Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712
Based on document review and interview, the facility failed to perform two of 12 required fire drills, affecting the entire facility.
Findings include:
Document review on August 3, 2026, at 9:00 a.m., revealed the facility lacked documentation for two of twelve required fire drills. The second shift, first and fourth quarter fire drills were missing.
Interview with the facility administrator and maintenance director on August 3, 2026, at 1:30 p.m., confirmed the facility lacked documentation for the two fire drills.
| | Plan of Correction - To be completed: 08/12/2026
The facility submits this Plan of Correction as its allegation of compliance.
1.The Administrator and Maintenance Director reviewed the facility's fire drill records and fire drill schedule following the survey finding. The facility identified that documentation was unavailable for two of the twelve required fire drills, specifically the second-shift fire drills for the first and fourth quarters. The facility reviewed its available fire drill documentation to verify completion and documentation of required fire drills.
2. Identification of Others Potentially Affected:
The deficient practice had the potential to affect all residents, staff, and areas of the facility. The Administrator and Maintenance Director reviewed the facility's available fire drill records to identify any additional missing or incomplete fire drill documentation.
3. Systemic Changes:
The Maintenance Director was re-educated by the Administrator regarding the requirement to conduct and document fire drills at least quarterly on each shift, at varying times and under varying conditions, in accordance with applicable Life Safety Code requirements.
A fire drill tracking system will be maintained identifying each quarter, shift, date, time, and completion status. Following each required fire drill, the Maintenance Director or designee will ensure that the fire drill documentation is completed and maintained in the facility's Life Safety records. The Administrator or designee will review the tracking system to verify that all required drills are completed and appropriately documented.
4. Monitoring / Quality Assurance:
The Administrator or designee will audit the fire drill tracking system and supporting documentation monthly for three months and quarterly for three additional quarters to verify that required fire drills are being completed and appropriately documented on each shift. Any identified concerns will be addressed promptly. Results of the audits will be presented to the facility's QAPI Committee for review and recommendations as indicated.
5. Completion Date:
8/12/26
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