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Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that smoke barriers were in full compliance with NFPA 101, 19.3.7.3 and 8.3.

In the morning, the fire/smoke compartment wall above the cross corridor door opening adjacent to the IT room had conduit penetrations that were caulked with non fire rated sealant.

Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that the automatic sprinkler system was in full compliance with NFPA 13.

The sprinkler system valves did not have permanent labels identifying their individual functions.

Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that the Essential Electrical System (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) Panels 'B1', ' B2', and 'B3' were not clearly identified as to which branch of the EES they served. They were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT' as applicable. Similarly, the automatic transfer switches serving the EES were not labeled to identify which branch they served.

(2) The panel board directories for panels 'B1', 'B2', and 'B3 were out of date, and there was a mix and match of items on the three branch panels that did not comply with the requirements for a Type I EES.

(3) The pharmacy did not have adequate lighting on emergency power. The pharmacy was comprised of three rooms, and only one of the rooms had any lighting on emergency power.

(4) The central nurses' station did not have any emergency lighting.

(5) The emergency department treatment and examination rooms did not have any emergency lighting.

Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that smoke barriers were in full compliance with NFPA 101, 19.3.7.3 and 8.3.

In the morning, the fire/smoke compartment wall above the cross corridor door opening adjacent to the IT room had conduit penetrations that were caulked with non fire rated sealant.

Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that the automatic sprinkler system was in full compliance with NFPA 13.

The sprinkler system valves did not have permanent labels identifying their individual functions.

Based on observations made during the tour of the facility on the morning of 03/18/10 with the facility director, the facility failed to assure that the Essential Electrical System (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) Panels 'B1', ' B2', and 'B3' were not clearly identified as to which branch of the EES they served. They were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT' as applicable. Similarly, the automatic transfer switches serving the EES were not labeled to identify which branch they served.

(2) The panel board directories for panels 'B1', 'B2', and 'B3 were out of date, and there was a mix and match of items on the three branch panels that did not comply with the requirements for a Type I EES.

(3) The pharmacy did not have adequate lighting on emergency power. The pharmacy was comprised of three rooms, and only one of the rooms had any lighting on emergency power.

(4) The central nurses' station did not have any emergency lighting.

(5) The emergency department treatment and examination rooms did not have any emergency lighting.