Alma's Home Care Assisted Living, LLC

Based on documentation review, record review and interview, the manager failed to establish, document, and implement tuberculosis infection control activities consistent with CDC recommendations. Findings include: 1. A review of the facility's policies and procedures revealed a policy manual, reviewed and approved by E1 on May 8, 2024. This policy manual included a Tuberculosis policy, however, the policy did not include baseline screening, annual facility risk assessments, or annual employee training, and did require annual testing of all staff and residents. 2. During the on-site inspection, E1 provided an updated policy and procedure manual, reviewed and approved by E1 on August 20, 2025. However, this policy manual did not include a Tuberculosis policy. 3. A review of R1's medical record revealed a negative TB skin test. However, documentation of baseline screening to include assessing R1's risks of prior exposure to infectious tuberculosis, and determining if R1 had signs or symptoms of tuberculosis, was not available for review. Based on R1's date of acceptance, this screening was required. 4. A review of E2's personnel record revealed annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. Based on E2's date of hire, this training was required. 5. In an interview, E1 reported having purchased a new policy and procedure manual, but stated not all sections had been printed and placed in the binder at the time of the on-site inspection. 6. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer an initial training and continued competency training program in fall prevention and fall recovery. Findings include: 1. The Compliance Officer requested E1's and E2's personnel records at 12:44 PM on May 7, 2024, during the on-site inspection. 2. A review of facility documentation revealed a policy and procedure titled, "Administering CPR, First Aid and Fall Recovery to Residents." The policy stated, "Upon employment all caregivers will be required to attend an initial training regarding fall prevention and fall recovery of residents. The caregiver will complete one hour of competency training in fall prevention and fall recovery annually. Documentation of this current training will be maintained in the personnel record and available for review. 3. A review of E1's and E2's personnel records revealed documentation of an initial and continued training in fall prevention and fall recovery was not available for review. 4. At 3:02 PM, E1 provided the Compliance Officer with a form titled, "Policy and Procedure for Fall Safety, Fall Prevention, First Aid for falls and Fall Recovery for residents. Review over initiating CPR and First Aid in emergency situations." The form included a list of five employees and had various dates for each. However, the form did not indicate the time elapsed during the training. The form indicated E1 had received this training on April 20, 2022 and E2 had received this training on August 10, 2022. 5. At 3:45 PM, E1 provided the Compliance Officer with a form titled, "Policy and Procedure for Fall Safety, Fall Prevention, First Aid for falls and Fall Recovery for residents. Review over initiating CPR and First Aid in emergency situations." The form included a list of three employees, E1, E2, and E3 and was dated April 20, 2023. However, the form did not indicate the time elapsed during the training. 6. At 4:40 PM, the Compliance Officer advised E1 the exit interview would commence and further documentation would not be accepted. However, documentation of current training for all staff on Fall Prevention and Fall Recovery had not been provided. 7. In an interview, E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

Based on record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C) and (G), for two of two employees sampled. The deficient practice posed a risk if E1 or E2 were a danger to a vulnerable population. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." A.R.S. \'a7 36-411(G) states: "G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety." Findings include: 1. The Compliance Officer requested E1's and E2's personnel records at 12:44 PM on May 7, 2024 during the on-site inspection 2. A review of E1's personnel record revealed E1 had been hired in February of 2006 and was a manager. E1's personnel record included a copy of a fingerprint clearance card with a marked expiration date of March 23, 2012. 3. Online research at AZDPS.Gov revealed E1 had a current, valid fingerprint clearance card not documented or verified in E1's personnel record. 4. A review of E2's personnel record revealed E2 had been hired in September of 2022 as a caregiver. E2's personnel file included an application for a fingerprint clearance card dated August 23, 2022. However, E2's personnel record did not include references or verification of the status of E2's fingerprint clearance card. 5. Online research at AZDPS.Gov revealed E2 had a current, valid fingerprint clearance card not documented or verified in E2's personnel record. 6. At 3:07 PM, E1 provided a copy of E2's fingerprint clearance card, and an application for E2 listing three prior employers. However, E2's personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations, and did not include verification of the status of E2's fingerprint clearance card. 7. In an interview, E1 acknowledged the personnel records provided for E1 and E2 did not include documentation of compliance with A.R.S. \'a7 36-411(C) This is a repeat deficiency from the on-site compliance inspection conducted on May 1, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed page which stated, "Policy and Procedures Manual must be reviewed every three years by manager [E1]." The page included multiple signature lines which stated, "Signature and Date of Review.... Amended: No / Yes...Changes made:...." The first signature line was signed by E1, however, the signature was not dated, and no other date was present in the Policy and Procedure manual to indicate when the manual was last reviewed and updated. 2. In an interview, E1 acknowledged the policy and procedure manual review date was not documented. This is a repeat deficiency from the on-site compliance inspection conducted on May 1, 2023.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of two employees sampled. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed E2 had been hired as a caregiver in August of 2022. However, E2's personnel record did not include documentation of E2's evidence of freedom from TB. 4. In an interview, E1 acknowledged the personnel file provided for E2 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure, for one of two sampled employees, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E1's personnel record revealed E1 was a manager and had been hired in February of 2006. 2. A review of the facility's work schedule revealed E1 had worked from 7 p.m. until 7 a.m. on Wednesday, May 1, Saturday, May 4, Sunday, May 5, and Monday, May 6, 2024. 3. A review of E1's personnel record revealed a CPR and First Aid Certification with a marked expiration date of November 6, 2023. Current documentation of CPR and First Aid training was not available for review. 4. In an interview, E1 acknowledged E1's personnel records did not include documentation of current First Aid and CPR training certification. This is a repeat deficiency from the on-site compliance inspection conducted on May 1, 2023.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed documentation of R1's freedom from infectious TB was not available for review. 3. In an interview, E1 acknowledged documentation of R1's freedom from infectious TB had not been provided for review

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when initially developed and when updated, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated April 19, 2024, for directed care services including medication administration. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 2. In an interview, E1 acknowledged the service plan provided for R1 did not include the dated signatures of the resident or their representative and the manager. This is a repeat deficiency from the on-site compliance inspection conducted on May 1, 2023.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. On May 7, 2024 at 12:44 PM, The Compliance Officer requested the facility's annual disaster plan review and provided E3 a list of the documents being requested, to include the annual disaster plan review document. However, documentation of a disaster plan review was not available. 2. On May 7, 2024 at 4:15 PM, the Compliance Officer advised E1 the annual disaster plan review documentation had not been provided and the exit interview would start at 4:30 PM, as all provided documentation had been reviewed and more than two hours had elapsed since the request. 3. On May 7, 2024 at 4:40 PM, the Compliance Officer advised E1 the exit interview would commence and documentation would no longer be accepted. However, documentation of a disaster plan review had not been made available. 4. In an interview, E1 acknowledged the annual disaster plan review had not been provided for review.

Based on documentation review, observation, and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. On May 7, 2024 at 12:44 PM, The Compliance Officer requested the facility's disaster drill documentation for the previous 12 months and provided E3 a list of the documents being requested, to include disaster drill documentation. However, documentation of disaster drills was not provided for review. 2. The Compliance Officer observed a posted work schedule indicated the facility had two shifts per day, with shift changes at 7 AM and 7 PM. 3. On May 7, 2024 at 4:15 PM, the Compliance Officer advised E1 the disaster drill documentation had not been provided and the exit interview would start at 4:30 PM, as all provided documentation had been reviewed and more than two hours had elapsed since the request. 4. On May 7, 2024 at 4:40 PM, E1 provided the Compliance Officer with a disaster drill dated August 20, 2023 for the 7 AM to 7 PM shift. However, the remaining seven required disaster drills for the 12 month period prior to the on-site inspection were not provided for review. The Compliance Officer advised E1 the exit interview would commence and documentation would no longer be accepted. 5. In an interview, E1 acknowledged documentation of disaster drills conducted on each shift at least once every three months had not been provided for review. This is a repeat deficiency from the on-site compliance inspection conducted on May 1, 2023.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. On May 7, 2024 at 12:44 PM, The Compliance Officer requested the facility's documentation of evacuation drills conducted during the previous 12 months and provided E3 a list of the documents being requested, to include the evacuation drill documentation. However, documentation of evacuation drills was not available. 2. On May 7, 2024 at 4:15 PM, the Compliance Officer advised E1 the evacuation drill documentation had not been provided and the exit interview would start at 4:30 PM, as all provided documentation had been reviewed and more than two hours had elapsed since the request. 3. On May 7, 2024 at 4:40 PM, the Compliance Officer advised E1 the exit interview would commence and documentation would no longer be accepted. However, evacuation drill documentation had not been made available. 4. In an interview, E1 acknowledged the facility's documentation of evacuation drills for employees and residents, conducted at least once every six months, had not been provided for review.

Based on observation, documentation review, and interview, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. Findings include: 1. The Compliance Officer observed the health care institution had converted a patio into a kitchen. A new dining room was located where the kitchen used to be. 2. The Compliance Officer observed an evacuation path posted in a hallway had not been updated and was inaccurate, depicting an exit from a resident's room which had been moved to an adjacent wall due to the kitchen addition. 3. In an interview, E1 acknowledged the kitchen had been recently constructed, was in use, and the licensee had implemented a modification of the facility without an approval or amended license issued by the Department.

Based on observation and interview, the manager failed to ensure that a list of resident rights was conspicuously posted. Findings include: A.A.C. R9-10-101(54) states conspicuously posted means, "a. A location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution". 1. During an environmental inspection of the facility, the Compliance Officer did not observe the required posting which contained a list of the resident rights in A.A.C. R9-10-810(C). 2. In an interview, E1 acknowledged a list of resident rights was not conspicuously posted.

Based on record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to the residents, for one of two personnel members sampled. Findings include: 1. A review of E2's personnel record revealed documentation of completion of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 acknowledged the manager had not administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C) and (G), for two of two employees sampled. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." A.R.S. \'a7 36-411(G) states: "G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety." Findings include: 1. A review of E1's personnel record revealed E1 had been hired in August of 2015 as a caregiver and had a valid fingerprint clearance card. However, E1's personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations, did not include verification of the status of E1's fingerprint clearance card, and did not include an employment record. 2. A review of E2's personnel record revealed E2 had been hired in June of 2018 as a caregiver and had a valid fingerprint clearance card. However, E2's personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations, did not include verification of the status of E2's fingerprint clearance card, and did not include an employment record. 3. In an interview, E1 acknowledged the personnel records provided for E1 and E2 did not include documentation of compliance with A.R.S. \'a7 36-411(C) and (G).

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility's policies and procedures revealed page which stated, "Policy and Procedures Manual must be reviewed every three years by manager [E3]." The page included multiple signature lines which stated, "Signature and Date of Review.... Amended: No / Yes...Changes made:...." The first signature line was signed by E3, however, the signature was not dated, and no other date was present in the Policy and Procedure manual to indicate when the manual was last reviewed and updated. 2. In an interview, E1 acknowledged the policy and procedure manual review date was not documented.

Based on documentation review, record review, and interview, the manager failed to ensure two of two caregiver personnel records sampled contained documentation indicating a caregiver or assistant caregiver received orientation before providing assisted living services to a resident. Findings include: 1. A review of the facility's work schedule revealed E1 had worked from 7 a.m. until 7 p.m. on Thursday, April 1, 2023, Friday, April 2, 2023, Monday, April 11, 2023 through April 15, 2023, Monday, and April 25, 2023 through Wednesday April 27, 2023. 2. A review of E1's personnel record revealed documentation E1 had received orientation prior to providing physical health services was not available for review. 3. A review of the facility's work schedule revealed E2 had worked from 7 p.m. until 7 a.m. on each Saturday and Sunday in April 2023.. 4. A review of E2's personnel record revealed an orientation checklist. However, the checklist had not been completed. 5. In an interview, E1 acknowledged the personnel records provided for E1 and E2 did not include documentation of orientation.

Based on record review, documentation review, and interview, the manager failed to ensure, for two of two sampled caregivers, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. Findings include: 1. A review of E1's personnel record revealed E1 had been hired as a caregiver in August of 2015. 2. A review of the facility's work schedule revealed E1 had worked from 7 a.m. until 7 p.m. on Thursday, April 1, 2023, Friday, April 2, 2023, Monday, April 11, 2023 through April 15, 2023, Monday, and April 25, 2023 through Wednesday April 27, 2023. 3. A review of E1's personnel record revealed a CPR and First Aid Certification with a marked expiration date of April 2018. Current documentation of CPR and First Aid training was not available for review. 4. A review of E2's personnel record revealed E2 had been hired as a caregiver in June of 2018. 5. A review of the facility's work schedule revealed E2 had worked from 7 p.m. until 7 a.m. on each Saturday and Sunday in April 2023. 6. A review of E2's personnel record revealed a CPR and First Aid Certification with a marked expiration date of April 2020. Current documentation of CPR and First Aid training was not available for review. 7. In an interview, E1 acknowledged E1's and E2's personnel records did not include documentation of current First Aid and CPR training certification.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed documentation, signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, was not available for review. 2. In an interview, E1 acknowledged the medical record provided for R1 did not include the required documentation.

Based on record review, documentation review, and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10), for two of two residents sampled. Findings include: 1. During the on-site inspection the Compliance Officer requested to review R1's and R2's medical records, including their residency agreements. However, residency agreements for R1 and R2 were not included in each resident's medical record and were not provided for review. 2. In an interview, E1 acknowledged residency agreements for R1 and R2 had not been provided for review during the on-site inspection.

Based on record review and interview, the manager failed to ensure a resident's service plan was reviewed and updated at least once every three months, for two of two residents sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated October 4, 2022. However, based on the date of R1's service plan, reviewed and updated service plans dated on or before January 4, 2023, and April 4, 2023, were required and were not available for review. 2. A review of R2's medical record revealed a service plan for directed care services updated December 12, 2022. However, based on the date of R2's service plan, a reviewed and updated service plan dated on or before March 12, 2023, was required and was not available for review. 3. In an interview, E1 acknowledged the medical records provided for R1 and R2 did not include required service plan updates at least once every three months. E1 reported a care plan nurse had updated the service plans on schedule, however, E1 was not able to provide this documentation during the on-site inspection.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, when initially developed and when updated, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated October 4, 2022, for directed care services including medication administration. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 2. A review of R2's medical record revealed a service plan updated June 12, 2022 for directed care services including medication administration. However the service plan update was not signed and dated by the resident or the resident's representative, or the manager. 3. A review of R2's medical record revealed a service plan updated December 12, 2022 for directed care services including medication administration. However the service plan update was not signed and dated by the resident or the resident's representative, or the manager. 4. In an interview, E1 acknowledged the service plans provided for R1 and R2 did not include the dated signatures of the resident or their representative, the manager, or the nurse who reviewed the service plan.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, updated December 12, 2022, for directed care services including medication administration. 2. A review of R2's medical record revealed an list of medication orders dated September 15, 2022, which included the following: -"L-Thyroxine TAB 137 mcg / PO / QD/ AM." 3. A review of R2's medical record revealed a medication administration record (MAR) dated April 2023. The MAR indicated R2 had been administered, "L-Thyroxine tab 150 mcg," at 8 am on each day in April 2023. 4. The Compliance Officer observed a box containing R2's medications included a bottle of Levothyroxine Sodium 150 microgram tablets. 5. In an interview, E1 acknowledged the medical record provided for R2 did not contain a medication order from a medical practitioner for the 150 microgram Levothyroxine tablets administered to R2.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a door on the west side of the facility leading to an unsecured side yard with access to the street. The door had a deadbolt with a thumb turn latch on the inside and controlled egress into the facility but not out of the facility. The door did not have a door alarm. No alert was heard upon opening the door. 3. During an environmental inspection of the facility, the Compliance Officer observed a door on the west side of the facility leading to a secured back yard. The Compliance Officer observed the door was equipped with a door alarm, however, the alarm was turned off and alert was heard upon opening the door. 4. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration. Findings include: 1. A review of R2's medical record revealed a service plan, updated December 12, 2022, for directed care services including medication administration. 2. A review of R2's medical record revealed a signed list of medication orders dated September 15, 2022. The list included: - "Citalopram 10 mg / PO / QD / PM;" - "Trazadone HCL 50 mg / PO / QD/ PM;" - "Olanzapine 10 mg / PO / QD / PM;" and - "Atorvastatin 40 mg / PO / QD / PM." 3. The Compliance Officer observed a box containing R2's medications included 10 milligram Citalopram, 50 milligram Trazodone, 10 milligram Olanzapine, and 40 milligram Atorvastatin tablets. However, the Trazodone bottle stated, "Take one half tablet daily at bedtime and as needed for anxiety every 6 hours." 4. A review of R2's medical record revealed a Medication Administration Record (MAR) dated April 2023. However, the MAR indicated the following: - For Citalopram and Trazodone, the MAR indicated R2 had not been provided the medications as ordered at 8 PM on April 19th, April 24th, April 25th, April 26th, and April 30th, 2023; - For Olanzapine, the MAR indicated R2 had been administered 125 milligrams of Olanzapine on each day in April 2023, instead of the ordered 10 milligrams; and - For Atorvastatin, the MAR indicated R2 had been administered "25 MG, take 1/2 tab PO QD," on each day in April 2023, instead of the ordered 40 milligrams. 5. In an interview, E1 reported R2's MAR included multiple errors and omissions and acknowledged the medication administered to R2 had not been accurately documented in R2's medical record.

Based on observation, documentation review, and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. Findings include: 1. The Compliance Officer observed the facility's drug reference guide was "Mosby's 2019 Nursing Drug Reference." 2. An Internet search revealed the current version of this drug reference guide was "Mosby's 2023 Nursing Drug Reference." 3. In an interview, E1 acknowledged the facility's drug reference guide was not current.

Based on observation, documentation review, and interview, the manager failed to ensure a current toxicology reference guide was available for use by personnel members. Findings include: 1. The Compliance Officer observed the facility's toxicology reference guide was "Toxicology Handbook Second Edition," published in 2010. 2. An Internet search revealed the current version of this toxicology reference guide was "Toxicology Handbook 4th Edition," published September 10, 2022. 3. In an interview, E1 acknowledged the facility's toxicology reference guide was not current.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a posted food menu, dated April 17 - April 23. 2. In an interview, E1 acknowledged a current menu had not been posted. E1 reported the manager had not yet provided the May menus to be posted.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented. Findings include: 1. A review of the facility work schedule revealed the facility operated on two shifts, with shift changes at 7 a.m. and 7 p.m. each day, which would require at least eight disaster drills to be conducted and documented each year. 2. A review of facility disaster drills revealed a disaster drill was conducted on October 8, 2022 at 10 am. However, no other documentation of disaster drills conducted during the previous 12 months was provided for review. 3. In an interview, E1 acknowledged the documentation of disaster drills provided for review did not indicate a disaster drill had been conducted on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the amount of time taken for employees and residents to evacuate the assisted living facility. Findings include: 1. A review of the facility's documentation revealed the following evacuation drills conducted during the previous 12 months: - July 8, 2022, at 10 a.m.; and - January 15, 2023 at 10 a.m. The evacuation drill form included a section labeled, "Total Evacuation Time," however, this section had been left blank on both documented evacuation drills. The provided documentation did not include the amount of time taken for employees and residents to evacuate the assisted living facility. 2. In an interview, E1 acknowledged the evacuation drills did not include the amount of time taken for employees and residents to evacuate the assisted living facility.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a storage shed on the west side of the facility. The storage shed did not have a lock and was accessible to residents. Inside the shed, the Compliance Officer observed the following poisonous or toxic materials: - Motor Oil; - "Large Tire Fix a Flat"; - Wood Stain; and - Concrete bonding adhesive. 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.