Failure to Document Emergency Preparedness Exercises
Summary
Edinboro Manor was found to be non-compliant with the emergency preparedness requirements as outlined in 42 CFR 483.73. The facility failed to conduct and document the necessary exercises to test its emergency preparedness plan. Specifically, the facility did not have documentation to verify that an annual tabletop exercise had been conducted. This deficiency was identified during a document review on February 4, 2025. The survey revealed that the facility also lacked documentation for an annual full-scale exercise. These exercises are crucial for testing and evaluating the facility's emergency preparedness plan, ensuring that staff and systems are ready to respond effectively in the event of an emergency. The absence of such documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. An interview with the maintenance supervisor confirmed the lack of documentation for both the full-scale and tabletop exercises. This confirmation further substantiates the finding that Edinboro Manor did not fulfill its obligations to conduct and document these critical emergency preparedness activities, as required by federal regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Edinboro Manor's credible allegation of compliance. The facility will ensure that there is at least one tabletop exercise, and one full-scale exercise completed annually. The facility recently had a change in Administrators effective 12/30/2024. During the Life Safety Survey, proof of an Emergency Preparedness Tabletop discussion could not be found during the inspection. After exit, the facility located documentation of an Emergency Preparedness Tabletop discussion that occurred on 03/21/2024 by past administration. Sign-in sheet and documentation will be provided with this Plan of Correction. The facility will conduct a "full-scale exercise" by 03/13/2025. The full-scale exercise will be reviewed at the monthly Quality Assurance and Performance improvement meeting.
Penalty
Armstrong Rehabilitation and Nursing Center did not conduct or document a full-scale exercise to test its emergency preparedness plan, as confirmed by a lack of records and staff interviews during a survey.
Surveyors found that the facility did not have documentation verifying completion of a required full-scale emergency preparedness exercise within the past year, and facility leadership confirmed the absence of this documentation during interviews.
Maple Winds Healthcare and Rehabilitation LLC did not maintain documentation for the two annual exercises required to test its Emergency Preparedness Plan, as confirmed by interviews and documentation review during a survey.
Surveyors found that the facility did not conduct or document the required annual full-scale emergency exercise or an additional exercise, as confirmed by interviews with facility leadership and a lack of supporting documentation.
The facility did not participate in or document a full-scale community-based emergency preparedness exercise as required, and failed to provide records or after action reports for the only exercise certificate presented, affecting all residents.
Surveyors found that the facility did not provide documentation of required emergency preparedness exercises, including an annual full-scale community-based exercise and an additional annual exercise, as required by federal regulations. This deficiency affected all residents in the facility and was identified during a Life Safety Code recertification survey.
Failure to Conduct and Document Required Emergency Preparedness Exercise
Penalty
Summary
Armstrong Rehabilitation and Nursing Center failed to maintain compliance with federal emergency preparedness requirements by not conducting, testing, and evaluating a full-scale exercise of its emergency plan. During a documentation review, surveyors found that the facility lacked records to verify that such an exercise had been planned or executed as required by regulation. The deficiency was confirmed through interviews with both the administrator and the maintenance supervisor, who acknowledged the absence of documentation related to the full-scale emergency exercise. This lack of evidence indicated that the facility did not meet the annual requirement to participate in a community-based or facility-based functional exercise to test its emergency preparedness plan. No information was provided in the report regarding specific residents, their medical histories, or their conditions at the time of the deficiency. The deficiency was identified during a Medicare/Medicaid Recertification Survey, and the finding was based solely on the facility's failure to document and perform the required emergency preparedness testing.
Plan Of Correction
The systematic change will be to have a full-scale exercise and training so the emergency plan can be tested and evaluated. The Administrator or designee will monitor the training to make sure it occurs and all employees have signed off receiving the training. Going forward, a planned full-scale exercise will be scheduled with local emergency personnel so the emergency plan can be tested and evaluated. Monthly Quality Assurance meetings will review training guidelines. The full-scale exercise will be completed by January 31, 2026. E 0039
Failure to Document Annual Full-Scale Emergency Exercise
Penalty
Summary
A deficiency was identified when the facility failed to maintain its Emergency Preparedness Program as required by federal regulations. During a Medicare/Medicaid Recertification Survey, surveyors reviewed documentation and conducted interviews to assess compliance with emergency preparedness testing requirements. The review, conducted on August 5, 2025, between 8:35 AM and 10:45 AM, revealed that the facility did not have documentation verifying that a full-scale emergency exercise had been conducted within the last twelve months. This documentation is necessary to demonstrate that the facility has tested its emergency plan as required by regulation §483.73(d)(2). During the exit conference, the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director confirmed that the facility lacked documentation of a full-scale exercise. This absence of documentation substantiated the finding that the facility was not in compliance with the emergency preparedness testing requirements.
Plan Of Correction
The facility lacked documentation verifying a full-scale exercise had been conducted in the last twelve months. No residents were affected. All residents have the potential to be affected. A full-scale exercise will be completed within 30 days by the Emergency Preparedness Plan Committee as required. The facility will reach out to the healthcare coalition and will participate in a full-scale exercise if available. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct a semi-annual audit on an ongoing basis to ensure compliance with conducting a full-scale exercise as required. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Failure to Document Required Emergency Preparedness Exercises
Penalty
Summary
Maple Winds Healthcare and Rehabilitation LLC failed to maintain documentation for the two required annual exercises to test its Emergency Preparedness (EP) Plan. During a Medicare/Medicaid Recertification Survey, surveyors reviewed the facility's EP Plan and found that documentation for these exercises was not available for review. An interview and documentation review conducted on July 7, 2025, at 9:05 a.m. confirmed the absence of records for the two annual exercises. The surveyors specifically noted that the facility could not provide evidence that the required emergency plan testing had been conducted as mandated by federal regulations. Further confirmation was obtained during an interview with the Facility Administrator and Maintenance Director later that day. Both individuals acknowledged that the documentation for the two required exercises was not available at the time of the survey. No information regarding specific residents or their medical conditions was included in the findings.
Plan Of Correction
Documentation for the two required annual exercises to test the Emergency Preparedness Plan is now present in the facility. The Maintenance Director/designee will ensure the facility maintains documentation for the two exercises required annually to test the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming documentation for the two exercises are present and available every six months times two. Findings will be reviewed at monthly Quality Assurance Meetings. E 0039
Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale emergency exercise or an accepted substitution, as well as the additional required exercise or accepted substitution, within the previous 12 months. This deficiency was identified through document review and interviews conducted on June 30, 2025. The surveyors found that there was no documentation available to demonstrate that these emergency preparedness exercises had been completed as mandated by federal regulations. During the investigation, interviews were conducted with the Maintenance Supervisor and the Director of Safety/Security. Both individuals confirmed that the necessary documentation for the emergency exercises was not available for review. This lack of documentation indicated that the facility did not meet the regulatory requirement to test its emergency plan through the specified exercises. The deficiency affected the entire facility, as the emergency preparedness exercises are designed to ensure that all staff are familiar with and able to implement the emergency plan. The absence of these exercises and the corresponding documentation was confirmed during the exit interview with facility leadership.
Plan Of Correction
Disaster drills have been scheduled for 2025. The Director of Safety & Security will develop the schedule and ensure at least two drills are scheduled annually. Facility emergency preparedness plan was activated in May 2025 due to elopement. Documentation was added to the emergency preparedness binder. A community-based drill is scheduled for September 2025.
Failure to Conduct and Document Required Emergency Preparedness Exercise
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency exercise within the last 12 months. During the annual Life Safety Code recertification survey, the surveyors requested documentation of such participation, but the facility was unable to provide any records indicating compliance with this requirement. The only documentation provided by the facility was a certificate for participation in the 2024 Great California ShakeOut. However, the facility did not supply an after action report or any record of staff participation related to this exercise. This lack of documentation meant that the surveyors could not verify whether the exercise met the regulatory requirements for a full-scale community-based emergency preparedness drill. During an interview, the Administrator acknowledged that the exercise was overlooked. As a result, the facility was found to be out of compliance with the emergency preparedness testing requirements, which affected all 35 residents in the facility at the time of the survey. No specific details about individual residents' medical histories or conditions were provided in relation to this deficiency.
Plan Of Correction
E 039 E 039 E 039 --- 1. Corrective Action: An after action participation report that will show actual involvement and activity in the community based exercise of the staff will be created on future community based exercise. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Emergency Preparedness Communication plans will be reviewed and updated annually. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of correction: 06/13/2025
Failure to Maintain Emergency Preparedness Testing Requirements
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness testing requirements as outlined in federal regulations. During a record review and interviews with the Director of Subacute and the Director of Plant Operations, surveyors requested documentation of the facility's Emergency Operations Plan and evidence of participation in required emergency preparedness exercises. The facility was unable to provide documentation showing participation in an annual full-scale community-based exercise or an additional annual full-scale exercise to test the emergency plan. The Director of Plant Operations indicated that they needed to locate the after-action report for an actual emergency event that had occurred in the past year, but this documentation was not provided by the deadline given by surveyors. The lack of documentation meant that the facility could not demonstrate compliance with the requirement to conduct at least two emergency preparedness exercises per year, including unannounced staff drills using emergency procedures. This deficiency affected all 59 residents in the facility at the time of the survey. The survey findings were based on the absence of required records and the inability of facility leadership to produce evidence of compliance with emergency preparedness testing standards during the annual Life Safety Code recertification survey.
Plan Of Correction
E 039 Facility was compliant with frequency of drills/actual events as evidenced by the following documents: On 5/30/2024, incident command was set up internally for a water pipe ruptured in the ceiling of a non-patient care hallway. This is contiguous to a supply room and near the kitchen. Code Triage Internal was called and facility engineers were already on-site mitigating the issue. Water was shut off to the building at the street. County and state were notified. (Please see the attachment) On 2/19/2025, incident command was set up due to phone outage and inability to receive incoming calls or make outgoing calls. Internal unit to unit and employee mobile phones being utilized to support communication. First information from IT is that is not a switch issue, but more widespread and involves AT&T. In addition, Pyxis is on critical override. Intermittent computer down. (Please see the attachment). PLAN: Facility will continue to perform mock disaster drills as scheduled per our Environment of Care (EOC)/Emergency Management (EM)/Life Safety (LS) in accordance with state and county guidelines and participate in tabletop exercises with the county and other agencies. All documents will be maintained by the disaster coordinator. A scheduled tabletop exercise is planned for October 16th, 2025 in collaboration with local and State agencies, "The great California shakeout".
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