E0020 E020: Establish policies and procedures including evacuation.
F

Failure to Maintain Updated Emergency Evacuation Agreements and Procedures

The Villa At The BayPetoskey, Michigan Survey Completed on 05-21-2025

Summary

The facility failed to develop and implement comprehensive emergency preparedness policies and procedures for safe evacuation, as required by federal regulations. Specifically, the facility's documentation indicated reliance on a specific bussing company for resident evacuation during emergencies. However, upon review and interview, it was revealed that the facility no longer uses this company and instead depends on the county emergency operations center for evacuation arrangements. Further investigation showed that the facility did not have a contract or written letter of understanding with the county emergency operations center to confirm the availability of transportation agreements. This lack of formal agreements and updated policies was confirmed by both the Maintenance Director and the Administrator during the survey. The deficiency could potentially affect all occupants in the event of an emergency, as the facility did not have established procedures addressing transportation, staff responsibilities, evacuation locations, and communication methods.

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.
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