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The facility failed to provide corridors that were separated from use areas by walls that were smoke resisting.

During the revisit, observation determined the basement and first floor corridor walls had multiple through-wall pipe, data cable, conduit, and duct penetrations that were not sealed. Also, ceiling tiles were missing in multiple areas throughout the facility.

The facility failed to ensure the walls and ceilings that enclosed the Boiler Room, Central Supply, Soiled Linen and Laundry were smoke resisting. Observation determined unsealed spaces around sprinkler hangers and other unsealed openings in the walls and ceilings of these hazardous areas.

The facility failed to ensure the one-hour fire resistance rating of the stair enclosures. Vertical openings must be enclosed or protected in accordance with 8.2.5.Openings through floors, such as stairways, must be enclosed with fire barrier walls. Such enclosures must be continuous from floor to floor. Openings must be protected as appropriate for the fire resistance rating of the barrier. Observation determined: 1) The northeast Kitchen exit stairway was not separated from the Boiler Room by a wall having a one-hour fire resistance rating. An opening was created in the wall from the Boiler Room.2) The Operating Room exit stairway was not separated from the Operating Room corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
3) The exit stairway by the Emergency Room was not separated from the first floor corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
4) The exit stairway south of the elevator was not separated from the first floor corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
5) The door in the opening between the northeast Kitchen exit stairway and the Kitchen corridor was missing.

The facility failed to ensure the automatic sprinkler system was installed to provide complete coverage for all portions of the building. NFPA 13.

Observation determined:

1) The sprinklers in the North Air Handling Room were obstructed by two (2) air handling units.

2) The sprinklers in the Main Air Handling Room were obstructed by a duct greater than four (4) feet in width.

3) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system. Suspended ceiling tiles were missing, broken, warped and/or water damaged in rooms and corridors throughout the building.
4) Privacy curtains with small mesh openings obstructed sprinklers in the Emergency Room and Physical Therapy.

5) The facility had no sprinkler wrench.

6) The minimum distance between sprinklers was not maintained. A newly installed sprinkler was located less than one (1) foot from an existing sprinkler. Sprinklers must be spaced not less than 6 ft. on center.

The facility failed to ensure the one-hour fire resistance rating of the stair enclosures. Vertical openings must be enclosed or protected in accordance with 8.2.5.Openings through floors, such as stairways, must be enclosed with fire barrier walls. Such enclosures must be continuous from floor to floor. Openings must be protected as appropriate for the fire resistance rating of the barrier. Observation determined: 1) The northeast Kitchen exit stairway was not separated from the Boiler Room by a wall having a one-hour fire resistance rating. An opening was created in the wall from the Boiler Room.2) The Operating Room exit stairway was not separated from the Operating Room corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
3) The exit stairway by the Emergency Room was not separated from the first floor corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
4) The exit stairway south of the elevator was not separated from the first floor corridor by a wall having a one-hour fire resistance rating. Unsealed spaces around a sprinkler pipe penetration were not sealed with fire-rated caulking installed in accordance with the manufacturer's UL listing.
5) The door in the opening between the northeast Kitchen exit stairway and the Kitchen corridor was missing.

The facility failed to ensure the automatic sprinkler system was installed to provide complete coverage for all portions of the building. NFPA 13.

Observation determined:

1) The sprinklers in the North Air Handling Room were obstructed by two (2) air handling units.

2) The sprinklers in the Main Air Handling Room were obstructed by a duct greater than four (4) feet in width.

3) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system. Suspended ceiling tiles were missing, broken, warped and/or water damaged in rooms and corridors throughout the building.
4) Privacy curtains with small mesh openings obstructed sprinklers in the Emergency Room and Physical Therapy.

5) The facility had no sprinkler wrench.

6) The minimum distance between sprinklers was not maintained. A newly installed sprinkler was located less than one (1) foot from an existing sprinkler. Sprinklers must be spaced not less than 6 ft. on center.