Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct the required number of fire drills, as evidenced by a lack of documentation for six out of twelve required drills over the past year. Specifically, there was no documentation for the second and third shift fire drills in the second quarter, the third shift in the third quarter, and all shifts in the fourth quarter. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of documentation for these fire drills.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0712 Fire Drills. The previous month's fire drills are unable to be corrected. Current fire drills are up to date. The Maintenance Director will ensure fire drills are held per regulation and policy. The NHA/designee will perform random audit monthly to ensure the fire drills are held per regulation and policy.