Failure to Conduct Fire Drills at Varying Times
Penalty
Summary
The facility failed to maintain proper fire drill procedures as required by NFPA 101. Record review and staff interviews revealed that fire drills were repeatedly conducted at the same times for both AM and PM shifts, rather than at varying times as required. Specifically, AM shift fire drills on three separate dates were all conducted at 10 a.m., and PM shift drills on two dates were both conducted at 3 p.m. Staff confirmed they were unaware that fire drill times could not be repeated. This deficiency affected all 103 residents across all five smoke compartments.
Plan Of Correction
K 712: How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? No residents were identified to have been affected by the deficient practice. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other residents were identified to have been affected by the deficient practice, but the facility recognizes that all residents have the potential to be affected by the deficient practice. To gain compliance, two fire drills were conducted on the AM and PM shifts at times different than previously completed. A fire drill was conducted on 04/03/2025 at 7:00 am and on 04/04/2025 at 6:30 pm. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? The Facilities Maintenance Director in-serviced all Maintenance staff that conduct fire drills of the requirements that such drills are to be held at expected and unexpected times, under varying conditions, at least quarterly on each shift. The Facilities Maintenance Director added a monthly fire drill task to the TELS system so that the Maintenance team can conduct such drills at unexpected and varying times on all shifts quarterly. The Maintenance Director and/or Maintenance Lead will be responsible for ensuring the time of the in-service is appropriate.