Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility did not perform these exercises within the previous 12 months, which is a requirement under the emergency preparedness regulations. The deficiency affects the entire facility, as the exercises are crucial for ensuring that the emergency preparedness plan is effective and that staff are adequately trained to respond to emergencies. The lack of documentation confirming the completion of these exercises indicates a significant oversight in maintaining compliance with regulatory requirements. During the exit interview on March 12, 2025, the Administrator, Director of Maintenance, and an assistant confirmed the absence of documentation for the required exercises. This confirmation further substantiates the finding that the facility did not meet the necessary standards for emergency preparedness testing.
Plan Of Correction
1. Facility conducted a tabletop exercise on an active shooter event. 2. 4/28/25. 3. The Director of maintenance will create a schedule to have tabletop exercises annually. 4. Director of maintenance will complete random facility audits.