Observations
Based on a review of fire drill logs from January 2025 - December 2025, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route.
This is a repeat citation from the December 23, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
EFFECTIVE December23,2025 the two exit doors from office area will be separately identified. Front door from outside into waiting room will be known as main door. The other door in main office area will be known as the side door. This door also exits outside. Fire drills will utilize both doors. |