Beehive Home of Snowflake

Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years. Findings include: 1. Review of the facility policy and procedure manual revealed no documentation indicating that the manual had been reviewed. No additional documentation indicating that the policies and procedures had been reviewed once every three years was available. 2. During an interview, E2 stated "We had that, I can't find it." 3. During an interview, E2 acknowledged the documentation failed to indicate that the policies and procedures were reviewed at least once every three years.

Based on documentation reviw and interview the manager failed to ensure that a documented report is submitted to the governing authority that includes any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. Review of facility quality management documentation revealed monthly quality management meeting minutes. No report that included any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care submitted to the governing authority was available for review. 2. During an interview E2 acknowledged the required documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on June 2, 2022.