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Based on observation and interview, the provider failed to maintain a smoke compartment separation from the area surrounding the nurses' station to the three smoke compartments adjacent to it (zone 7, zone 4, and zone 2 or the areas on the other side of the doors surrounding the nurses' station). Four of seven zones were impacted by the noted penetrations. Findings include:

1. Observation beginning on 8/10/22 at 7:45 a.m. revealed two three-inch penetrations above the ceiling at the smoke doors which seperated the nurses' station from the nurse breakroom (zone 6 from zone 7). The penetrations include one with a bundle of low voltage wiring and one empty. Neither of these was fire protected.

2. Observation beginning on 8/10/22 at 7:55 a.m. revealed two penetrations above the ceiling at the smoke doors north of the nurses' station (zone 6 from zone 2). The penetrations were both empty and were approximately 2" x 2" and 1" x 4". Neither of these was fire protected.

3. Observation beginning on 8/10/22 at 8:05 a.m. revealed a penetration above the ceiling at the smoke doors east of the nurses' station (zone 6 from zone 4). The penetration was a 4" bundle of low voltage wiring. The bundle was not fire protected.

Interview with the maintenance manager at the time of the observations confirmed those findings.

The deficiencies affected four smoke compartments required to maintain corridor smoke separations.

Based on record review and interview, the provider failed to ensure staff was familiar with the provider's fire drill procedures (no drills were conducted on second or third shift, or two of three total shifts were not drilled). Findings include:

1. Record review on 8/10/22 at 10:15 a.m. revealed there was no documentation of drills being conducted during second or third shift over the last twelve-month period. All drills were conducted during first shift otherwise called day shift. The requirement is for fire drills to be conducted once per shift per quarter, or every other month on each shift if only two shifts are used.

An interview with the maintenance supervisor at the time of the record review confirmed those findings. He was unaware of the requirement to conduct drills on all shifts.

The deficiency had the potential to affect 100% of the occupants of the building.