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800 SCHOOL ST

CARROLLTON, IL 62016

No Description Available

Tag No.: K0017

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. An office/charting area, not staffed 24-hours, contains furnishings, multiple shelves, files etc and is stationed at the corridor intersection across from the D.O.N. office (shown on the facility life safety plan). This area contains a pass through sliding window which is open to the corridor. This area is not provided with smoke detection to comply with 19.3.6.1, Exceptions

Update 09/04/12: The facility did not meet the completion date of 05/18/12 noted on their Plan of Correction dated 05/30/12, therefore the above item remains open.

B. Corrected 09/04/12
C. Corrected 09/04/12



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No Description Available

Tag No.: K0018

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.2 for a means to keep the door closed. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. Corrected 09/04/12

B. Corrected 09/04/12


C. The pair of cross corridor doors leading to the East corridor of the MedSurg wing both open in the same direction and were observed to not be resistant to the passage of smoke due to the lack of a coordinator.

Update 09/04/12: The coordinator hardware for the above pair of cross corridor door was installed but this door did not close properly when tested for fire alarm condition.


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No Description Available

Tag No.: K0044

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies to comply with 8.2.3.2.4.2. These deficiencies could affect all patients, staff and visitors in the facility, because the lack of compartmentation could result in smoke compromising the use of the facility's exit access corridors.


Findings include:

A. 1. Corrected 09/04/12
2. Corrected 09/04/12

B. An indicated 2-hour fire barrier separating the building in half is located east west from Diatary, to the exterior wall at hazardous waste was observed to contain an unprotected steel beam as part of the barrier assembly. Location observed The North section of the wall across the corridor from Diatary.

Update 09/04/12: The surveyor observed the unprotected steel beam located along the indicated 2-hour fire barrier which still does not comply to provide two-hour fire rating assembly.

C. Corrected 09/04/12

No Description Available

Tag No.: K0056

Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 101 2000.

Findings include:

A. During the survey walk-through of the Cat Scan Room and Medical Records areas were observed with 2 sprinkler heads in CT and 6 sprinkler heads in Medical Records all supplied by the same 1" copper pipe and not in accordance with 101 9.7.1.2 for up to 6 sprinkler heads on the domestic water system.

B. The sprinkler supply valve between the domestic water system and the sprinklers was observed to be a valve with no indicator to show what position the valve was in and not in accordance with 13 5-14.1.1.2.

C. The sprinkler piping observed above the ceiling in CT was observed to be reduced to 1/2" piping from the branch line and not 1" to the sprinkler head, thus not in accordance with 13 5-13.20.1.

D. The sprinkler piping observed above the ceiling in CT was observed without a sign to indicate what portion of the sprinkler system it controlled and not in accordance with 5-14.1.1.12.

E. The sprinkler valve observed above the ceiling in CT was observed without a supervisory circuit for monitoring the valve position in accordance with 13 5-14.1.1.3 (2).

These deficiencies could cause injury to patients and staff due to no warning and improper water flow to put out the fire.



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No Description Available

Tag No.: K0062

Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 25 1998 and NFPA 13 1999.

Findings include:

A. During the document review process records were not available for any quarterly testing of flow switches in accordance with NFPA 25 2-3.3. There was no documentation available for the annual sprinkler inspection which includes from the floor visual to comply with NFPA 25 2-2.1.1.

These deficiencies could cause injury to patients due to equipment failure.




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No Description Available

Tag No.: K0069

Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. Corrected 09/04/12

B. During an interview held at the hood location with the Director of Maintenance it was confirmed the electric supply to the fat fryer, the 6 burner stove and the griddle top did not automatically disconnect with the activation of the fire suppression system in accordance with 7-4.1.
Update 09/04/12: The facility did not meet the completion date of 07/19/12 noted on their Plan of Correction dated 05/30/12, therefore the above item remains open.

C. Corrected 09/04/12





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No Description Available

Tag No.: K0077

Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 50 1996 and NFPA 99 1999.

Findings include:

A. Corrected 09/04/12


B. The bulk supply location was observed to have a concrete pad approximately 3' in the direction of the vehicle axis and not 8' in accordance with 2-1.4.

Update 09/04/12: The facility did not meet the completion date of 05/18/12 noted on their Plan of Correction dated 05/30/12, therefore the above item remains open.

C. During the survey of the basement area the medical vacuum system was observed with a manifolded exhaust pipe without check valves, a valve or other arrangement for isolating the running pump from the malfunctioning pump for maintenance in accordance with 99 4-3.2.1.9.

D. During the survey of the Emergency Room area a medical gas zone valve box labeled as Recovery Room was observed. During an interview held at that location with the Director of Maintenance, it was discovered the Recovery room had been changed to storage and the zone valve box was labeled incorrectly and not in accordance with 99 4-3.1.2.14 (b).

E. Trauma room 1 zone valve box was observed to be labeled as OR 1 and not in accordance with 99 4.3.1.2.14 (b).

F. Trauma room 1 was observed to only have a shut off valve for oxygen and not vacuum for anesthetizing locations in accordance with 99 4-3.1.2.3 (n).

These deficiencies could cause injury to patients and staff due to fire or explosion.




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No Description Available

Tag No.: K0106

Based on random observation during the survey walk-through on January 30, 2012, not all portions of the facility's emergency generator are installed in accordance with NFPA 110 1999.

Findings include:

A. During the survey of the generator location normal utility distribution electrical equipment was observed in the generator enclosure and not separated in accordance with 110 5-2.2

This deficiency could cause injury to patients and staff due to failure of both electrical systems.




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No Description Available

Tag No.: K0130

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.




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No Description Available

Tag No.: K0144

Based on random observation, document review and staff interview during the survey walk-through on January 30, 2012, not portions of the facility's emergency electrical system are test in accordance with NFPA 110 1999.

Findings include:

A. During the document review process records were not available for the monthly testing of the transfer switch in accordance with 6-4.5.

B. During the document review process records were not available for the annual transfer switch maintenance in accordance with 6-3.5.

C. During the document review process records for the amperage during monthly load testing showed less than 30% load with no load bank test in accordance with 6-4.2.

D. During the document review process records for the weekly generator inspection did show electrolyte level checking in accordance with 6-3.6 for verifying the battery meets the generator manufacture requirements.

These deficiencies could cause injury to patients due to equipment failure.




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No Description Available

Tag No.: K0145

Based on random observation and staff interview during the survey walk-through on January 30, 2012, not all portions of the facility's emergency electrical system are installed and maintained in accordance with NFPA 99 and 110 1999.

Findings include:

A. During the survey of the generator location an interview was held with the Director of Maintenance and it was discovered the monthly generator test was initiated by turning off the normal electrical main breaker and not in accordance with 110 4-2.4.10.

B. The transfer switch at the generator location was not provided with pilot lights to indicate switch position in accordance with 4-2.4.11.

C. During the survey of the facility various electrical panels were observed with normal and emergency electrical circuits fed from the same panel and not separated in accordance with 99 3-4.2.2.4 (a). Example location - panel EM located in the partial basement housing the water heaters contains breakers marked for equipment, medical gas and fire alarm.

These deficiencies could cause injury to patients and staff due to loss of electric circuits.




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No Description Available

Tag No.: K0147

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch. Should the transfer switch fail upon return to normal power, the facility could be left with no power even though utility power is available.

Findings include:

A. All power serving the facility including the emergency department, patient rooms, the clinic, etc. is fed through a single transfer switch. This was confirmed during an interview held with the Director of Maintenance, who confirmed that everything is on emergency power. There are no normal power circuits which feed these areas without going through the transfer switch. This creates a single point of failure that could leave the facility completely out of power during critical care and does not meet the intent of NFPA-70, Section 517-30 through 35.



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