Complaint·July 28, 2022

On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff say they have attended training on fire drills and there have been some impromptu fire drills. They state this happens between monthly and every 3-4 months. One staff stated “we have not had one this year.” Another staff stated they were not familiar with who was responsible for evacuating which residents. On 7/22/22 between 9:55 am to 10:45 am, LPA interviewed two staff. Staff report there are approximately three fire drills per year and that the maintenance manager conducts them. Further, that the maintenance manager takes staff around the facility and shows them were the fire extinguishers and exits are located. They state that on one occasion, the fire department came out to show them how to evacuate, and on another occasion, “the Alpha Fire guy came and did a demonstration with staff on putting out a fire.” On 7/28/22 at 11:00 am, LPA interviewed the Maintenance Manager who stated that a fire occurred in the laundry room of the facility in 2020. At 12:28 pm, LPA interviewed part-time maintenance staff who stated that there was a fire in the laundry room in July 2020. Maintenance staff does not remember the exact date and specifies that the Wellness Coordinator contacted them at 12:05 am on that day. Maintenance staff arrived at 12:20 am to find the fire department finishing up. Staff says the sprinkler above the dryer put out the fire. On 7/28/22 at 11:26 am, LPA reviewed the training sign-in sheets for fire drills. Between July 2019 and September 2020, fire drill training was conducted on 7/11/19, 11/14/19, 3/12/20, and 6/18/20. The first three trainings were conducted four months apart. LPA reviewed the staff schedule dated 9/24/20 which lists 83 staff, 41 of which are direct care staff. LPA compared this with the list of attendees for each training. At the 7/11/19 training, 14 out of 41 direct care staff attended (34% attendance); at the 11/14/19 training, 19 of 41 care staff attended (46% attendance); at the 3/12/20 training, 27 of 41 care staff attended (66% attendance); and, at the 6/18/20 training, 26 of 41 staff attended (64% attendance). Trainings were not attended by all direct care staff. Based on the evidence obtained, the allegation “Facility staff are not conducting fire drills,” is deemed Substantiated at this time. The facility did not conduct fire drills at minimum once every three months with, at minimum, all direct care staff on each shift attending the training as required with facilities caring for residents with dementia. Deficiency cited on the LIC 9099-D. Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the Vice President and the Administrator.