Stellar Healthcare, INC - Stellar 2

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. Findings include: 1 . A review of facility documentation included a staff schedule for July 2025 which revealed the facility operated with the following shifts: 7:00AM-7:00PM; and 7:00PM- 7:00AM. 2 . A review of facility documentation revealed the following evacuation drills which included both personnel and members were conducted on both shifts the following months: May 2024; August 2024; and April 2025. However, no documentation of evacuation drills for employees conducted on each shift every three months was available for review. 3 . In an interview, E5 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 not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed no documentation of a disaster drill for employees conducted was available for review. 2 . In an interview, E5 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 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, E5 reported the reviews were completed. However, E5 was unsure where the documentation was. E5 acknowledged the disaster plan was not reviewed at least once every 12 months and documented.