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Based on observation and interview, the facility failed to ensure the "Bubble" office located on the 2nd floor was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception per 19.3.6.1(7). LSC 19.3.6.1(7) states that spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be open to the corridor and unlimited in area, provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits. This deficient practice could affect staff and patients on the 2nd floor.

Findings include:

Based on observation on 06/14/21 at 9:45 a.m., with the Compliance Officer/Director of Quality, the 2nd floor "Bubble" office across from the top of the center stairs was enclosed with plexiglass windows and two glass doors. Each glass door had a hole in the door where a dead bolt latch had been removed. The glass doors also did not latch into the frame. The Bubble office was not separated from the corridor due to the holes in the doors not being capable of resisting the passage of smoke and due to the doors not latching into the frames. The Bubble office did not meet the requirements of the exception of LSC 19.3.6.1(7) in that the Bubble office lacked protection of an electrically supervised automatic smoke detector. Based in interview with the Compliance Officer/Director of Quality, the latches had been removed to correct the issue that had been previously cited involving having 2 steps to open the doors to the Bubble office.