Observations
Based off of a review of facility records, the facility failed to complete a fire drill during sleeping hours at least every six months.
Fire drill logs provided by the facility documented a fire drill occurring on September 27, 2022 at 2:05am. The next fire drill during sleeping hours was due to be completed no later than March 31, 2023. The next fire drill that occurred during sleeping hours was documented on April 20, 2023 at 6:25am. Fire drills were reviewed from September 2022 through August 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted monthly on rotating shifts, with one drill each quarter being conducted during sleeping hours. The Facility Director will ensure ongoing compliance. |