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Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 19 of 19 residents.


Findings:

During the record review on 1/13/2015 it was observed that fire drills were not being conduted 1 per shift per quarter.

Interview with Maintenance Director revealed the facility was made aware on 12/19/2014 fire drills were not being held. Maintenance Director informed that this was security dept responsibility and they have started correcting this issue.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 19 of 19 residents.

Findings:

During the facility tour and the record review on 1/13/2015 it was revealed that the fire alarm system's last annual certification was conducted on 8/27/2013.

Interview with Maintenance Director revealed the facility was aware that the required inspections had not been conducted on the fire alarm system. Maintenance Director advised part is on order and will be installed upon arrival so system can be certified.