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Based on observation and record review, the facility failed to conduct fire drills at one per shift per quarter. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This facility has a capacity of 12 and census of 1 patient at the time of the survey.

Finding are:

On 8/20/2020 at 11:45 A.M., record review, the facility failed to conduct fire drills for the second shift in the first and second quarters of 2020 and the fourth quarter of 2019. The facility also failed to conduct fire drills in the third shift for the first and second quarters of 2020 and fourth quarters of the third shift of 2019.

During interview conducted on 8/20/2020 at 11:45 A.M., Maintenance personnel stated that they could not find the paperwork for the drills that were missing and did not know where it would be located.