Failure to Conduct Timely and Varied Fire Drills
Penalty
Summary
The facility failed to properly maintain fire drill procedures as required by NFPA 101. Fire drill records showed that drills were conducted at the same time on multiple occasions, specifically with PM shift fire drills occurring at 3:30 p.m. on two separate dates. Additionally, the facility did not provide evidence of conducting required shift fire drills for several quarters, including the first, second, and fourth quarters of the specified years. Staff interviews confirmed that drills were sometimes scheduled to overlap shifts in an attempt to involve more staff, but this resulted in missing required drills for individual shifts. These deficiencies affected all 95 residents across four smoke compartments.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained: e) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility maintaining a functional HVAC system to ensure proper facility temperatures. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Maintenance Director and/or designee. The Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025 K712 Fire Drills: How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) A fire drill was conducted for PM shift on 01/31/2025, for NOC shift on 02/27/2025, and for AM shift on 03/25/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified as being affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by the Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring that the facility is following the proper procedures and regulations as it pertains to fire drills for all three shifts (AM, PM, and NOC). d) Maintenance Director and/or designee will bring monthly to the department manager morning meeting the fire drill binder to validate that fire drills are being conducted as required.