K0712

E

Failure to Activate Fire Alarm System During Day and Evening Fire Drills

Claremont, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s conduct of fire drills, specifically the failure to activate and transmit the fire alarm signal during drills that occurred between 6:00 a.m. and 9:00 p.m., as required by NFPA 101, 2012 Edition, Section 19.7.1. Review of the Life Safety materials binder on 3/12/2026 showed that three of twelve documented fire drills—held at 9:30 a.m. on 4/8/2025, 5:30 p.m. on 5/2/2025, and 8:30 p.m. on 8/19/2025—were conducted outside the nocturnal hours of 9:00 p.m. to 6:00 a.m., yet the records indicated that the fire alarms were not activated during these drills. During an interview, the DES reported that for the 5:30 p.m. drill, staff may have chosen not to pull the alarm because it occurred around dinner time, and also suggested that the technician might have mistakenly documented that alarms were not activated, but the DES could not explain why the records were marked that way.

This deficient practice was cited as having the potential to negatively affect staff response during an actual fire emergency, potentially affecting the health and safety of residents, staff, and visitors.

Plan Of Correction

K712 – Fire Drills (NFPA 101) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the Director of Environmental Services (DES) immediately re-educated staff responsible for conducting fire drills on requirements to activate and transmit the fire alarm signal during all drills conducted between 6:00 a.m. and 9:00 p.m. Fire drill procedures were reinforced to ensure compliance with NFPA 101 standards.

How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, the DES conducted a review of all fire drill documentation for the past 12 months to ensure compliance with required alarm activation and documentation standards. Any identified discrepancies were reviewed, and staff involved were re-educated on proper fire drill procedures.

What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has revised its fire drill policy to clearly require activation of the fire alarm system during all drills conducted between 6:00 a.m. and 9:00 p.m. On 3/12/2026, the DES contacted the company responsible for fire drills to ensure understanding of regulatory requirements, proper documentation, and expectations. On 3/31/2026 the DES in-serviced staff on compliance with required alarm activation and documentation standards.

How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will review all fire drill documentation monthly for 3 months to ensure compliance with alarm activation requirements and proper documentation. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any identified issues will be corrected immediately. The QAPI committee will monitor compliance until sustained.

Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026