Observations
Based on a review of the facility's September 2024 through July 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation indicating fire drills were conducted during posted operating hours throughout the months of September 2024, November 2024, December 2024, March 2025, and June 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs will include a
cover sheet detailing the findings to include the following:
Exact time of evacuation.
Exit route used.
Number of persons.
Fire alarm or smoke detector operative or inoperative. The director of safety and security will be completing the logs which will be reviewed by the Sr. Manager of Operations. The director of safety and the executive director will ensure that the corrective action plan is implemented by September 25, 2025.
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