Fire Drill Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire drill requirements as evidenced by the lack of documentation for 11 out of the 12 required fire drills. The document review conducted on January 22, 2025, revealed that the facility did not have records for the first shift during the second, third, and fourth quarters, and for the second and third shifts for all four quarters. The facility explained that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Fire Drill conducted immediately following the safety survey. No negative findings identified. NHA/designee to educate maintenance staff by 21MAR2025 on the fire drill schedule to ensure fire drills are conducted on each shift quarterly. NHA/designee will monitor the fire drills and fire drill documentation quarterly x 3 to ensure they are being done on varying shifts. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.