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Based on record review and staff interview, the facility failed to ensure that they conducted fire drills during varying times per the requirements of:

NFPA 101 Life Safety Code (LSC) 2012 edition, 4.7.1, 4.7.2, 4.7.4, 4.7.6, 19.7.1.4, 19.7.1.6, 19.7.1.7
Code of Federal Regulations (CFR) -42-483.470(i)

This deficiency is a patterned event and has the potential to cause minimal harm to all residents, staff and visitors located throughout the facility.

Findings include:

Record review during facility tour on 12/04/2017 at approximately 1040 hrs to 1210 hrs revealed no documentation for fire drills being conducted during varying times for 1st shift (all quarters of 2017), (9:03 a.m., 9:00 a.m., 8:33 a.m., and 8:10 a.m.); 2nd shift (1st, 2nd, and 3rd quarters of 2017), (4:00 p.m., 3:17 p.m., and 3:18 p.m.); 3rd shift (2nd, 3rd, and 4th quarters of 2017/2016), (6:28 a.m., 6:12 a.m., and 6:30 a.m.).

The Plant Director was present when the deficiency was identified (during record review). Exit interview with the Plant Director and Administrator on 12/04/2017 at approximately 1425 hrs verified knowledge of having no documentation for fire drills being conducted during varying times.