Observations
Based on the review of the facility's fire drill log for the months of July 2021 through June 2022, the facility failed to conduct a fire drill on different days of the week, at different times of the day and on different staffing shifts. All drills were conducted between the hours of 7 am and 9 am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/12/22, Maintenance Supervisor sent an email was to staff who conduct fire drills to "rotate exits and rotate times of the day when doing the fire drills". On 8/18/22, the fire drill tracking sheet was updated, and Maintenance Supervisor will keep track of all drills to ensure the drills meet the regulatory requirements.
Copy of email and tracking sheet sent to auditor 9/07/2022
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