Failure to Conduct Fire Drills at Unexpected Times
Summary
The facility failed to conduct fire drills at unexpected times as required by regulations 19.7.1.4 through 19.7.1.7. Record review on May 12, 2023, showed that first shift fire drills for the 2nd and 3rd quarters were both conducted in the early afternoon, while third shift fire drills for the 1st, 2nd, and 4th quarters were all conducted in the early morning hours. This pattern indicates that fire drills were not held at varying and unexpected times as mandated. These findings were confirmed during interviews with the Director of Maintenance and Security and the Maintenance Director at the time of record review. All 39 residents in the facility could be affected by this deficient practice in the event of a fire emergency, as staff may not be adequately prepared for fire situations occurring at truly unexpected times.
Penalty
Surveyors found that the facility did not activate or transmit the fire alarm signal during multiple fire drills conducted during daytime and evening hours, as required by NFPA 101. Documentation showed that three drills held during non-nocturnal hours were recorded as having no alarm activation. In an interview, the DES stated that staff may have avoided pulling the alarm during a drill held around dinner time and also suggested there might have been documentation errors, but could not clearly explain the discrepancies. This practice was cited as having the potential to negatively affect the health and safety of residents, staff, and visitors.
The facility did not conduct fire drills at varied times as required, with records showing that drills for both PM and NOC shifts repeatedly occurred at the same times. This issue was confirmed through record review and staff interview, affecting all residents and smoke compartments.
The facility did not conduct or document six out of twelve required quarterly fire drills across various shifts, as confirmed by both the Administrator and Maintenance Director during the survey exit interview.
Surveyors found that the facility did not have documentation to verify that staff participated in required quarterly fire drills over the past year. The Administrator confirmed that records of fire drills prior to a certain date were not available.
The facility did not conduct or document nine of twelve required quarterly fire drills, with missing records for all shifts in three separate quarters, as confirmed by facility leadership during interviews and document review.
The facility did not perform four out of twelve required fire drills on a random basis, with all first shift drills occurring within the same hour over a twelve-month period. This was confirmed by both the Administrator and Director of Maintenance.
Failure to Activate Fire Alarm System During Day and Evening Fire Drills
Penalty
Summary
Surveyors identified a deficiency in the facility’s conduct of fire drills, specifically the failure to activate and transmit the fire alarm signal during drills that occurred between 6:00 a.m. and 9:00 p.m., as required by NFPA 101, 2012 Edition, Section 19.7.1. Review of the Life Safety materials binder on 3/12/2026 showed that three of twelve documented fire drills—held at 9:30 a.m. on 4/8/2025, 5:30 p.m. on 5/2/2025, and 8:30 p.m. on 8/19/2025—were conducted outside the nocturnal hours of 9:00 p.m. to 6:00 a.m., yet the records indicated that the fire alarms were not activated during these drills. During an interview, the DES reported that for the 5:30 p.m. drill, staff may have chosen not to pull the alarm because it occurred around dinner time, and also suggested that the technician might have mistakenly documented that alarms were not activated, but the DES could not explain why the records were marked that way. This deficient practice was cited as having the potential to negatively affect staff response during an actual fire emergency, potentially affecting the health and safety of residents, staff, and visitors.
Plan Of Correction
K712 – Fire Drills (NFPA 101) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the Director of Environmental Services (DES) immediately re-educated staff responsible for conducting fire drills on requirements to activate and transmit the fire alarm signal during all drills conducted between 6:00 a.m. and 9:00 p.m. Fire drill procedures were reinforced to ensure compliance with NFPA 101 standards. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, the DES conducted a review of all fire drill documentation for the past 12 months to ensure compliance with required alarm activation and documentation standards. Any identified discrepancies were reviewed, and staff involved were re-educated on proper fire drill procedures. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has revised its fire drill policy to clearly require activation of the fire alarm system during all drills conducted between 6:00 a.m. and 9:00 p.m. On 3/12/2026, the DES contacted the company responsible for fire drills to ensure understanding of regulatory requirements, proper documentation, and expectations. On 3/31/2026 the DES in-serviced staff on compliance with required alarm activation and documentation standards. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will review all fire drill documentation monthly for 3 months to ensure compliance with alarm activation requirements and proper documentation. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any identified issues will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Conduct Fire Drills at Varied Times
Penalty
Summary
The facility failed to conduct fire drills at varied times as required by regulation. Record review showed that fire drills for both the PM and NOC shifts were conducted at the same times on multiple occasions within the last 12 months, specifically with PM drills at 4:00 p.m. and NOC drills at 2:30 a.m. This deficiency was identified during a review of fire drill records and confirmed in an interview with the Administrator, who stated that the drills were conducted by the Director of Staff Development. The failure to vary the timing of fire drills affected all 116 residents and all four smoke compartments in the facility.
Plan Of Correction
by the deficient practice. Missing Fire Drill was completed on 12/24/2025 and education was provided to The Maintenance Director and designee. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: The Maintenance Director or designee will maintain Fire drills according to regulation quarterly and be held at different times during the day, with a coded announcement being completed instead of audible alarms. Record keeping of quarterly tests to be gathered in a fire drill binder for reference and evidence of completion and compliance. Any updates necessary will be completed timely and reported to the Safety and QA Committee. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/24/25 K0712
Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that fire drills were conducted quarterly on each shift as required by NFPA 101 standards. Document review revealed that six out of twelve required fire drills were not documented as completed, specifically missing drills for the 1st quarter on the 1st and 2nd shifts, the 2nd quarter on the 2nd shift, the 3rd quarter on the 1st and 2nd shifts, and the 4th quarter on the 3rd shift. During an exit interview, both the Administrator and Maintenance Director confirmed the absence of documentation for these fire drills. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Maintenance director completed all first, second, and third shift fire drills to be in compliance. Maintenance director reeducated by NHA/Designee on K0712 with focus on completing monthly fire drills, logging drills, and placing in life safety binder as per regulation. Maintenance director/designee to audit monthly x 4 to ensure that fire drills are completed and logged into life safety binder. Results of audits to be reviewed at QAA committee monthly to determine the need for further follow-up/monitoring.
Lack of Documentation for Quarterly Fire Drills
Penalty
Summary
The facility failed to provide documentation verifying that staff participated in required quarterly fire drills within the previous twelve months. During a document review, it was found that there was no documentation available to confirm that fire drills were conducted prior to June 2, 2025. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of records verifying the completion of fire drills before that date. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1) The facility could not retroactively perform the missing fire drills for 2024. 2) A fire drill was conducted for the month of August to ensure the facility is back into compliance. 3) The maintenance director was re-educated on the quarterly fire drill schedule per shift. 4) The NHA or designee will conduct an audit of the fire drills quarterly for 1 year to ensure fire drills are being completed. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring.
Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that the required quarterly fire drills were conducted and properly documented for nine out of twelve required instances. Specifically, there was no documentation available to confirm that fire drills had been conducted on all shifts for the 1st, 3rd, and 4th quarters. This was determined through interviews and a review of facility records, during which the facility was unable to provide the necessary logs to demonstrate compliance with fire drill requirements. The Maintenance Supervisor and Director of Safety/Security confirmed the absence of documentation for the specified shifts and quarters during the exit interview. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Missing fire drill documentation is on hand. Director of Safety & Security will ensure fire drills are conducted and that documentation is available for survey team during all inspections.
Failure to Conduct Fire Drills on a Random Basis
Penalty
Summary
The facility failed to conduct four out of twelve required fire drills on a random basis, as evidenced by documentation review and staff interviews. Specifically, observations showed that all first shift fire drills over the past twelve months were performed within the same hour each time (between 9:08 am and 10:03 am), rather than at varying times as required. During the exit conference, both the Administrator and Director of Maintenance confirmed that the fire drills were not performed randomly.
Plan Of Correction
A fire drill has been conducted for the first shift at 11:15 AM. Administrator to re-educate Maintenance Director on fire drills being held at random. Maintenance Director will continue to perform monthly fire drills on a random basis. NHA/designee will conduct audits weekly for 4 weeks and monthly for 2 months to ensure fire drills are being held randomly each month. Audits to be submitted to QAPI for review and recommendations.
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