Failure to Document All-Hazards Risk Assessment
Penalty
Summary
The facility failed to meet emergency preparedness guidelines as required by regulations. During a document review on April 8, 2025, it was found that the facility did not have a documented risk assessment that utilized an all-hazards approach. This is a critical component of the emergency preparedness plan that should be reviewed and updated at least annually for long-term care facilities. An interview with the maintenance director on the same day confirmed the absence of the necessary documentation. The lack of a documented risk assessment indicates that the facility did not comply with the requirement to develop and maintain an emergency preparedness plan based on a facility-based and community-based risk assessment, which is essential for addressing potential emergency events.
Plan Of Correction
Risk assessment was completed for the facility in our company's electronic system. The facility printed the assessment and has placed it in our life safety binder. The maintenance director and administrator will ensure that when the risk assessment is completed, it is printed and placed in the life safety binder at the time of completion.