Failure to Conduct Fire Drills at Unexpected Times and Varying Conditions
Penalty
Summary
The facility failed to conduct fire drills at unexpected times and under varying conditions as required by regulations 19.7.1.4 through 19.7.1.7. Record review on April 9, 2025, showed that first shift fire drills in the first quarter were held at similar times in the morning, specifically at 10:00 am and 10:30 am, while third shift drills in the first and second quarters were both conducted around 3:30 am and 3:40 am. This pattern indicates a lack of variation in the timing and conditions of the fire drills. The deficiency was confirmed through an interview with the facility Maintenance Director during the observation period.
Plan Of Correction
K712 Fire Drills Element 1: There have been no negative effects concerning residents related to the fire drills not being conducted at unexpected times, under varying conditions. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on conducting fire drills on all shifts at unexpected times, under varying conditions. Element 4: Facility fire drills will be audited monthly for 4 months to ensure completion at unexpected times, under varying conditions. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.