Based on interview and record review, during a site visit conducted on 06/05//24, it was confirmed the facility failed to conduct and record unannounced fire drills every other month at different times of day, evening, and night shifts. Findings include, but are not limited to:

During an interview on 06/05/24, Staff 1 (ED) and Staff 2 AED) indicated the last documented fire drill occurred on 05/23/23. Staff 1 indicated s/he believed the facility had conducted a fire drill more recently, however, could not provide documentation of it.

A review of the fire drill form dated 05/23/23 indicated the facility conducted a fire drill at 11:15 AM.

It was confirmed the facility failed to conduct and record unannounced fire drills every other month at different times of day, evening, and night shifts.

On 06/05/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will have a planned fire drill by the end of this week and conduct one the following week.