Lack of Documentation for Quarterly Fire Drills
Penalty
Summary
The facility failed to provide documentation verifying that staff participated in required quarterly fire drills within the previous twelve months. During a document review, it was found that there was no documentation available to confirm that fire drills were conducted prior to June 2, 2025. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of records verifying the completion of fire drills before that date. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1) The facility could not retroactively perform the missing fire drills for 2024. 2) A fire drill was conducted for the month of August to ensure the facility is back into compliance. 3) The maintenance director was re-educated on the quarterly fire drill schedule per shift. 4) The NHA or designee will conduct an audit of the fire drills quarterly for 1 year to ensure fire drills are being completed. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring.