Failure to Conduct Fire Drills at Varied Times
Penalty
Summary
The facility failed to conduct fire drills at varied times as required by regulation. Record review showed that fire drills for both the PM and NOC shifts were conducted at the same times on multiple occasions within the last 12 months, specifically with PM drills at 4:00 p.m. and NOC drills at 2:30 a.m. This deficiency was identified during a review of fire drill records and confirmed in an interview with the Administrator, who stated that the drills were conducted by the Director of Staff Development. The failure to vary the timing of fire drills affected all 116 residents and all four smoke compartments in the facility.
Plan Of Correction
by the deficient practice. Missing Fire Drill was completed on 12/24/2025 and education was provided to The Maintenance Director and designee. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: The Maintenance Director or designee will maintain Fire drills according to regulation quarterly and be held at different times during the day, with a coded announcement being completed instead of audible alarms. Record keeping of quarterly tests to be gathered in a fire drill binder for reference and evidence of completion and compliance. Any updates necessary will be completed timely and reported to the Safety and QA Committee. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/24/25 K0712