Failure to Maintain and Communicate Emergency Evacuation Plan Amid Inoperable Sprinkler System
Summary
The facility failed to maintain a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During a record review, it was found that the annual dry sprinkler inspection revealed the attic dry system was capped, leaving only six sprinkler heads active, and the system failed inspection. At the time of the survey, both a CNA and the ADON were unaware that a portion of the sprinkler system was not operational and not functioning as designed and installed. No education or instruction was provided to staff regarding how their response to a fire should change given the inoperable sprinkler system. This finding was confirmed by the Maintenance Director during the survey. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility failed to adequately communicate to staff that the dry sprinkler system was not functioning properly throughout the building and did not clearly define emergency evacuation procedures in the event of system failure. 2. Lack of communication regarding system malfunction and absence of defined evacuation procedures could place all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions taken include: - All facility staff were immediately notified that the dry sprinkler system was not functioning and responded appropriately by initiating fire watch procedures. - The Fire Watch policy has been revised to include specific evacuation protocols. The updated policy now requires immediate evacuation of the affected fire/smoke compartment upon any detection of smoke or fire. - The Maintenance Director was educated on the importance of prompt and clear communication to all staff regarding emergency system failures. - All staff have been re-educated on the updated Fire Watch policy and the emergency evacuation procedures. 4. The Maintenance Director is responsible for timely communication of any emergency system failures to facility staff and will report compliance and communication actions to the Quality Assurance (QA) Committee.
Penalty
During an electrical fire in the main panel room, staff failed to activate the manual fire alarm as required by facility policy. Instead, staff called 911 and notified others verbally, but did not use the nearest manual pull station, resulting in the fire alarm not being triggered and the facility not being fully alerted.
The facility did not provide adequate staff training on fire safety procedures, as two dietary staff members could not correctly explain how to activate the range hood suppression system, and one could not identify the correct extinguisher for a grease fire. These deficiencies were confirmed by the Maintenance Director and Dietary Manager, potentially affecting all residents during a kitchen fire emergency.
Surveyors found that the required evacuation map was missing in the Maple Ridge corridor, which is necessary for identifying locations and evacuation routes. This deficiency was confirmed with the Maintenance Director and could impact 26 of 64 residents during an emergency evacuation.
Two kitchen staff members were found to be unaware of proper response protocols for grease fires and reported not having received training on this topic. This deficiency was observed during a facility tour and interview with the DOM and Kitchen Lead Staff, affecting one of four smoke compartments.
Nursing staff on an upper floor reported not receiving training on evacuation procedures for moving residents to the ground level when elevators are unavailable or during a fire. This was confirmed by the Maintenance Director, indicating a lack of compliance with required emergency preparedness training.
Failure to Activate Fire Alarm During Electrical Fire
Penalty
Summary
The facility failed to follow its own Fire Policy during an incident in which the main electrical panel room's switchboard caught fire. When smoke was discovered, staff members responded by calling 911 and notifying other staff, but did not activate the manual fire alarm system. The fire alarm did not trigger automatically, and no one pulled the nearest manual fire alarm, which was located near the exit doors by Resident Room 17 and the Director of Staff Development's office. This omission was confirmed through interviews with the Director of Staff Development and the Maintenance Supervisor, as well as direct observation of the location of the manual pull station. A review of the facility's Fire Policy indicated that staff are required to alert others over the intercom and pull the nearest fire alarm in the event of a fire. Despite this clear directive, staff did not follow the procedure, resulting in a failure to alert all individuals in the facility during the fire event. The deficiency was identified through interviews, record review, and observation, and it affected the safety of all 49 residents, staff, and visitors present at the time.
Plan Of Correction
K 0711 Corrective action for residents found to have been affected by this deficiency: On 07/28/2025, the Administrator provided a 1:1 in-service to the Director of Staff Development (DSD) and to Housekeeping 1 (HSK 1) on the Facility's Fire Policy and Procedure; and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Corrective action for residents that may be affected by this deficiency: On 07/27/2025, 07/28/2025, and 08/03/2025, the DSD provided an in-service to department heads, nurses, dietary, activity, housekeeping/laundry, maintenance, and other staff on the Facility's Fire Policy and Procedure and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Measures that will be put into place to ensure that this deficiency does not recur: During daily rounds, the DSD will randomly ask staff members on all shifts what to do in case of fire to ensure pulling the fire alarm is identified. Discussion on activating the fire alarm will be part of the monthly fire drills performed by the facility's Fire Life Safety & Security vendor. During the initial orientation, the DSD will ensure new hires will be familiar with the facility's Fire Policy and Procedure, including pulling the fire alarm. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use the indicator, "Fire Drill Program," monthly, to ensure staff
Deficient Fire Safety Training and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.
Plan Of Correction
Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.
Missing Evacuation Map in Corridor
Penalty
Summary
The facility failed to provide the required evacuation map in the Maple Ridge corridor, as observed during a survey. The evacuation map is necessary to identify locations within the facility and to highlight designated evacuation routes to the exterior of the building. This deficiency was confirmed through observation and interview with the Maintenance Director. The lack of an evacuation map could affect 26 of 64 residents in the event of a fire or other emergency requiring area evacuation. Employees were not periodically instructed in their duties under the evacuation plan as required by regulatory standards, and the written plan for the protection and evacuation of all residents was not fully implemented in this area.
Plan Of Correction
ELEMENT 1 On 6/27/25 an evacuation map was placed on Autum Ridge to identify the current location within the facility and highlight designated evacuation routes to the exterior of the facility. ELEMENT 2 Rounds were conducted by the Maintenance Director and/or designee on all fire corridors to ensure there are evacuation maps present. ELEMENT 3 The Maintenance Director has been reeducated on maintaining evacuation maps throughout the building in all fire corridors. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 1 month to ensure all fire corridors have the required evacuation maps. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Kitchen Staff Lacked Training on Grease Fire Response
Penalty
Summary
During a facility tour and interview with the Director of Maintenance, it was observed that kitchen staff were not aware of the proper response protocols for addressing a grease fire in the cooking facilities. Two kitchen staff members were specifically asked about the procedures to follow if a grease fire were to occur on the griddle or stove top. Both staff members stated that they did not know the appropriate response protocols and confirmed that they had not received training on how to respond to a grease fire. The deficiency was identified in one of four smoke compartments and was witnessed by the Director of Maintenance and the Kitchen Lead Staff during the interview. The lack of staff knowledge and training regarding grease fire response was cited as a failure to maintain the cooking facilities in accordance with NFPA 101: Life Safety Code, which requires employees to be instructed in life safety procedures and devices.
Failure to Train Staff on Emergency Evacuation Procedures
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During an interview, nursing staff on the second floor reported that they had not received periodic training on procedures for removing residents from elevated floors to the ground level if elevators were not operable or during a fire situation. This lack of training was confirmed by the Maintenance Director at the time of observation. The deficiency was identified through direct questioning of staff and was based on their statements regarding the absence of such training since their employment at the facility. No specific residents or their medical conditions were mentioned in the report, and the findings were based solely on staff interviews and confirmation by facility leadership.
Plan Of Correction
K711 - Evacuation and Relocation Plan. 1. The facility failed to ensure there is a written plan for the protection of all residents and for their evacuation in the event of an emergency, employees are periodically instructed in their duties under the plan as required by 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3. a. The facility will schedule annual education and drill for the evacuation of residents from elevated floors to the ground level. 2. The Administrator/safety committee will be educated on the importance of routinely educating and scheduling drills of the evacuation of residents from elevated levels to the ground. 3. To ensure compliance is maintained, the Administrator will complete audits monthly to ensure staff are educated on the evacuation of residents from elevated levels. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
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