Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale emergency exercise or an accepted substitution, as well as the additional required exercise or accepted substitution, within the previous 12 months. This deficiency was identified through document review and interviews conducted on June 30, 2025. The surveyors found that there was no documentation available to demonstrate that these emergency preparedness exercises had been completed as mandated by federal regulations. During the investigation, interviews were conducted with the Maintenance Supervisor and the Director of Safety/Security. Both individuals confirmed that the necessary documentation for the emergency exercises was not available for review. This lack of documentation indicated that the facility did not meet the regulatory requirement to test its emergency plan through the specified exercises. The deficiency affected the entire facility, as the emergency preparedness exercises are designed to ensure that all staff are familiar with and able to implement the emergency plan. The absence of these exercises and the corresponding documentation was confirmed during the exit interview with facility leadership.
Plan Of Correction
Disaster drills have been scheduled for 2025. The Director of Safety & Security will develop the schedule and ensure at least two drills are scheduled annually. Facility emergency preparedness plan was activated in May 2025 due to elopement. Documentation was added to the emergency preparedness binder. A community-based drill is scheduled for September 2025.