Observations
The facility failed to conduct an unannounced fire drill for the months of April, May, June, July, August and September 2018. This was discovered during the review of the April 2018 through January 2019 fire drill logs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/01/2019, the Office Manager will complete fire drills monthly as required by the regulation. Ongoing compliance will be monitored by the Nursing Director through random review of the agency Fire & Safety Record log book. |