Windsor Park Nursing Home Skilled Nursing Facility - Comprehensive Emergency Management Plan - September 2019

Aug 30, 2026

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Comprehensive Emergency Management Plan (CEMP) for Windsor Park Nursing Home Skilled Nursing Facility, reviewed and endorsed for use. The plan formalizes compliance with CMS Emergency Preparedness Requirements for Medicare and Medicaid providers and the Joint Commission accreditation requirements, aligned with NIMS implementation objectives and NFPA standards. It defines leadership accountability and establishes activation procedures linking Switchboard notification, emergency operations activation, incident command, facility command center functions, departmental emergency operations plan execution, and initial response activities through rapid reference guides and annexed forms.

LanguageEnglish

CategoryGeneral

FormatDOCX

Pages193

Reading Time1 h 8 min

AccessFree to download

To activate this plan

Notifications and activation workflow

Quick Reference

Rapid response guides and plan information

Promulgation document

Endorsement and compliance commitments

Initial Action Quick-Start Guide

Emergency operations plan criteria and command structure

Rapid Response Guides

Critical phone numbers and immediate first steps

Initial activities by threat type

Bomb threat, earthquake, evacuation, extreme weather, fire, flood

Windsor Park Nursing Home Skilled Nursing Facility Emergency Preparedness Program COMPREHENSIVEEMERGENCY MANAGEMENT PLAN September 2019 To activate this plan: NOTIFY SWITCHBOARD OPERATOR (Dial “2222”) State: “This is an EMERGENCY PLAN ALERT” DESCRIBE LOCATION, SITUATION and SPECIFIC ASSISTANCE NEEDED During an incident, refer directly to the EMERGENCY OPERATIONS PLAN ACTIVATION section, beginning on HYPERLINK \l "_CONCEPT_OF_OPERATIONS_1" \o "EOP Activation Section" Page 69. It contains procedures, checklists, and forms that are required for Nursing Home Incident Command System implementation. Quick Reference: Red Borders: HYPERLINK \l "_Introduction" Quick-Start Rapid Response Guides White Borders: HYPERLINK \l "_Introduction" General Information Pink Borders: HYPERLINK \l "_EMERGENCY_OPERATIONS_PLAN" \o "Emergency Operations Plan" Emergency Operations Plan Green Borders: HYPERLINK \l "_APPENDIX_I:__1" \o "Job Action Sheets" Job Action Sheets Blue Borders: HYPERLINK \l "_APPENDIX_J:_" \o "EOP Forms" NHICS Forms Event-Specific Annexes: Tabbed Section at Back of Book Promulgation document This Comprehensive Emergency Management Plan (CEMP) has been reviewed and endorsed for use at Windsor Park Nursing Home. This plan establishes full compliance with applicable provisions of the CMS Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, Part 483, as effective November 16, 2016; as well as The Joint Commission Nursing Care Center Accreditation Program, Leadership Chapter and Emergency Management Chapter, as effective January 1, 2016. Compliance is additionally established with the 11 National Incident Management System (NIMS) Implementation Objectives for Healthcare Organizations, as well as the National Fire Protection Association (NFPA) Standard 99-12 Health Care Emergency Management and Standard 1600, Standard on Disaster/Emergency Management and Business Continuity Programs. By their signatures below, senior facility leadership establishes their commitment to, and accountability for, this emergency management program, including all aspects of planning, implementation, effectiveness, and performance improvement. [Original signatures on file] Initial Action Quick-Start Guide Any person discovering an unusual or emergency incident calls Switchboard Operator (Dial “10/31”) to report the situation. “If you see something, say something” Switchboard operator immediately notifies Facility Administrator (business hours) or Nursing Supervisor (all other times) Facility Administrator or Nursing Supervisor determines if incident meets criteria for Emergency Operations Plan (EOP) activation (refer to HYPERLINK \l "_APPENDIX_B:_" \o "Appendix B: EOP Activation Matrix" Appendix B: EOP Activation Matrix) [page 155] If HYPERLINK \l "_Activation/Response" \o "EOP Activation Matrix" Activation Criteria is met, Facility Administrator or Nursing Supervisor: Activates the EOP Assumes command / becomes the HYPERLINK \l "_Assumption_of_Command" \o "Assumption of Command" Incident Commander (IC) [page 75] Activates the HYPERLINK \l "_Establishment_and_Functions" \o "Establishment and Functions of the Hospital Command Center" Facility Command Center (FCC) [page 91] Switchboard Operator announces HYPERLINK \l "_General_Announcement_of" \o "General Announcement of Plan Activation" Emergency Plan [page 72] and initiates notifications as directed Each department carries out actions as specified in their HYPERLINK \l "_DEPARTMENTAL_PLANS_/" \o "Departmental Plans / Preparedness" Department Emergency Operations Plan (DEOP) [page 53] The IC determines whether the FCC activation is HYPERLINK \l "_Virtual_vs._Actual" \o "Virtual versus Actual Activation" actual or virtual [page 72] Operations proceed as shown below, using the Nursing Home Incident Command System (NHICS) under the direction and control of the Incident Commander RAPID RESPONSE GUIDES Foll

FAQs

How is the emergency plan activated at Windsor Park Nursing Home?

An unusual incident is reported by calling the Switchboard operator (dial “10/31”). The operator notifies the Facility Administrator (business hours) or Nursing Supervisor (all other times), who determines whether emergency operations plan activation criteria are met and activates the EOP if required.

What role does the Incident Commander play once the EOP is activated?

After activation, the Facility Administrator or Nursing Supervisor assumes command and becomes the Incident Commander. The Incident Commander then activates the Facility Command Center functions and directs operations using the Nursing Home Incident Command System (NHICS).

Where are initial response procedures and forms referenced?

During an incident, procedures, checklists, and forms are referenced in the EMERGENCY OPERATIONS PLAN ACTIVATION section. The plan also provides quick reference guidance using rapid response guides and event-specific annexes, with related activation and department materials via appendices and forms.

Aug 30, 2026

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