Missing Attendance Sheets for Fire Drills
Summary
The facility failed to ensure that fire drills were conducted under varied conditions as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the fire drill logs for the fourth quarter of 2024 were missing attendance sheets for the Day, Evening, and Night shifts. This omission made it impossible to verify staff participation in the drills. The Director of Maintenance confirmed in an interview that the fire drills are conducted by an outside vendor and acknowledged the absence of the attendance sheets.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K712 Completion Date: (No later than 60 days from exit date 03/20/2025) (05/19/2025). I. Immediate Corrective Action: 1. Fire Drill Attendance Sheets for Fourth Quarter of 2024: - On 3/20/25, the Director of Maintenance contacted the outside vendor responsible for conducting the fire drills to request the missing attendance sheets for the Day, Evening, and Night shifts from the fourth quarter of 2024. - The vendor provided the missing attendance sheets on 3/20/25, which were then added to the facility's fire drill records for the appropriate quarter. 2. Fire Drill Documentation Review: - The Director of Maintenance immediately reviewed the fire drill documentation for all prior quarters to ensure that attendance sheets for all shifts were present and complete. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of the fire drill logs for the entire year 2024 to ensure that all attendance sheets were accounted for. III. Systemic Changes: 1. An in-service was conducted by the Director of Maintenance for all maintenance staff on the importance of verifying and maintaining complete fire drill records, including attendance sheets. - A reminder was also issued to the outside vendor to ensure that all necessary documentation is submitted following each drill. IV. Quality Assurance: 1. The Director of Maintenance established a monthly internal audit to ensure that fire drill logs, including attendance sheets, are complete and accurate. - The audit will be conducted monthly for six months, and findings will be reviewed to ensure full compliance with NFPA 101. 2. The results of the audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
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.
The facility did not comply with NFPA 101 fire drill requirements when document review showed that, in most quarters reviewed, second and third shift fire drills were conducted within the same hour slot instead of at varied times. Fire drills are required to occur at expected and unexpected times under varying conditions on each shift, and the administrator and maintenance supervisor confirmed this scheduling deficiency during the survey.
Surveyors found that the facility did not comply with NFPA 101 fire drill requirements when record review with the Maintenance Director showed missing documentation of quarterly fire drills for the third shift in one quarter and for the second and third shifts in another quarter. Required drills, which must simulate emergency fire conditions and include fire alarm activation or coded announcements at night, were not documented as completed for these periods. The Maintenance Director acknowledged the absence of records, and the deficiency was cited under NFPA 2021 19.7.1 as a Class III violation affecting all occupants.
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.
Surveyors found that the facility did not activate or transmit the fire alarm signal during multiple fire drills conducted during daytime and evening hours, as required by NFPA 101. Documentation showed that three drills held during non-nocturnal hours were recorded as having no alarm activation. In an interview, the DES stated that staff may have avoided pulling the alarm during a drill held around dinner time and also suggested there might have been documentation errors, but could not clearly explain the discrepancies. This practice was cited as having the potential to negatively affect the health and safety of residents, staff, and visitors.
The facility did not conduct fire drills at varied times as required, with records showing that drills for both PM and NOC shifts repeatedly occurred at the same times. This issue was confirmed through record review and staff interview, affecting all residents and smoke compartments.
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 Vary Fire Drill Times Across Shifts
Penalty
Summary
The facility failed to meet NFPA 101 fire drill requirements by not varying the times of fire drills across work shifts as required. Document review showed that for three of four testing quarters, the second and third shift fire drills were conducted within the same hour slot, rather than at different, varying times. Fire drills are required to be held at expected and unexpected times under varying conditions at least quarterly on each shift, including between 9:00 p.m. and 6:00 a.m. when a coded announcement may be used. During an interview, the administrator and maintenance supervisor confirmed this fire drill deficiency at the time of the survey. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the scheduling and conduct of fire drills for staff and facility safety procedures.
Plan Of Correction
Formatted text (without <text> tags or quotes): Maintenance department was educated on the need for fire drills – quarterly on each shift at varying hour time slots. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that monthly inspections are completed at varying timeframes and hour time slots. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Conduct and Document Required Quarterly Fire Drills on All Shifts
Penalty
Summary
Surveyors identified a deficiency related to fire drill compliance and documentation under NFPA 101 (2021). During record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that required fire drills had been performed. Specifically, fire drills were missing for the first quarter of 2026 on the third shift, as well as for the second and third shifts of the last quarter of 2025. The cited regulations require that fire drills in health care occupancies simulate emergency fire conditions, include activation of the fire alarm system notification appliances (with limited exceptions for nighttime coded announcements), and be conducted at least quarterly on each shift. The survey findings noted that these missing drills and lack of documentation represented a failure to comply with NFPA 101 2021, Section 19.7.1, which mandates quarterly fire drills on each shift to familiarize personnel with emergency signals and required actions. The Maintenance Director acknowledged that the facility failed to provide documentation that the fire drills were performed for the identified quarters and shifts. The deficiency was classified under NFPA 2021 19.7.1 as a Class III violation and was determined to have the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
Facility conducted fire drills on all three shifts. These drills were done on [R] , and [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. Facility conducted fire drills on all three shifts. These drills were done on [R] , [R] , and [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
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.
Failure to Activate Fire Alarm System During Day and Evening Fire Drills
Penalty
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
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
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