Failure to Conduct and Document Required Fire Drills
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. During a record review on May 21, 2025, it was found that the facility could not provide documentation showing that the required first shift, first quarter fire drills had been conducted. This deficiency was confirmed through an interview with the maintenance director at the time of the record review. The lack of documentation indicates that staff may not have participated in or been prepared for fire emergency procedures as mandated.