Deficiency in Emergency Preparedness Plan for Heating/Cooling
Penalty
Summary
Avalon Care Center was found to have deficiencies in its emergency preparedness plan, specifically related to maintaining appropriate heating and cooling conditions in resident rooms. On November 30, 2024, the facility's air handler heat exchanger failed, affecting twelve out of twenty-four resident rooms. The facility consulted an HVAC vendor who determined that parts needed to be ordered, which would take twenty-one days. In the interim, the facility used space heaters and provided blankets and coats to residents but did not implement additional emergency action plans to ensure resident safety. The vendor later offered a full replacement option that could be completed within a week, and the facility chose to wait for this solution. However, there were no additional interim safety measures implemented while waiting for the replacement. The replacement was completed on December 6, 2024, but the facility's failure to maintain an adequate emergency preparedness plan was confirmed through interviews with the maintenance director and administrator. This deficiency was noted during an emergency preparedness survey conducted on December 6, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. Facility will review and revise emergency preparedness plan as needed to ensure that the building can maintain/provide heating and cooling in resident rooms per requirements.