Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct one of the twelve required fire drills, specifically the third shift fire drill for the fourth quarter. This deficiency was identified during a documentation review on January 28, 2025, at 8:30 a.m., which revealed the absence of documentation for the fire drill that should have occurred between October and December 2024. An interview with the Facility Administrator and Maintenance Director confirmed the lack of documentation for this drill, indicating that it was not performed as required by the NFPA 101 standards.
Plan Of Correction
The facility will perform all fire drills as required. The facility will schedule an additional 11-7 fire drill that was missed for the fourth quarter of 2024 and will complete fire drills quarterly for all three shifts as required. Documentation will be stored and maintained by facility.