Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide correct and accurate documentation of shift and staff participation in monthly fire drills for the months of July 2024 through November 2024. An exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance confirmed the reuse of shift and participation documentation for these months.
Plan Of Correction
While paperwork was present, there was missing information. Fire Drill paperwork will be completely redone by January 15th, 2025, to fill in the missing information. Information will be checked monthly for accuracy.