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Based on observations made during the tour of the facility at building #2 on the afternoon of 02/21/12 with the director of nursing, the safety officer, the host hospital director of maintenance, and the host hospital electrician, the facility failed to assure that hazardous areas were in full compliance with NFPA 101, 18.3.2.1.

The door to the soiled utility room did not have a 45 minute fire rating label.

Based on observations made during the tour of the facility at building #2 on the afternoon of 02/21/12 with the director of nursing, the safety officer, the host hospital director of maintenance, and the host hospital electrician, the facility failed to assure that the fire alarm system was in full compliance with NFPA 101, 19.3.4 and 9.6.

Duduis hospital did not have a fire alarm annunciator panel at a 24 hour staffed location, such as the nurse station on that floor.

Based on observations made during the tour of the facility at building #1 on the morning of 02/22/12 with the safety officer, the host hospital director of plant services, and the host hospital senior electrician, the facility failed to assure that the fire alarm system was in full compliance with NFPA 101, 19.3.4 and 9.6.

Duduis hospital did not have a fire alarm annunciator panel at a 24 hour staffed location, such as the nurse station on that floor.

Based on observations made during the tour of the facility in building #1 on the morning of 02/21/12 with the director of nursing, the safety officer, the building director of maintenance, and the building electrician, the facility failed to assure that the Type I Essential Electrical System (EES) was in full compliance with NFPA 99, 3.4.2.2.

(1) The pyxis/medication room did not have emergency lighting.

(2) Exhaust fan 426 was being supplied with power from the life safety panel of the EES.