NY State Tag

F

Emergency Preparedness Deficiency

Eddy Village GreenCohoes, New York Survey Completed on 04-01-2025

Summary

The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility failed to include strategies for addressing each emergency event identified by their risk assessment. There was no documented evidence of emergency policies and procedures for the loss of the sprinkler system, cyber-attacks, and the use of portable generators. This deficiency could potentially affect all residents at the facility. During an interview, the Facilities Manager acknowledged the absence of these policies and procedures and indicated an intention to update the Emergency Plan.

Plan Of Correction

Plan of Correction: Approved April 25, 2025

Element 1
The Emergency Plan was updated to include policy and procedures for:
- Loss of sprinkler
- Cyber-attack
- Use of portable generators

Element 2
All required elements for Emergency Preparedness reviewed to ensure facility plan includes all required elements. No additional changes required.

Element 3
Nursing Education will provide education to all staff regarding the above named areas. The education includes but not limited to the following:
- Interruption of the fire system/sprinkler system
- Cyber-attack
- Portable generators

This education will be included in the annual education and new hire education programs.

Element 4
Emergency Preparedness Plan will be reviewed monthly as part of the safety meeting agenda. Results of the Review will be reported to Quality Committee monthly. This will continue to be a standing item of the Quality Committee and Safety committee. Executive Director responsible for ongoing compliance.

Penalty

No penalty information released