Outdated Emergency Preparedness Plan
Summary
The facility failed to maintain an updated Emergency Preparedness Plan as required by regulations. During the recertification survey, it was found that the plan was not reviewed and updated at least annually, and updated copies were not maintained in the designated locations. Specifically, the emergency plan included outdated information, such as instructions for a fire emergency that mentioned not using elevators, despite the facility being a single-floor building without elevators. Additionally, the plan contained a training posttest dated July 2018, which was outdated and not replaced with a current version. During an interview, the administrator acknowledged the outdated posttest and fire plan, indicating they would be purged and replaced with current documents.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The reference to elevator use was removed from the Emergency Plan tab 21 on 12/17/2024. The updated posttest was added to the Emergency Plan tab 22 on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The administrator has been educated by the regional administrator on completing a comprehensive annual review of the emergency plan. The emergency plan will be reviewed annually and as needed if changes occur. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The Emergency Plan will be updated where necessary during the annual review. Emergency plan changes/updates will be reviewed for recommendations by the Quality Assurance Performance Improvement Committee annually and as needed when changes occur. Responsible Party: Administrator
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.