Observations
Based on a review of administrative records and staff interview, the facility failed to conduct unannounced fire drills at least once a month. The facility fire drill log showed that no fire drills were conducted in March 2025 and April 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will conduct unannounced fire drills at least once per month and document each drill using the standardized digital fire drill log. The Facility Director, or a designated backup when unavailable, will be responsible for completing and documenting the drill. All staff will be re-educated on fire drill requirements and documentation procedures by 11/28/2025, with expectations reviewed during new-hire onboarding. To ensure ongoing compliance, the Facility Director will review the digital fire drill log one week prior to the end of each month to verify that the drill has been completed and properly documented and will take immediate corrective action if it has not. Monthly fire drill completion will also be included in the agency's internal quality assurance monitoring. Full compliance will be achieved by 11/28/2025. |