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Based on observation and interview, the provider failed to maintain corridor separation from use areas by ceilings with at least a 30 minute fire resistance rating. The housekeeping closet and electrical room by the board room had no ceiling to maintain a smoke barrier. (Refer to LSC 2000 Section 8.4.1.2 Special Hazard Protection.) Findings include:

1. Observation at 8:30 a.m. on 2/15/12 revealed the ceiling in the housekeeping closet and adjoining electrical room by the board room did not exist. The rafters were visible in both ceilings. The automatic sprinkler heads and smoke detection system was located in the attic space of those visible rafters. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that finding. He stated he was aware those ceilings had not been finished with gypsum board, tape, and texture like the walls of the room. He stated the chief executive officer (CEO) was working with the contractors to have the ceilings finished. Interview with the CEO at 8:45 a.m. on that same day revealed she had been in contact with the general contractor. She stated she had contacted the Department of Health regarding the pending repairs to those ceilings and why they were needed. She stated she had not contacted the Department of Health to request a waiver to extend the date of the plan of correction past 2/9/12.