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Based on record review, interview, and policy review the facility failed to ensure fire drills were held for all shifts of staff quarterly for The third and fourth quarters of 2022 and the first quarter of 2023. The facility cesus was two Swing Bed patients.

Findings included:

1. Review of the fire drill reports for the facility showed:
- The third quarter of 2022 no drills recorded:
- The fourth quarter of 2022 no drill for the second shift: and
- The first quarter of 2023 no drill recorded for the second shift.

2. During an interview on 06/13/23 at 2:30 PM, Staff N, Reespiratory Therapy Lead, stated if there was no record of the fire drill in the book it did not get done.

3. Review of the facility's policy titled, "Fire Plan", dated 01/20/20 showed exercise of the activation of this plan is accomplished by quarterly drills involving all shifts.

Based on policy review and interview, the facility failed to ensure a risk assessment for the facility included failure of utility systems and the potential impact to the facility. The facility census was two Swing Bed patients.

Findings included:

1. Review of the facility's document titled, "Risk Assessment 2023" showed categories for natural disasters, biological disasters, chemical disasters, and radiological disasters. (note: the assessment did not include utility failures)

2. During an interview on 06/13/23 at 2:50 PM, Staff N, Respiratory Therapy Lead, stated he had checked with another staff and there were some policies regarding utility failures such as water which included a backup supply. The facility did not include the risk to the facility for loss of building utilities on the risk assessment.

Based on observation and interview the facility failed to ensure a remote generator stop button was installed. The facility census was two Swing Bed patients.

Findings included:

1. Observation on 06/12/23 at 2:50 PM, the generator location and vicinity did not show a remote stop button.

2. During an interview on 06/12/23 at 2:50 PM, Staff O, Maintenance Technician Lead, stated the facility generator did not have a remote stop button.