Incomplete Fire Drill Records
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101. During a record review and interview with the Administrator, it was found that fire drill documentation for the AM shift during the fourth quarter of 2024 (October, November, December) was missing. The Administrator was unable to provide these records when requested and stated that it was unusual for them not to be in the binders. The facility was given an opportunity to submit the missing fire drill records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. No additional information about the medical history or condition of the residents at the time of the deficiency was provided in the report.
Plan Of Correction
Corrective Action Facility will ensure that fire drills are conducted each quarter each shift. The Director of Staff Development and Maintenance Supervisor is on board with the new plans. Facility already contacted the vendor and explained to them the importance of fire drills in each quarter. Facility got the copies of the missing fire drills conducted from the vendor. Please see attached. Facility will make sure that disaster drill is not mingled with the quarterly fire drills. Identify Other Residents Facility will ensure that other residents in the facility are not affected by this deficiency. As a new plan, there will be a new schedule for the fire drills for the whole year to make sure each quarter, each shift are covered, and with the new documentation sheet, it will be clearly documented. Disaster drills will be separated from the fire drill.