Failure to Conduct Fire Drills at Varied Times
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
Penalty
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not have documentation showing that a required quarterly fire drill was conducted for one month, despite multiple requests for records during the survey. The missing documentation related to a specific quarter and was confirmed by the Maintenance Director, and this lapse had the potential to affect all 69 residents in the facility.
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Conduct and Document Required Quarterly Fire Drill
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required fire drills on each shift at least quarterly in accordance with NFPA 101 – 2012 Edition, Section 19.7.1. Surveyors reviewed facility records on 03/25/26 beginning at 8:45 A.M. and found no documentation to verify that a fire drill had been conducted in May 2025. Documentation of fire drills was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of exit. The survey identified that this failure to document a quarterly fire drill had the potential to affect all 69 of the 69 residents in the facility. Interview with the Maintenance Director at the time of observation confirmed that there was no documentation available to show that the required fire drill had been conducted for that period.
Plan Of Correction
1. Based on record review and staff interview, no residents experienced negative outcomes related to fire drill documentation deficiencies. 2. The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to provide documentation verifying a fire drill was conducted in May 2025. 3. Fire drill schedule has been implemented and documentation will be maintained for all required drills. 4. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 on the requirements for conducting fire drills on every shift every quarter.
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