Failure to Conduct Quarterly Fire Drills on Night Shift
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101 standards, specifically not holding a fire drill for the night shift (11 PM - 7 AM) during the fourth quarter of 2024. The review of the facility's fire drill logs during the Life Safety Code Survey on June 6, 2025, revealed this deficiency. The drills that were conducted on March 20, June 20, and August 22, 2024, were all held at similar times in the early morning hours, specifically at 6:00 AM, 6:30 AM, and 6:50 AM, respectively. This lack of variation in timing and the omission of a drill for the night shift in the specified quarter led to the citation. The Director of Maintenance initially stated that all drills had been conducted, but the Administrator later acknowledged the finding during the exit interview.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance will complete the fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. All fire drills will be a minimum of 1 hour apart on each shift and not duplicated in the same 12 month period. Fire drills conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. All Fire Drills are conducted by the Director of Maintenance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Director of Maintenance was re-educated on how to properly conduct fire drills to ensure the facility meets standards established by the National Fire Protection Association (NFPA). The Director of Maintenance developed a Fire Drill spreadsheet to document varied times and conditions of each monthly drill to maintain compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, The Director of Maintenance or Designee will review the fire drill spreadsheet to ensure compliance and report any outstanding findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.