Failure to Conduct Required Fire Drill
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 a required fire drill for the second shift during the second quarter of 2024. This deficiency was identified during a document review on April 7, 2025, at 9:00 a.m. The absence of this fire drill was confirmed during an exit interview with the Administrator and the Maintenance Director later that day at 2:00 p.m. The report indicates that the facility did not meet the requirement of holding fire drills at least quarterly on each shift, as mandated by NFPA 101 standards.
Plan Of Correction
Maintenance staff will ensure fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. Maintenance staff will review fire drill logs with the Quality Council to ensure compliance.