| 6400.72(b) | There was no screen for the bathroom window. | Screens, windows and doors shall be in good repair. | Root Cause:
The bathroom window is extremely small and is not designed to hold a standard screen. Because the window size does not accommodate a traditional screen frame, a screen was not installed at the time of inspection.
Immediate Corrective Action Taken:
Curtains were installed on the inside of the bathroom window to provide privacy and prevent insects. |
11/14/2025
| Implemented |
| 6400.112(c) | -The fire drill completed in March 2025 does not include the AM/PM designation nor does it include whether it was a sleep or awake drill.
***Note: Inspector is unable to determine whether two sleep drills were conducted in accordance with regulatory guidelines. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Root Cause:
This was a staff oversight. The drill was completed, but the staff member responsible for documentation forgot to indicate whether the drill occurred during AM or PM hours and whether it was a sleep or awake drill. The correct form was used, but required fields were unintentionally left blank.
Immediate Corrective Action Taken:
The staff member who completed the March 2025 drill was interviewed and confirmed the time and drill conditions.
The fire drill form was corrected and updated based on staff verification.
Staff involved in fire drills were immediately retrained on the importance of completing all required fields accurately and fully. |
09/10/2025
| Implemented |