| 6400.67(a) | At the time of inspection, the individual bedroom door had a large hole in the middle of the door which was covered with what appeared to be contact paper. Additionally in the living far right corner of the room, the plaster wall was separated and there was a space between both walls which began at the ceiling and went to the floor. | Floors, walls, ceilings and other surfaces shall be in good repair. | The crevice was filled with proper wall trim. (Please see images sent via email)
The damaged door was replaced. (KCF per validation documentation) |
03/20/2023
| Implemented |
| 6400.112(e) | The fire drill provided on 3/25/2022 had the time of 11:40 documented. Staff did not distinguish if it was AM or PM. The check box had markings on both awake and asleep areas. The word asleep was written in at the top however due to the form not being filled out properly it is unable to be determined if this was in fact a sleep drill. (for example the Fire Drill provided on 2/24/22 which was held at 6:32pm also had sleep drill written in and that was not a sleep drill but was able to be verified by the correct date and time written on the fire drill form). There was another sleep drill provided on 6/17/2023 which was completed at 11pm. Due to the conflicting documentation provided, this does not fulfill the requirement of a fire drill being held during sleeping hours every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | The fire drill form has been amended with a Large AM or PM to delineate the proper time. As for the Asleep versus Awake the error was made by the staff and erroneously passed internal audit. The clearer form should assist all responsible for the drill procedures. |
03/20/2023
| Implemented |