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Based on observation the facility failed to provide an acceptable separation at two smoke barriers.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there were two locations where the smoke barriers were not completely sealed: 1) above the smoke barrier doors at dietary, and 2) the smoke barrier doors at the nurse ' s station.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the hospital.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there were three locations where a hazardous area was not separated from the rest of the hospital in an acceptable means. They were as follows: 1) at the centeral storage the closer was not functioning properly, 2) at the soiled utility on the 2nd corridor there was no closer, and 3) the medical records room did not have a closer.

Based on observation the facility failed to provide correct cross labeling of the FACP and the electrical panel that provides the power for the FACP and subpanels.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there was not a label on the fire alarm panels and subpanels that referenced the electrical panel and breaker supplying power to the fire alarm panels. Also the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there were items stored above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. This was found in the storage room behind the purchasing office.

Based on a review of the records with the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel, no fire resistance documentation for cubical curtains was provided.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there was no tag on the radiology cubical curtains nor did the facility have any documentation.

Based on observation the facility failed to provide acceptable labels on the essential electrical system panels.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there were no labels on the essential electrical system panels calling them out as " Life Safety " , " Critical " , and " Equipment " .

Based on observation the facility failed to provide current directories within the electrical panels.

The inspector observed while accompanied by the Hospitals Administrator, Director of Material Management, Compliance Director, and maintenance personnel during the hours of the inspection from 10:30 am to 1:30 pm that there were electrical panels that did not have current directories.