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Based on record review and discussion with staff during the course of the survey, it was determined that the facility failed to contain all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. This was evidenced by the following:

During review of the facility records, with the Environmental Services Director, the facilities fire safety plan failed to contain the element of the; Preparation of Floors and Buildings for Evacuation

The Environmental Services Director acknowledge the missing required element of the fire plan during the facility record review.

The Life Safety Code Section 19.7.2.3 requires that; a written health care occupancy fire safety plan shall provide for the following:
(1) Use of Alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and buildings for evacuation
(8) Extinguishment of fire

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect all patient ' s when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted under varying conductions. Time of shifts is one of the conductions. Each shift is 12 hours long. Drills were conducted with in a 60-minute time frame from January, 2016 through December, 2017.

1) 1st shift-four out of four fire drills in the past year were conducted at 1:50, 2:10, 2:30 and 3:00 pm.
2) 2nd shift-three out of four fire drills in the past year were conducted at 05:45, 06:00 and 07:00 pm.

The Environmental Services Director acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.