Failure to Conduct Fire Drills at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. Specifically, record review showed that fire drills for both the 1st and 2nd shifts from the 2nd quarter of 2024 to the present were consistently held at similar, expected times, rather than at unexpected times under varying conditions as required. The times for the 1st shift drills were all around midday, and the 2nd shift drills were all in the mid-afternoon. This pattern was confirmed during an interview with the Maintenance Director at the time of record review. The deficiency could potentially affect all 175 residents in the facility in the event of a fire situation.
Plan Of Correction
K712- Fire Drills 1. The facility failed to conduct fire drills as required by 19.7.1.4 through 19.7.1.7. a. The facility conducted a fire drill at an unexpected time and under varying conditions from the previous month/quarter. 2. The Maintenance Director was educated on the importance of running fire drills at unexpected times and under varying conditions from previous drills. 3. To ensure substantial compliance, the Administrator will do an audit of fire drills monthly for the 6 months. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.