Failure to Conduct Annual Security Vulnerability Assessment
Penalty
Summary
The facility failed to maintain its security management plan in accordance with NFPA 99 standards. During a record review conducted on April 30, 2025, it was found that the facility did not provide documentation of an annual security vulnerability assessment. The last assessment available was dated January 25, 2023, indicating that the required annual review had not been conducted. This deficiency was identified during a review with the Director of Plant Operations, who acknowledged the findings. The issue was also discussed with the Administrator and the Director of Plant Operations during the exit conference on the same day.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K1150. The annual security vulnerability assessment was completed on 05/15/25 by the Executive Director. The assessment was brought to QAPI on 05/21/25 for review. The security vulnerability assessment will be reviewed annually per K1150 by the Executive Director and QAPI Committee.