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E0036
F

Failure to Annually Update Emergency Preparedness Training and Testing Program

Redding, California Survey Completed on 06-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain compliance with emergency preparedness requirements by not updating its emergency preparedness plan (EPP) training and testing program on an annual basis. During a record review and interview with staff, it was found that the last update to the EPP training and testing program occurred in November 2023, and no subsequent annual update was provided as required. Staff confirmed that the most recent review date was in 2023, indicating that the program had not been reviewed or updated within the required timeframe. This deficiency was identified during a survey in which the facility was unable to produce documentation of an updated EPP training and testing program. The lack of an annual update could affect the facility's ability to ensure proper planning and preparation for emergencies for all 90 residents. The findings were based solely on the absence of the required annual review and update of the emergency preparedness training and testing program.

Plan Of Correction

The facility recognizes the importance of developing and maintaining an emergency preparedness training and testing program. The facility shall continue to provide an EPP training and testing program update annually. The Emergency preparedness training and testing program shall be reviewed June 26, 2025 during the QA Committee meeting. The emergency training and testing program shall be included in the annual review of facility policy and procedures in January 2026 and then each year consecutively in the following January. Further issues regarding the training and testing program of the EPP shall be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or more frequent if necessary. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.

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