Observations
Base on a review of pre-submission paperwork and a review of the fire drill logs on May 29, 2018, the facility failed to conduct an unannounced fire drill durning the month of Febuary 2017.
These findings were confirmed with facility staff during the licensing process
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Plan of Correction
The Maintenance Manger is responsible for maintaining fire drill logs. The Director of Operations met with the Maintenance Manager on 6/1/2018 and discussed fire drill procedures. The Maintenance Manager was re-instructed on all fire drill procedures. A written schedule has been developed that includes scheduling of fire drills at varying hours and routes of exit. This will be monitored by the Director of Operations. |