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Tag No.: K0712
Based on observation and record review, the facility failed to conduct fire drills at one per shift per quarter. This deficient practice has the potential of affecting all occupants in two of two smoke zones. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This facility has a capacity of 15 and census of 0 patients at the time of the survey.
Finding are:
On 6/10/2025/2025 at 1200 P.M., record review, the facility failed to conduct a fire drill for the second shift in the third quarter of 2024.
During interview conducted on 6/10/2025 at 12:00 P.M., Maintenance personnel stated that they were unaware of the missing drill.