Deficiency in Required Policies for Snow Removal and Fire Evacuation
Summary
The facility was found deficient in providing required policies during a document review conducted on May 1, 2025. Specifically, the facility failed to produce policies related to snow removal and fire evacuation, which are essential for ensuring the safety and operational readiness of the facility. This deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the absence of the necessary documentation. The lack of these critical policies affects the entire facility, indicating a gap in the facility's preparedness for emergency situations.
Plan Of Correction
Facility will provide required policies, snow removal and fire evacuation affecting the entire facility. Snow removal contract was received, and the fire evacuation was completed and updated in the EP book.
Penalty
Surveyors found that the facility did not have a policy to ensure egress routes to the public way are kept clear of snow or ice. This was confirmed by both the DON and the Director of Maintenance during interviews.
Lack of Snow Removal Policy for Egress Routes
Penalty
Summary
Surveyors determined that the facility failed to provide a policy ensuring that egress routes to the public way remain free and clear in the event of snow or ice. During a document review, it was found that there was no existing snow removal policy in place. This finding was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy.
Plan Of Correction
1. The facility has a Snow Removal Policy that is available for review. 2. The Snow Removal Policy will be placed in the Safety and Disaster Policy & Procedure Manual. 3. The Environmental Services Director will be educated on the Snow Removal Policy. 4. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly every July.
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