Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, which affected the entire facility. During a document review on March 12, 2025, it was revealed that the facility could not provide accurate documentation of shift participation in monthly fire drills for several months, specifically March, May, June, August, and October of 2024, and February of 2025. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of accurate documentation.
Plan Of Correction
1. The facility will conduct fire drills immediately on all three shifts. Going forward, the facility will create a schedule for fire drills to ensure they are completed as required. 2. 4/28/25 3. The Maintenance Director was educated on conducting the fire drills once per shift per quarter and intermittently throughout the year on different dates and times. 4. The Director of maintenance will complete random audits.