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Based on observation and interview it was discovered the facility failed to properly maintain smoke barriers. The deficient practice affected 7 of 10 smoke compartments on the 1st floor, staff and approximately 80 of 110 residents.

The STANDARD is not met as evidenced by:
On January 25, 2010, between approximately 10:00 AM and 12:30 PM, accompanied by the Maintenance Facilitator, it was revealed by observation the smoke barriers in the Birthing Center (west wing) 1st floor, above the ceiling between postpartum and OB, in the electric room in the birthing connector corridor above the door and over the door between the birthing center corridor and the main hospital had penetrations in them. The Maintenance Facilitator observed the findings.

On January 25, 2010, between approximately 1:00 PM and 3::00 PM, accompanied by the Maintenance Facilitator, it was revealed by observation the smoke barriers in the main hospital on 1st floor, located above the doors; by the ultrasound 3 room, the entrance between sub-waiting and ED registration, the entrance between adult ED and pediatric ED, the operating room corridor 30 foot from the double doors, above the cysto main door, above the ceiling in room 1646 and the office crossed from electric closet 1100 -B1, had penetrations in them. The Maintenance Facilitator observed the findings.

An interview on January 26, 2010, between approximately 10:00 AM and 3:00 PM, the Maintenance Facilitator confirmed this evidence.

Based on observation and interview it was discovered the facility failed to properly maintain smoke barriers. The deficient practice affected 1 of 6 smoke compartments on the 2nd floor, staff and approximately 11 of 128 residents.

The STANDARD is not met as evidenced by:
On January 26, 2010, between approximately 9:00 AM and 3:00 PM, accompanied by the Maintenance Facilitator, it was revealed by observation the smoke barriers in the 2nd floor, in the wall in the post surgical mechanical room, above the ceiling in the ICU connector hallway, in the ICU corridor above stairwell #5 and above the ceiling over door 2200-C2 had penetrations in them. The Maintenance Facilitator observed the findings.

An interview on January 26, 2010, between approximately 9:00 AM and 3:00 PM the Maintenance Facilitator confirmed this evidence.

Based on observation and interview it was discovered the facility failed to properly maintain smoke barriers. The deficient practice affected 2 of 2 smoke compartments on the 3rd floor, staff and approximately 14 of 14 residents.

The STANDARD is not met as evidenced by:
On January 27, 2010, between approximately 9:30 AM and 12:00 PM, accompanied by the Maintenance Facilitator, it was revealed by observation the smoke barriers on the 3rd floor, above the ceiling at the entrance to the Pediatric Unit had penetrations in it. The Maintenance Facilitator observed the findings.

An interview on January 27, 2010, between approximately 9:30 AM and 12:00 PM, the Maintenance Facilitator confirmed this evidence.

Based on observation and interview it was discovered that the facility failed to properly install the fire alarm system. The deficient practice affected the entire facility, staff and all residents.

The STANDARD is not met as evidenced by:
On January 26, 2010, between approximately 11:30 AM and 1:30 PM, accompanied by the Maintenance Facilitator, it was revealed by observation the fire alarm control panel by the emergency department located by the ambulance entrance doors was not equipped with a smoke detector.

Interviews on January 26, 2010, between approximately 11:30 AM and 1:30 PM, the Maintenance Facilitator confirmed this evidence.