Lauderdale Community Hospital

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 35244 Based on interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that met the requirements for Critical Access Hospitals (CAH), utilizing an all-hazards approach. The findings included: 1. The CAH failed to develop and maintain an EP plan to be reviewed and updated every 2 years. Refer to E 004 2. The CAH failed to establish a documented community and facility-based risk assessment, utilizing an all hazards approach. Refer to E 006 3. The CAH failed to document the patient population served, patients at risk and services available during an emergency. Refer to E 007 4. The CAH failed to document efforts to contact and collaborate with local, regional, state and Federal EP officials to ensure its participation in collaborative and cooperative planning efforts during a disaster or emergency situation. Refer to E 009 5. The CAH failed to implement, document, review and update policies and procedures every 2 years based on the emergency plan. Refer to E 0013 6. The CAH failed to develop policies and procedures for provision of subsistence needs for hospital staff and patients during an emergency. Refer to E 0015 7. The CAH failed to document a system to track the location of on-duty staff and sheltered patients during an emergency. Refer to E 0018 8. The CAH failed to document a means for sheltering in place during an emergency. Refer to E 0022 9. The CAH failed to ensure it developed policies for maintaining confidentiality of records during an emergency. Refer to E 0023 10. The CAH failed to develop policies and procedures for the use of volunteers and other staffing strategies in case of an emergency. Refer to E 0024 11. The CAH failed to develop policies and procedures for prearranged transfer agreements to receive patients during an emergency. Refer to E 0025 12. The CAH failed to develop a written communication plan that contained how the facility would coordinate patient care within the facility, across healthcare providers and with state and local health departments during an emergency. Refer to E 0029 13. The CAH failed to include updated contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan. Refer to E 0030 14. The CAH failed to include updated contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. Refer to E 0031 15. The CAH failed to ensure it developed a communication plan that included primary and alternate means of communication with facility staff, Federal, State and local emergency management agencies. Refer to E 0032 16. The CAH failed to ensure it developed a plan for sharing medical information and documentation during an emergency. Refer to E 0033 17. The CAH failed to ensure it developed a way of providing information about the facility’s needs and its ability to provide assistance to the authority having jurisdiction during an emergency. Refer to E 0034 18. The CAH failed to develop a training and testing program based on the facility ’ s risk assessment and communication plan. Refer to E 0036 19. The CAH failed to train all staff on the EP program, based on facility risk assessment and communication plan. Refer to E 0037”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 35244 Based on observation and interview, the facility failed to ensure supplies were not stored past their expiration date for 1 of 4 (11/17/2025) observation days. The findings included: 1. Observations in the surgical central supply room on 11/17/2025 at 10:35 AM revealed the following expired supplies: a. Blade shield scalpel holder 12 per box-7 boxes expired 10/31/2025. b. Central Venous Pressure (CVP; central line) Dressing Tray- 5 expired 3/31/2025. c. Universal Retrieval System 5 millimeter (ml) Endoscopic Pouch- 2 expired 9/19/2025. In an interview on 11/17/2025 at 10:35 AM, the Chief Nursing Officer (CNO) verified the expired supplies. Observations in the surgical overflow supply room on 11/17/2025 at 10:40 AM revealed the following expired supplies: a. Magnetic Drape 10 inches by 16 inches (10x16)- 1 expired 12/31/2024. 7 drapes expired 5/31/2025. Observations in Nurse’s Station #1 crash cart on 11/17/2025 beginning at 11:20 AM revealed the following expired supplies: a. Ultrasite injection site cap- 2 expired 7/31/2025. b. 22 gauge (ga) x 1.00 inch catheter intravenous (IV) needles- 4 expired 9/30/2025. c. 14 ga x 1.75 inch catheter IV needles- 1 expired 1/31/2024. 1 expired 7/31/2024. d. 20 ga x 1.00 inch catheter IV needles- 4 expired 8/31/2025. e. 16 ga x 1.16 inch catheter IV needles- 2 expired 2/28/2025. f. 18 ga x 1.16 inch catheter IV needles- 4 expired 8/31/2024. g. 50 ml syringe cap tip- 1 expired 7/31/2024. h. 60 cubic centimeter (cc) syringe luer lock tip-1 expired 1/5/2024. i. Primary Plum blood set- 1 expired 2/1/2025. 1 set expired 8/1/2025. j. Tracheostomy tube cuffed with inner cannula, 2 per box- 1 expired 4/23/2024. 1 cuff expired 2/19/2025. k. Tracheostomy tube cuffless with disposable inner cannula- 1 expired 12/17/2023. l. Surgical gloves size 7 ½- 2 pairs expired 8/28/2024. m. Biogel ultra touch gloves size 8 ½- 2 pairs expired 2/28/2025. In an interview on 11/17/2025 at 11:25 AM, the CNO verified the expired supplies. Observations in Nurse’s Station #2 medication room on 11/17/2025 beginning at 11:30 AM revealed the following expired supplies: a. Pneumothorax kit 8 French 16 centimeter (cm)- 1 expired 11/30/2024. b. Central Venous Catheter (CVC) insertion tray 7 French 20 cm- 2 trays expired 5/16/2024. In an interview on 11/17/2025 at 11:30 AM, the CNO verified the expired supplies.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 35244 Based on policy review, observation and interview, the facility failed to ensure medications were not stored past their expiration date and failed to ensure medication containers were labeled with the date they were opened for 1 of 4 (11/17/2025) observation days. The findings included: 1. Review of the facility’s “SAFE/SECURE STORAGE AND HANDLING OF MEDICATIONS” policy (revised 7/2025) revealed, “ ...6. Expired, damaged and/or contaminated medications are segregated until they are removed from the institution. A. Storage areas for these medications are clearly distinct and separate from usable medications...” Review of the facility’s “Policies and Procedures for Hospital Pharmacy Services” policy (revised 9/2025) revealed, “ ...Multi-dose vials are dated and discarded according to hospital policy ...Expired, unusable, and improperly labeled medications are removed and returned to the pharmacy...” 2. Observations in the Emergency Department (ED) medication room on 11/17/2025 beginning at 11:10 AM revealed the following opened medications with no label of the open date: a. Pepto Bismol Ultra 4 fluid ounces x 1. b. Cough and Chest Congestion DM 4 fluid ounces x 1. c. Hydrogen Peroxide 8 fluid ounces x 1. In an interview on 11/17/2025 at 11:15 AM, the Chief Nursing Officer (CNO) verified the medications were opened with no label of open date. The CNO stated opened medications should be labeled with date they were opened. Observations on Nursing Station #1 crash cart on 11/17/2025 beginning at 11:20 AM revealed the following medications stored past their expiration date: a. 0.9 percent (%) Sodium Chloride 10 milliliter (ml) syringe-1 expired 4/30/2025. In an interview on 11/17/2025 at 11:25 AM, the CNO verified the expired medication. Observations in the Nursing Station #2 medication room on 11/17/2025 beginning at 11:30 AM revealed the following opened medications with no label of the open date: a. Acetaminophen 160 milligrams (mg) per 5 ml 4 fluid ounces x 1. b. Milk of Magnesia 16 fluid ounces x 1. c. Children’s Allergy Relief Diphenhydramine 12.5 mg/5 ml oral solution 4 fluid ounces x 1. d. Children’s Ibuprofen 4 fluid ounces x 1. In an interview on 11/17/2025 at 11:35 AM, the CNO verified the medications were opened with no label of the open date.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to ensure nursing staff followed physician orders and policy for wound care for 1 of 1 (Patient #4) patients reviewed with wounds. The findings included: 1. Review of the facility’s “ORDERS: VERBAL, TELEPHONE AND WRITTEN POLICY” policy (reviewed 6/2025) revealed, “...The record should contain both a valid physician’s order and documentation that the service was provided ...” 2. Medical record review for Patient #4 revealed an admission date of 11/1/2025 with diagnosis of Sepsis. a. Review of physician order dated 11/3/2025 revealed Left hip wound to be cleansed with wound cleanser, skin prep (protective barrier) applied to peri-wound, foam dressing placed on wound and changed every 3 days. Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed left hip dressing was changed on 11/3/2025 and 11/19/2025. There was no documentation nursing staff changed the left hip wound dressing every 3 days as ordered. b. Review of a physician order dated 11/3/2025 revealed the left lateral ankle wound was to be cleansed with wound cleanser, skin prep applied to peri wound area, areas of tissue loss covered with xeroform (non-adhesive, petrolatum impregnated gauze) then abdominal (ABD) pad (wound dressing with thick absorbent layer), wrapped with kerlix (type of stretchy bandage roll) and secured with tape. Dressing to be changed daily and as needed for soiling. Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed the left lateral ankle dressing was changed 11/3/2025, 11/8/2025, 11/12/2025, 11/15/2025 and 11/19/2025. There was no documentation nursing staff changed the left lateral ankle wound dressing every day as ordered. c. Review of physician orders dated 11/3/2025 revealed the right foot wound was to be cleaned with cleanser, covered with 4 X 4 adaptic (non-adhering wound dressing), ABD, kerlix and tape; Dressing to be changed daily. Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed the right foot dressing was changed 11/3/2025, 11/4/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/15/2025 and 11/18/2025. There was no documentation nursing staff changed the right foot wound dressing every day as ordered. In an interview on 11/19/2025 at 2:00 PM, the Vice President of Clinical services verified wound care for Patient #4 was not documented as ordered by the physician.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 35244 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of infectious bacteria for 3 of 4 (11/18/2025, 11/19/2025 and 11/20/2025) observations days. The findings included: 1. Review of the facility’s “HAND HYGIENE” policy (reviewed/revised 2/2025) revealed, “ ...personnel should always wash ...Before contact with wounds or IV [intravenous] sites ...After glove removal ...After contact with objects visibly or likely to be contaminated with blood or body fluids whether or not gloves are worn ...After each direct patient contact ...” 2. Observations in Patient #5’s room on 11/18/2025 at 9:00 AM, revealed Registered Nurse (RN) #1 was performing medication administration. RN #1 picked an object up off the floor, put on gloves, and proceeded to administer medications to Patient #5. RN #1 failed to perform hand hygiene after picking an object up off the floor. Observations in Patient #4’s room on 11/19/2025 at 10:00 AM, revealed Licensed Practical Nurse (LPN) #1 was performing wound care to two wounds (left ankle and left hip) on Patient #4. LPN #1 donned gloves and removed the dirty dressing from the left ankle wound. LPN #1 then proceeded to clean the left ankle wound without performing hand hygiene and changing gloves. LPN #1 completed the dressing change for the left ankle. With the same pair of gloves on, LPN #1 proceeded to clean the left hip wound without performing hand hygiene and changing gloves. LPN #1 provided wound care to two wounds for Patient #4 with the same pair of gloves on throughout the entire procedure. LPN #1 performed no hand hygiene during wound care, after removing a dirty dressing and when moving from one wound to the other. Observations in the Emergency Room (ER) on 11/19/2025 at 10:31 AM, revealed RN #2 initiated an IV line on Random Patient (RP) #1. RN #2 performed hand hygiene then touched the table where supplies were located and rolled the table to the Patient’s bedside. RN #2 then adjusted the Patient’s bed rails and donned clean gloves. RN #2 failed to perform hand hygiene after touching objects that were possibly contaminated, before donning clean gloves. Observations in Operating Room (OR) #1 on 11/20/2025 at 9:44 AM revealed RN #3 picked an instrument up off the floor with her left hand. RN #1 removed her left glove and donned a new glove. RN #3 did not perform hand hygiene after removing the glove. RN #1 proceeded to remove dirty linens from the OR table and placed them in a dirty linen container. RN #3 then removed gloves and donned a new pair of gloves without performing hand hygiene. In an interview on 11/20/2025 at 11:15 AM, the Chief Nursing Officer (CNO) verified hand hygiene should be performed after glove changes, after touching wounds or contaminated objects.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop and maintain an Emergency Preparedness (EP) plan to be reviewed and updated every 2 years. The findings included: During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility had not developed a comprehensive EP plan to be reviewed and updated every 2 years.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to ensure a documented facility-based and community-based risk assessment was completed utilizing an all hazards approach. The findings included: During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility had not completed a facility and community based risk assessment.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to document the patient population served, strategies to address vulnerable patient populations and services available during an emergency. The findings included: During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility’s Emergency Preparedness plan did not address patient population serviced, ways to address vulnerable patient populations and services available during an emergency.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to document efforts to contact and collaborate with local, regional, state and Federal EP officials to ensure its participation in collaborative and cooperative planning efforts during a disaster or emergency situation. The findings included: During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the EP plan did not document contacts or collaboration with other emergency officials.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to implement, document, review and update policies and procedures every 2 years based on the emergency plan. The findings included: During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified policies and procedures related to the emergency plan had not been reviewed and updated every 2 years.”

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop policies and procedures for provision of subsistence needs for patient and staff, failed to develop policies and procedures for alternate energy sources and sewage and waste disposal during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified no policies or procedures were developed for subsistence needs, alternate energy sources and sewage and waste disposal during an emergency.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to document a system to track the location of on-duty staff and sheltered patients during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was no documentation of ways to track on-duty staff and sheltered patients during an emergency.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to document means to shelter in place for patients, staff and volunteers during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was no documentation of means to shelter in place for patients, staff and volunteers during an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop policies to address how medical record confidentiality and security would be preserved during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no policies developed to address medical record confidentiality and security during an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop policies and procedures for the use of volunteers and other staffing strategies during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no policies related to volunteers and staffing strategies during an emergency.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop updated policies and procedures for prearranged transfer agreements to receive patients during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no updated policies related to transfer agreements during an emergency.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop written communication plans that contained how the facility would coordinate patient care within the facility, across healthcare providers and with state and local health departments during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a communication plan that documented coordination of patient care within the facility, with other providers and outside departments during an emergency.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to include updated contact information for staff, physicians, volunteers and other health facilities as part of a written communication plan. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan with updated contact information.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to include updated contact information for Federal, State, regional and local emergency preparedness officials as part of a written communication plan. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan with updated contact information.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop a communication plan that included primary and alternate means of communication with facility staff, Federal, State and local emergency management agencies during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included primary and alternate means of communication during an emergency.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop a communication plan that addressed means for sharing medical information and documentation during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included ways to share medical information and documentation during an emergency.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop a communication plan that included ways to provide information about the facility’s needs during an emergency, and the facility’s ability to provide assistance to the authority having jurisdiction during an emergency. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included ways to provide information about the facility’s needs and ways to provide assistance during an emergency.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to develop a training and testing program based on the facility’s risk assessment and communication plan. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility’s training and testing program was not based on a risk assessment or emergency communication plan.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 35244 Based on interview, the facility failed to train all staff on the Emergency Preparedness (EP) program based on facility risk assessment and communication plan. The findings included: In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified staff were not trained on an EP program based on risk assessment and emergency communication plan.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: *residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2. *cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or *cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 39759 Based on record review, the facility failed to maintain cooking facilities. The findings include: Record review on 11/17/2025 at 12:00 PM, revealed the facility failed to provide documentation of the kitchen vent hood semi-annual cleanings. The last cleaning was in 2024. National Fire Protection Association (NFPA) 101, 18.3.2.5.3 (10), NFPA 96, Table 11.4 (2011 Ed.) The findings were verified by the maintenance director and acknowledged by the front office staff during the exit conference on 11/17/2025.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 39759 Based on observations, the facility failed maintain portable space heaters. The findings include: Observations on 11/17/2025 at 9:30 AM, revealed a portable space heater exceeding 212 degrees Fahrenheit at the 100 hall nurses station. The findings were verified by the maintenance director and acknowledged by the front office staff on 11/17/2025.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 39759 Based on record review, the facility failed to maintain the emergency generator. The findings include: Record review on 11/17/2025 at 12:00 PM, revealed the facility failed to provide documentation for the annual load bank test for the diesel generator. National Fire Protection Association (NFPA) 101, 18.5.1.1 (2012 Ed.), NFPA 101, 9.1.3.1 (2012 Ed.), FPA 110, 8.4.2.3 (2010 Ed.) The findings were verified by the maintenance director and acknowledged by the front office staff during the exit conference on11/17/2025.”