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A) Sprinkler systems are not installed and maintained in accordance with NFPA 101, NFPA 13, and NFPA 25:

1) Corrected 10/27/11

4) 4 East is a fully sprinklered fire compartment or smoke compartment. The wardrobe units in each patient room lack sprinkler protection.

K056 to be cleared with the completion of IDPH Project 9041. Currently, Phases I, II and III of VII phases have been found to be completed.

A) Interim Life Safety Measures: 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.

1) Corrected 10/27/11

2) New items observed on 10/27/11 for which a corrective action is required

a) The 2nd Floor Center Nurse's Station for a form SNF Unit is currently vacant and open to the corridor. The space does not comply with 19.3.6.1, exception # 1, unless smoke detection for the space open to the corridor is provided.

b) Boiler Room: several B Label fire doors were found propped open by means that does not comply with 7.2.1.8.

A) Based on random observation, the surveyor observed wiring and panel directories throughout the facility which were not installed and maintained in accordance with NFPA 70 1999.

3) Cables were observed throughout the facility which were not supported by the structure as required by 800-6.

The correction of the above item is on-going and will be cleared upon completion of all other citations.

A) Modified 3/31/11: Based upon random observation and document review that surveyors find that three elevators are not installed and/or tested in accordance with ANSI A17.3.

3) (New 11/18/07): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor of fire origin.