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Based on observation and interview the provider failed to maintain the fire sprinkler system reaction time as designed in two randomly observed locations (InformationTechnology (IT) closet and IT room) Findings include:

1. Observation on 12/11/24 at 12:02 p.m. revealed approximately one-quarter of the ceiling in the IT closet near the nurse station was missing. That missing portion of the ceiling would allow smoke and hot gasses to bypass the sprinkler head and slow the response of the building's fire suppression system.

Interview with the administrator at that same time revealed she was unaware of that condition.

The deficiency had the potential to affect 100% of the occupants of that smoke compartment.
2. Observation on 12/11/24 at 12:32 p.m. revealed a six inch by one foot ceiling tile in the IT room near the reception desk was missing. That missing portion of the ceiling w would allow smoke and hot gasses to bypass the sprinkler head and slow the response of the building's fire suppression system.

Interview with the administrator at that same time revealed She was unaware of that condition.

The deficiency had the potential to affect 100% of the occupants of that smoke compartment.

Based on observation and interview, the provider failed to maintain a corridor separation from areas not protected by an approved electrically supervised automatic smoke detection system (fire alarm) in one randomly observed areas (employee dining/break room). Finding include:

1. Observation and interview on 12/10/24 at 12:47 p.m. revealed the employee dining/break room area had previously had 2 doors that opened into the corridor. Those doors had been removed and therefore left that area open to the corridor. That area did not have smoke detectors connected to the building's fire alarm system.

Interview with the administrator at that same time confirmed those findings.

The deficiency could affect 100% of the smoke compartment occupants.
Ref: LSC 19.3.6.1(1)(c), NFPA 72 chapter 17.