Legend

Based on record review and interview, the administrator did not ensure a resident’s medical record contained documentation of the resident’s placement evaluation. Findings include: 1. A review of R2’s medical record revealed no documentation of R2’s placement evaluation was available for review. 2. In an interview, E1 acknowledged the R2’s medical record did not contain documentation of R2’s placement evaluation.

Based on documentation review and interview, the administrator did not ensure a disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility’s documentation revealed documentation of the facility’s disaster plan being reviewed was not available for compliance officer review. 2. In an interview, E1 reported E1 was not aware the disaster plan was required to be reviewed annually. E1 acknowledged the disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the administrator did not 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. A review of facility documentation revealed no documentation of disaster drills being conducted was available for review. 2. In an interview, E1 reported E1 was unaware of the frequency and documentation required when conducting disaster drills. E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation 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. A review of the facility’s documentation revealed no documentation of employee evacuations drills being conducted was available for review. 2. In an interview, E1 reported E1 was unaware of the requirement for employee evacuation drills to be conducted. E1 acknowledged an evacuation drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did to ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. Findings include: 1. In an interview E1 reported the facility schedule consists of the following two shifts: 7:00AM to 7:00PM; and 7:00PM to 7:00AM. 2. A review of facility documentation revealed documentation of the following evacuation drills were conducted: November 8, 2024 at 16:05PM; and February 21, 2025 at 16:30PM. However, no documentation of an evacuation drill for residents being conducted during the 7:00PM to 7:00AM shift was available for review. 3. In an interview, E1 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.