Failure to Conduct Required Community-Based Exercise
Penalty
Summary
The facility failed to meet the emergency preparation testing requirements as outlined in the emergency preparedness plan. Specifically, the deficiency was identified during a document review conducted on March 17, 2025, at 8:40 a.m. The review revealed that the facility did not fulfill the annual requirement for conducting a community-based, full-scale exercise. This exercise is a critical component of the emergency preparedness plan, designed to ensure that the facility is adequately prepared to respond to emergencies. The deficiency was confirmed during an interview with the Facility Administrator and the Maintenance Director on the same day at 1:30 p.m. During this interview, it was acknowledged that the facility had not conducted the required community-based exercise. This lapse indicates a failure to adhere to the regulatory requirements set forth for emergency preparedness in long-term care facilities. The absence of the community-based, full-scale exercise suggests a gap in the facility's emergency preparedness efforts. Such exercises are essential for testing the effectiveness of the emergency plan and ensuring that staff are well-prepared to handle potential emergencies. The failure to conduct this exercise as required could potentially impact the facility's ability to respond effectively in the event of an actual emergency.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0039 Testing Requirements. The facility had previously conducted a community based full scale exercise on March 11, 2025. The facility completed a tabletop exercise on March 25, 2025. The NHA/Designee will ensure the facility completes a community based full scale exercise and tabletop exercise per the regulation.