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Based on document review and interview, the facility failed to provide a complete fire alarm system with coverage throughout the entire facility. This deficient practice could affect all patients, in all Smoke Zones, as well as an indeterminable number of staff and visitors if the fire-alarm system failed to notify occupants and the fire department in a fire emergency.

Findings include:

A. On 11/25/24at 1:45 PM, during review of the Fire Alarm System Inspection and Testing Report and by interview with E-1 and E-2, it was revealed that the facility failed to have all the devices, attached to the fire alarm system, tested to determine if they are fully functional in the past 12 months. This did not meet the requirements of NFPA 72, 2010 Edition, Section 14.4 and Table 14.3.1(9) and LSC; Section 9.6.1.4.

B. On 11/25/24at 1:45 PM, during review of the Fire Alarm System Inspection and Testing Report and per interview with E-1 and E-2, the facility failed to provide current records for the required Semi-Annual Visual Fire Alarm System Inspection with an itemized list and a physical address for each Fire Alarm Device and Fire Alarm Panels in accordance with NFPA 72, 2010 Edition, Section 14.4.5 and Table 14.4.5.

Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Fire Alarm System is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the fire alarm system was inoperable.

Findings include:

A. On 11/25/24 at 2:25 PM, accompanied by E1 and E2 Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 11/25/24 at 2:25 PM, accompanied by E1 and E2 Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the fire alarm system has been returned to service in accordance with NFPA 101, 2012 Edition, Section 9.6.1.8.

Examples of missing Key Directives:

1. Facility shall provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuate effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6.

2. IDPH Regional Office (AHJ) shall be notified.

3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: "The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104

(1) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(2) The fire watch is continuous
(3) The personnel conducting the fire watch shall have no other duties.
(4) A method of recording and documenting the fire watch
(5) Identification of Staff performing the Fire Watch
(6) Access to all spaces provided to Fire Watch Staff (keys, codes or badges)

Based on document review the facility failed to maintain the sprinkler system. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the sprinkler system failed to operate during a fire emergency due to a lack of required maintenance.

Findings include:

A. On 11/25/24 at 1:52 PM, accompanied by E1 and E2 during review of the Sprinkler System Inspection Reports it was revealed that the facility failed to provide three (3) of the four (4) required quarterly sprinkler inspections within the past twelve (12) months in accordance with NFPA 25; 2011 Edition, Section 5.1.1.2 and Table 5.1.1.2.

Example of missing inspections include:
1. 1st Quarter 2024
2. 2nd Quarter 2024
3. 3rd Quarter 2024

B. On 11/25/24 at 1:52 PM, accompanied by E1 and E2 during review of the Sprinkler System Inspection Reports it was revealed that the facility had no documents indicating that the sprinkler system's piping has received internal inspection in the past 5-years. This did not meet the requirements of NFPA 25; 2011 Edition, Section 14.2.1. An inspection of piping and branch line conditions shall be conducted every 5 years.

C. On 12/07/10 at 12:50 PM, during document review and by interview with E-1 and E-2, it was revealed that the facility failed to have necessary repairs made to the Sprinkler System. Per the Annual Sprinkler System Inspection by V-1, three (3) items were noted as having "FAILED." Per an interview with E-1 and E-2, it was noted that none of these items have been corrected and are still deficient. The facility had no documentation of repairs. The following three items were noted as "Non approved antifreeze solution in system per NFPA 24":
1. Wet Pipe, ER awning antifreeze
2. Wet Pipe, front awning antifreeze
3. Wet Pipe, old ambulance Dock (antifreeze)

D. On 11/25/24 at 3:01 PM, while accompanied by E-1 and E-2, an observation revealed that the Food Service Smoke Zone - walk-in refrigerator had one (1) dirty sprinkler head. This sprinkler head was loaded with corrosion and must be replaced in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.2 and NFPA 101; 2012 Edition, Section 9.7.

E. On 11/25/24 at 3:05 PM, while accompanied by E-1 and E-2, an observation revealed that the Food Service Smoke Zone - Kitchen had six (6) dirty sprinkler heads. These sprinkler heads were loaded with corrosion and must be replaced in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.2 and NFPA 101; 2012 Edition, Section 9.7.

Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Sprinkler System is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the sprinkler system was inoperable.

Findings include:

A. On 1/25/24 at 1:52 PM, accompanied by E1 and E2 Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 1/25/24 at 1:52 PM, accompanied by E1 and E2 Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6).

Examples of missing Key Directives:

1. Impairment Coordinator is established in accordance with NFPA 25, 2011 Edition Section 15.2.1

2. Impairment tags are posted at each fire department connection and control valves in accordance with NFPA 25, 2011 Edition Section 15.3.2

3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(4):

(1) Evacuation of the building or portion of the building affected by the service outage
(2) An approved Fire Watch

4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: "The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers in accordance with NFPA 101, 2012 Edition Section 3.3.104:

(1) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(2) The fire watch is continuous
(3) The personnel conducting the fire watch have no other duties
(4) A method of recording and documenting the fire watch
(5) Identification of Staff performing the Fire Watch
(6) Access to all spaces provided to Fire Watch Staff (keys, codes or badges)

5. When the sprinkler is out of service the facility shall notify the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(6):

(1) The insurance carrier
(2) The alarm company
(3) IDPH Regional Office
(4) All other authorities having jurisdiction

6. Restoring System to Service the following are provided:

(1) Necessary inspections and tests have been conducted to verify that the effected systems are operational
(2) Supervisors are notified
(3) Fire Department is notified
(4) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified
(5) Impairment tags are removed

Based on document review the facility failed to maintain fire rated building separation doors. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the fire rated doors failed to function and keep the integrity of the rated opening during a fire.

Findings include:

On 11/25/24 at 3:30 PM accompanied by E1 and E2 document review revealed to facility failed to provide records for the annual testing and inspection of the required fire rated doors of the facility, in accordance with NFPA 80, 2010 Edition, Section 5.2.4, NFPA 101; 2012 Edition, Section 7.2.1.15. The Fire Door Inspection report provided was dated 05/09/23.