Missed Fire Drill for Evening Shift
Summary
The facility failed to conduct a required fire drill for the evening shift during the first quarter of 2024. This deficiency was identified during a Life Safety Code recertification survey conducted from January 8 to January 10, 2025. The facility was unable to provide documentation proving that the evening shift fire drill had been completed for the specified period. During an interview on January 10, 2025, the Maintenance Director acknowledged that the evening shift fire drill was missed and confirmed awareness of the requirement to conduct quarterly fire drills for each shift to ensure the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Fire drills are up to date. Maintenance Director will preplan quarterly fire drills to ensure no shift is ever missed going forward. All Maintenance Staff have been educated on the importance of fire drills, including maintaining the quarterly schedule per shift. The Director of Environmental Services will monitor compliance with a fire drill audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Penalty
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