Failure to Conduct Fire Drills with Varying Activation Types
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Section 19.7.1.4 through 19.7.1.7. This deficiency was identified during a documentation review and interview on December 4, 2024, where it was found that for 12 out of 12 fire drills conducted over the past year, there was no indication of the type of device used to activate the fire alarm system, such as pull, smoke, or page. This lack of documentation and variation in activation types had the potential to affect all 83 residents in the facility. The findings were verified by the surveyor at the time of the record review, and the facility's representative confirmed the absence of descriptive details in the fire drill reports. The issue was communicated to the facility's representative during the Life Safety Code survey exit conference on December 5, 2024.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K712 - (F) Fire Drills Element One: The facility immediately modified the fire drill reports to include the type of device used to activate the fire alarm system (pull, page, and smoke). Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to conducting fire drills with varying activation types. Element Four: The maintenance director / designee will audit the newly modified fire drill reports ensuring they are being followed through with an indication of an activation type monthly x3. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024