Emergency Preparedness Plan Lacks Required Resident Population Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included policies and procedures addressing the resident population, specifically persons at-risk, the types of services the facility could provide during an emergency, and continuity of operations such as delegations of authority and succession plans. This deficiency was identified through document review and interviews conducted on June 30, 2025, which revealed that the required documentation was not present in the facility's Emergency Preparedness Plan. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the necessary documentation addressing these critical components was not available. The lack of these policies and procedures affected the entire facility, as the plan did not meet the regulatory requirements for addressing the needs of the resident population in emergency situations.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys.