Observations
Based on a review of ten fire drills from January 2021 through October 2021, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The facility used a handheld fire alarm to complete the fire drills rather than setting off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A smoke detector will be purchased and installed Tuesday 11/30/2021 to use for fire drills, since we are not able to use the existing fire system, it goes directly to the fire company went it is set off. The Facility Director will make sure it is installed and operational. |