Failure to Conduct Fire Drills Across All Shifts
Penalty
Summary
The facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. Specifically, fire drills were not conducted on the first or third shift in the first quarter of 2024, and no fire drill was conducted on the third shift in the third quarter of 2024. This was confirmed through staff interviews and review of fire drill reports, corrective action plans, and a state fire marshal report. The facility's Emergency and Disaster Plan, last reviewed in November 2024, required that fire drills be conducted monthly and rotated so that each shift participated in a drill at least once per quarter. An interview with the Administrator and Environmental Services Director confirmed the missed fire drills, and a follow-up interview revealed that the state fire marshal issued a violation for this failure. The census at the time was 14 residents, and the deficiency had the potential to affect all residents. The report does not mention any specific residents' medical history or condition at the time of the deficiency.