are constructed and maintained in accordance with 39.3.1.1.

Findings include:

A. The door to the Ground Floor landing of the Exit Stair adjacent to the Medical Records Storage Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.1.1., 8.2.5., and 7.2.1.8.2.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 18.3.7.5., 18.3.7.6., and 18.3.7.7.

Findings include:

A. One leaf of the smoke barrier doors at the Second Floor Med-Surg Unit was observed to be bound on the carpet and did not close upon activation of the building fire alarm system; the door is thus not self-closing as required by 18.3.7.6.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1.

Findings include:

A. An area of approximately 200 square feet of stored combustibles were observed, in the Lower Level Kitchen, which are not separated from the remainder of the building as required by 18.3.2.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. A series of hazardous areas were observed that are not separated from the remainder of the building by minimum 1 hour fire rated enclosures, as required by 39.3.2.1. and 8.4.1.1., because the walls and floor/ceiling assemblies do not carry fire ratings and because the rooms are not provided with minimum 3/4 hour fire rated doors. Locations observed include (all Ground Floor):

1. Medical Records Storage Room.

2. Shared Corridor, which is used for storage.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1.

Findings include:

A. The door to the Ground Floor Medical Records Storage Room was observed to not be self-closing as required by 39.3.2.1. and 8.4.1.1.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 18.3.1.1.

Findings include:

A. Lockers were observed being stored at the Lower Level landing of the Physical Plant Exit Stair as prohibited by 7.1.3.2.3.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1.

Findings include:

A. Combustible and other materials were observed being stored in the Ground Floor landing of the Exit Stair adjacent to the Medical Records Storage Room as prohibited by 39.3.1.1. and 7.1.3.2.3.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1.

Findings include:

A. The Exit Stair was observed to not be enclosed with minimum 1 hour fire rated construction as required by 39.3.1.1., 8.2.5., and 7.2.2.5.1.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 18.2.1.

Findings include:

A. The pair of doors from the First Floor Emergency Department to the Ambulance Bay Vestibule, which was observed to be equipped with a magnetic lock , was observed to not be provided with a sensor on the egress side of the doors required by Subpart (a) to 7.2.1.6.2.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. During the survey walk-through, it could not be determined that the common path of travel, as measured from the most remote point of the First Floor EAP/OCS Unit to the point near the Exit Stair at which building occupants have to egress paths, was less than 75'-0" as required by 39.2.5.3. Surveyor 14290 notes that both exits for the EAP/OCS Unit discharge into the same Corridor.

A. Doors were observed which are equipped with locking devices which require a key to exit as prohibited by 7.2.1.5.1. Locations observed include:

1. First Floor EAP/OCS Unit exit door.
2. Ground Floor Kishwaukee Cancer Care Center, exit door to Corridor.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 18.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. Second Floor OB Unit, egress path in the west North-South Corridor, toward the south.

2. First Floor:

a. Emergency Department Lobby, egress path toward the north (toward Administration.

b. Radiology Department, Light Room Passage, egress paths toward the east and west.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4.

Findings include:

A. The manual fire alarm pull station at the First Floor Emergency Department Ambulance Bay exit doors was observed to be in excess of 5'-0" of the door as prohibited by NFPA 72 1999 2-8.2.2.

Based on random observation during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

Findings include:

A. The manual pull station for the Lower Level Kitchen hood suppression system was observed to be obstructed by carts as prohibited by NFPA 96 1998 7-5.1.

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 in accordance with 18.2.3.3.

Findings include:

A. Stools and step stools were observed in exit access corridors, at standing height work counters, which obstruct egress as prohibited by 18.2.3.3. and 7.1.10.2.1. Locations observed include:

1. Second Floor:
a. Med-Surg Unit, 3 Corridors.

b. Intensive Care Unit Corridor.

2. First Floor:
a. Med-Surg Unit, 3 Corridors.

b. Surgical Corridor.

B. A portable X-Ray machine was observed being stored, in the First Floor Radiology Department Corridor, as prohibited by 18.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. Second Floor Intensive Care Unit Clean Utility Room.

2. First Floor Respiratory Therapy Storage/Work Room.

Based on random 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:

A. 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.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. Electrical receptacles served by the building emergency electrical system, located at the headwalls of Treatment Rooms in the First Floor Emergency Department, were observed to not be labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).