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The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 05/11/16 at10:00 AM, the surveyor was not provided with documentation by the Plant Facilities Engineer 1 and Environment of Care Coordinator that fire drills were conducted for all building staff for all three shifts (one per building, per shift, per quarter). Documentation reviewed on the day of survey indicated that drills were held in one wing of the building for each shift, however the staff and occupants of the wings not involved in the drill had no function or duties other than to standby for further instructions. The facility fire safety policy dated 02-2016 doesn ' t indicate specific duties for staff for the other wings indicating they don ' t participate in the drills other than to standby during a fire alarm announced for another wing.