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.