Observations
Based on a review of the facility's February 2025 through February 2026 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
At the time of the inspection, every fire drill conducted during the reviewed period had logs which indicated that only the front door was utilized. There was no other documentation indicating alternate exit routes were prepared and used during drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action Taken:
Staff have been trained on the use of both primary and alternate exits, and a fire drill utilizing the alternate exit has been completed 3/31/26 and documented.
Systemic Changes to Prevent Recurrence:
Moving forward, fire drills will utilize alternating exit routes on a monthly basis. Each month, a different emergency exit route will be used to ensure staff and clients are familiar with all designated evacuation paths.
Monitoring Plan:
The Facility Director will be responsible for ensuring compliance. Fire drill logs will be reviewed on a monthly basis to confirm that alternate exits are being utilized and properly documented. Any deficiencies will be addressed immediately with staff retraining.
Responsible Party:
Facility Director |