HospitalInspections.org

Based on record review and staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. This had the potential to affect 7 of 7 patients, that are currently patients in the facility, as identified by the nursing staff on 05/22/25. The facility had a census of 7 patients.

Findings:

1. A review of the facilities fire drill reports was conducted on 05/22/25 at 11:15 a.m.. There was no documentation the facility had conducted a fire drill the first or second shifts during the fourth quarter of the year 2024.

2. The maintenance director acknowledged there were missing reports.