MORNINGSTAR AT GOLDEN RIDGE

<p>Based on record review and interview, the health care institution failed to initiate cardiopulmonary resuscitation (CPR) in accordance with its certification training for CPR before the arrival of emergency medical services, to a resident who was nonresponsive or has a cessation of normal respiration, in accordance with that resident's advance directives, if known. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1.      A review of R1’s medical record revealed a document titled “Resident Information”. This document, stated in the Advance Directive section, “CPR”.</p><p><br></p><p><br></p><p>2.      A record review revealed a document titled “Incident Report” dated May 25, 2025. The incident report indicated that neither E2 nor E3 administered CPR when R1 was found on the floor, unresponsive, and without a pulse. The document reported that 911 was called.</p><p><br></p><p><br></p><p>3.      In an interview, E1 acknowledged CPR was not initiated by the caregivers and stated that “when E3 called 911, E3 was instructed not to do CPR because of the condition of the resident”.  </p><p><br></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for four of four sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on August 6, 2024. The POC indicated this deficiency was corrected on March 7, 2025. The POC stated: “Community now has a Policy and Procedure that designates how a caregiver’s skill and knowledge will be verified. All caregivers’ and assistant caregiver’s skills and knowledge have now been verified and documented according to the Policy and Procedure.”</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled “New Hire Training and Competency Policy” dated March 1, 2025. The P&P stated: “A competency checklist will be used and completed upon hire and for retraining. All checklists will be reviewed and verified by the Business Officer Manager/Executive Director or designee to ensure compliance, and stored in their personnel file. The assessment/evaluation may include skills, tasks or competencies identified in the associate’s job description (i.e., bathing, handwashing, ambulation, transfer, etc.).”</p><p><br></p><p><br></p><p>3. A review of E3's, E4’s, and E6’s personnel records revealed E3, E4, and E6 were hired as caregivers before March 7, 2025 (the correction date on the POC). However, the review revealed no documentation demonstrating the manager ensured E3's, E4’s, and E6’s skills and knowledge were verified and documented before E3, E4, and E6 provided physical health services or before the correction date on the POC.</p><p><br></p><p><br></p><p>4. A review of E5's personnel record revealed E5 was hired as a caregiver after March 7, 2025 (the correction date on the POC). However, the review revealed no documentation demonstrating the manager ensured E5's skills and knowledge were verified and documented before E5 provided physical health services.</p><p><br></p><p><br></p><p>5. A review of facility documentation revealed a series of personnel schedules dated between November 2024 and May 2025. The schedules revealed E3, E4, E5, and E6 provided physical health services without E3’s, E4’s, E5’s, and E6’s skills and knowledge having first been verified and documented.</p><p><br></p><p><br></p><p>6. In an interview, E2 stated, “[E4’s] is incomplete.” When the Compliance Officer asked if E5 did not have documentation of E5’s skills and knowledge, E2 stated, “Yeah, I did not find one.” When the Compliance Officer asked about the same documentation for E3 and E6, E2 stated, “I don’t have one for any of them.”</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on August 6, 2024.</p>

<p>Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed a medication order dated April 1, 2025, for the following medications:</p><p><br></p><p>- “OLANZAPINE 5 MG TABLET…TAKE 1 TABLET BY MOUTH DAILY AT BEDTIME;”</p><p><br></p><p>- “OLMESARTAN MEDOXOMIL 40 MG TAB…TAKE 1 TABLET BY MOUTH DAILY;”</p><p><br></p><p>- “PAROXETINE HCL 40 MG TABLET…TAKE 1 TABLET BY MOUTH DAILY;”</p><p><br></p><p>- “QUETIAPINE FUMARATE 25 MG TAB…TAKE 1 TABLET BY MOUTH AT BEDTIME;”</p><p><br></p><p>- “STIMULANT LAXATIVE PLUS TABLET…TAKE 2 TABLETS BY MOUTH DAILY AT BEDTIME;” and</p><p><br></p><p>- “TRAZODONE 50 MG TABLET…TAKE 1 TABLET BY MOUTH DAILY AT BEDTIME.”</p><p><br></p><p><br></p><p>The review revealed a series of medication administration records (MAR) dated April 2025 and May 2025 which indicated the following:</p><p><br></p><p>- R1 did not receive olanzapine on April 7-8 and 10, 2025, as the “Medication [was] not available;”</p><p><br></p><p>- R1 did not receive olmesartan on May 4, 2025, as the “Medication [was] not available;”</p><p><br></p><p>- R1 did not receive paroxetine on May 4, 2025, as the “Medication [was] not available;”</p><p><br></p><p>- R1 did not receive quetiapine on April 6-8 and 10, 2025, and May 19, 2025, as the “Medication [was] not available;”</p><p><br></p><p>- R1 did not receive Stimulant Laxative Plus on April 17, 28, and 30, 2025, and May 2-3 and 13, 2025, as the “Medication [was] not available;” and</p><p><br></p><p>- R1 did not receive trazodone on April 30, 2025, and May 1-2 and 11-12, 2025, as the “Medication [was] not available.”</p><p><br></p><p><br></p><p>2. A review of R3’s medical record revealed a service plan which indicated R3 received medication administration. The review revealed a medication order dated April 15, 2025, for “dorzolamide 22.3 mg-timoloL 6.6 mg/mL eye drops INSTILL 1 DROP INTO AFFECTED EYE(S) TWICE DAILY” and “latanoprost 0.005 % eye drops INSTILL 1 DROP INTO BOTH EYES AT BEDTIME.” The review revealed MARs dated April 2025 and May 2025 which indicated R3 did not receive R3’s second dose of dorzolamide on April 26, 2025, and R3’s latanoprost on May 11, 2025, as both “Medication[s were] not available.”</p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged medications administered to R1 and R3 were not administered in compliance with medication orders, stating there were, “Holes in the MAR.”</p><p><br></p><p><br></p><p>This is an uncorrected deficiency from the complaint inspections conducted on December 12, 2024; November 25, 2024; and September 13, 2024; and no acceptable plans of correction have been received by the Department.</p>

Based on documentation review, observation and interview, the governing authority failed to designate, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules.

Findings include:

1. A review of Department documentation on January 4, 2025, revealed that O1 notified the Department O1 would no longer serve as the Assisted Living Manager at "AL11067 MorningStar at Golden Ridge" effective January 8, 2024.

2. A review of Department documentation revealed E1 notified the Department on January 14, 2025 that E1 would serve as "interim executive director". However, a review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) website revealed no managers certificate for E1.

3. The Compliance Officer observed that an assisted living facility manager certificate was not conspicuously posted in the facility during a complaint investigation conducted on February 06, 2025.

4. In a telephone interview, O1 reported O1 removed O1's license on January 8, 2024, and the facility has had no manager since.

5. In an interview, E3 and E4 reported the facility did not currently have a certified manager. E3 and E4 acknowledged the facility did not designate in writing a manager who either had a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of four sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R1's medical record revealed a current service plan which indicated R1 was to receive medication administration. The review revealed a medication order for "mesalamine PO 400 mg...2 caps twice daily" and "rivastigmine patch transdermal 9.5 mg...apply 1 patch daily"dated July 8, 2024. The review further revealed two medication administration records (MARs) dated September 2024 and October 2024. The MARS revealed the following:
- R1 did not receive R1's second dose of mesalamine on September 11-12, 2024, due to the "Medication not [being] available;"
- R1 did not receive R1's rivastigmine on October 25 and 28-30, 2024, due to the "Medication not [being] available;"and
- R1 received ciclopirox 8% solution nearly every day between September 1, 2024, and November 21, 2024, without a medication order.

2. A review of R3's medical record revealed a current service plan which indicated R3 was to receive medication administration. The review revealed a medication order for "HYDROCORTISONE 1 % CREAM APPLY TOPICALLY TWICE DAILY" with a start date of January 12, 2023. The review further revealed a MAR dated November 2024 which indicated R3 did not receive R3's first dose of hydrocortisone cream on November 1 and 21, 2024.

3. A review of R4's medical record revealed a current service plan which indicated R4 was to receive medication administration. The review revealed medication orders for "levetiracetam (500mg/5mL) 10mL BID PO" dated March 4, 2024, and "Atenolol 25 mg Tab TAKE 1 TABLET BY MOUTH EVERY NIGHT AT BEDTIME" dated October 11, 2024. The review further revealed MARs dated September-November 2024. The MARS revealed the following:
- R4 did not receive R4's first dose of levetiracetam on September 21, 2024, due to the "Medication not [being] available;"
- R4 did not receive R4's second dose of levetiracetam on September 20-21, 2024, due to the "Medication not [being] available;"
- R4 did not receive R4's atenolol on October 29 and 31, 2024, due to the "Medication not [being] available;"and
- R4 did not receive R4's atenolol on November 17-18, 2024.

4. In an interview, E2 reported having an order to hold R4's atenolol on November 17-18, 2024.

5. A review of R4's medical record revealed an order to hold R4's atenolol on November 17-18, 2024, "due to pharmacy issue." However, the order was dated November 23, 2024, the day after the first day of the inspection and several days after the medication was not administered.

6. In an interview, E1 acknowledged medication administered to R1, R3, and R4 were not administered in compliance with the corresponding medication orders.

This is an uncorrected citation from the complaint inspection conducted on September 13, 2024.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection.

Findings include:

1. During the environmental inspections of the facility conducted on November 22, 2024, and November 25, 2024, the Compliance Officer observed garbage in uncovered containers lined with plastic bags in R4's bedroom, in an upstairs conference room, and in an upstairs common bathroom.

2. In an interview, E1 reported the containers should have had covers.

Technical assistance was provided on this rule during the complaint and compliance inspection conducted on August 5-6, 2024.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of four sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R2's medical record revealed a current service plan which indicated R2 was to receive medication administration. The review revealed a medication order for "STIMULANT LAXATIVE PLUS TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY *HOLD FOR LOOSE STOOLS* [at 8:00 AM and 8:00 PM]" dated August 24, 2024, and a medication order for "STIMULANT LAXATIVE PLUS TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY [at 8:00 AM and 5:00 PM]," dated August 30, 2024. The review further revealed two medication administration records (MAR) dated August 2024 and September 2024. The MARS revealed the following:
- R2 did not receive "STIMULANT LAXATIVE PLUS TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY *HOLD FOR LOOSE STOOLS* [at 8:00 AM and 8:00 PM]" at 8:00 AM on August 27-30, 2024, and due to the "Medication not [being] available;"
- R2 did not receive "STIMULANT LAXATIVE PLUS TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY *HOLD FOR LOOSE STOOLS* [at 8:00 AM and 8:00 PM]" at 8:00 PM on August 25-28 and 30, 2024, and September 1-3, 2024, due to the "Medication not [being] available;" and
- R2 did not receive "STIMULANT LAXATIVE PLUS TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY [at 8:00 AM and 5:00 PM]" at 5:00 PM on September 1-3 , 2024, due to the "Medication not [being] available."

2. In an interview, when the Compliance Officer asked if R2's laxatives had been unavailable to administer at the aforementioned times and dates, E3 stated, "Yes." E3 reported R2's family was to provide the laxatives.

Based on interview and documentation review, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request.

Findings include:

1. In an interview conducted at approximately 9:40 AM on August 5, 2024, the Compliance Officer requested personnel schedules dated August 2023 through August 2024.

2. A review of facility documentation revealed the provided personnel schedules did not cover the following dates:
- August 5, 2023, through October 8, 2023;
- November 20-30, 2023;
- December 23-31, 2023;
- January 23-31, 2023;
- February 21-29, 2024;
- March 23-31, 2024;
- May 29-31, 2024; and
- June 29-30, 2024.

3. In an interview, E4 reported the facility changed systems in March or April and would have to contact legal to get the missing personnel schedules.

4. During the exit interview conducted at approximately 12:00 PM on August 6, 2024, E1 acknowledged facility personnel did not provide all of the requested personnel schedules within two hours after a Department request.

This is a repeat citation from the complaint and compliance inspection conducted on February 1, 2023.

Based on documentation review and interview, a manager who had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises failed to immediately report the suspected abuse, neglect, or exploitation of the resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk to the health and safety of a resident.

Findings include:

1. A.R.S. \'a7 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online."

2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay."

3. In an interview, E1 mentioned three incidents where E1 had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises. E1 reported E1 submitted reports regarding each incident to Adult Protective Services (A.P.S.).

4. A review of facility documentation revealed three incident reports and the corresponding reports to A.P.S. However, the incidents were not reported to A.P.S. immediately. The first incident, regarding the suspected abuse of R7, occurred on April 22, 2024, at 5:50 PM and was not reported to A.P.S. until April 23, 2024, at 9:47 AM. The second incident, regarding the suspected abuse of R3, occurred on July 10, 2024, at 7:00 AM and was not reported to A.P.S. until July 10, 2024, at 12:03 PM. The third incident, regarding the suspected abuse of R4, occurred on July 12, 2024, at 8:23 PM and was not reported to A.P.S. until July 13, 2024, at 1:24 PM.

5. In an interview, E1 acknowledged E1 did not immediately report the aforementioned suspected abuse.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services and according to policies and procedures, for one of five sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure (P&P) titled "New Hire Training and Competency Policy" dated January 1, 2022. However, the P&P did not include how a caregiver's or assistant caregiver's skills and knowledge verification would be documented.

2. In an interview, E1 reported the aforementioned P&P was the only P&P the facility had covering this rule.

3. A review of E9's personnel record revealed E9 was hired as a caregiver. However, the review revealed E9's skills and knowledge were not verified until approximately two months after E9 was hired.

4. A review of facility documentation revealed a series of personnel schedules which indicated E9 provided physical health services before E9's skills and knowledge were verified.

5. In an interview, E1 confirmed E9 provided physical health services before E9's skills and knowledge were verified.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training certification specific to adults before providing assisted living services to a resident, for one of five sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E8's personnel record revealed E8 was hired as a caregiver. However, the review revealed no documentation of first aid training certification specific to adults.

2. A review of facility documentation revealed a series of personnel schedules which indicated E8 provided assisted living services to residents without having first aid training certification.

3. In an interview, E1 confirmed E8 provided assisted living services to residents without having first aid training certification.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an office in the memory care section of the facility with the door open and no facility personnel within sight. Inside the office, the Compliance Officer observed a large tote of resident medication.

2. In a series of interviews, E1 and E2 reported the office should have been locked.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C); for two of seven personnel sampled

Findings include:

A.R.S. \'a7 36-411(C), states, "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."

1. A review of E4's personnel record revealed E4's job application. E4 listed four previous employers. However, E4's personnel record revealed no documentation of good faith efforts to contact previous employers to obtain information or recommendations of E4's fitness to work in the assisted living facility.

2. A review of E5's personnel record revealed E5's job application. E5 listed two previous employers. However, E5's personnel record revealed no documentation of good faith efforts to contact previous employers to obtain information or recommendations of E5's fitness to work in the assisted living facility.

3. A review of policies and procedures (P&P) revealed a P&P titled "Background Check Policy." The P&P revealed a subsection titled, "Employment reference checks." The P&P stated, "To ensure that individuals who join us are well qualified and have a strong potential to be productive and successful, we will check the employment references of all applicants."

4. During the exit interview on February 6, 2023, E1, E9, and E10 provided other copies of E4's and E5's personnel records. However, a review of E4's and E5's provided personnel records revealed no documentation of good faith efforts to contact previous employers to obtain information or recommendations of E4's and E5's fitness to work in the assisted living facility.

Based on record review and interview the manager failed to ensure documentation required in this Article was provided to the Department within two hours after a Department request.

Findings include:

1. The Compliance Officer requested for E1's, E2's, E3's, E4's, E5's, and E6's, complete personnel records on February 2, 2023.

2. A review of E4's personnel record revealed no documentation of E4's high school diploma as required by E4's job description. In addition, E4's personnel record revealed no documentation of good faith efforts to contact E4's previous employers.

3. A review of E5's personnel record revealed no documentation of E5's high school diploma as required by E5's job description. In addition, E5's personnel record revealed no documentation of good faith efforts to contact E5's previous employers.

4. During the exit interview on February 6, 2023, E1, E9, and E10 provided other copies of E4's and E5's personnel records. However, a review of E4's and E5's provided personnel records revealed the aforementioned missing documentation was not in E4's and E5's personnel records. E1, E9, and E10 acknowledged documentation was not provided to the Department within two hours after a Department request.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver had current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training certification specific to adults; for one of seven personnel sampled. The Department was provided false and misleading information.

Findings include:

1. The Compliance Officer was on-site at AL11067 on February 1, 2023.

2. A review of E3's personnel record revealed E3 was hired as a Med Tech/Caregiver in January 2020. Further review of E3's personnel record revealed a picture of E3's "NationalCPRFoundation" CPR/FA card. The information on the card appeared to be altered. The information on E3's card was blurry, but the date on the card was printed in a different font and was clearly visible. The card was post-dated for "3/1/2023." In addition, the Compliance Officer verified E3's CPR/FA card on https://www.nationalcprfoundation.com/verify/. The search indicated E3's CPR/FA card was issued on March 1, 2022.

The www.nationalcprfoundation.com website also showed that the training is online-only, with no demonstration of the ability to perform CPR.

3. A review of the facility staffing schedule for 2022 revealed E3 worked February 2022 - February 2023 as a Med Tech/Caregiver.

4. A review of policies and procedures (P&P) revealed a P&P titled "Background Check Policy." The P&P revealed a subsection titled, "Verification of licensure." The P&P stated, Staff must submit any licenses for duplication for our files. We reserve the right to verify licenses with the appropriate authority . . . Team members are subject to disciplinary action up to and including termination if work cards and proper licenses are not maintained." Furthermore, a P&P titled, "Employee Conduct Policy" stated, "MorningStar will follow rules of conduct that will protect the interest and safety of all team members and the organization . . . The following are examples of infractions of rules of conduct that may result in disciplinary action, up to and including termination of employment . . . Falsification of records . . . Violation of safety or health rules."

5. In an interview, E1 reported they did not know E3's CPR/FA was altered. In addition, E1 reported they did not know how to verify CPR/FA cards.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record included documentation of the individual's education applicable to the individual's job duties.

Findings include:

1. A review of the February 2023 staffing schedule revealed E4 was a med care manager and E5 was a care manager.

2. A review of facility documentation revealed job descriptions titled, "Medication Care Manager" and "Care Manager." The "Medication Care Manager" job description stated, "Job Qualifications: . . . Education/Experience: Minimum high school diploma or equivalent." The "Care Manager" job description stated, "Job Qualifications: . . . Education/Experience: Minimum high school diploma or equivalent preferred."

3. A review of E4's personnel record revealed no documentation of E4's high school diploma or equivalent education as required by the aforementioned job description.

4. A review of E5's personnel record revealed no documentation of E5's high school diploma or equivalent education as required by the aforementioned job description.

5. During the exit interview on February 6, 2023, E1, E9, and E10 provided other copies of E4's and E5's personnel records. However, a review of E4's and E5's provided personnel records revealed no documentation of E4's and E5's education applicable to E4's and E5's job duties. E1, E9, and E10 acknowledged E4's and E5's personnel records did not contain documentation of E4's and E5's education applicable to their job duties as required by E4's and E5's job descriptions.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record included documentation of evidence of freedom from infectious tuberculosis (TB) for one of seven personnel sampled. The Department was provided false and misleading information.

Findings include:

1. The Compliance Officer observed E2 working at AL11067.

2. A review of E2's personnel record revealed E2's TB test results. E2's TB test results had correction tape over another person's name. E2's name was written over the correction tape.

3. A review of the facility staffing schedule revealed E2 worked every month between February 2022 - February 2023.

4. A review of policies and procedures (P&P) revealed a P&P titled "Vaccination Tuberculosis Screening Policy." The P&P stated, "Policy . . . Resident and Employee Screening for tuberculosis . . . This form is to be used for persons who are required to have a TB screening for employment . . . or fulfillment of other regulation." However, the form was not in E2's personnel record. Furthermore, a P&P titled, "Employee Conduct Policy" stated, "MorningStar will follow rules of conduct that will protect the interest and safety of all team members and the organization . . . The following are examples of infractions of rules of conduct that may result in disciplinary action, up to and including termination of employment . . . Falsification of records . . . Violation of safety or health rules."

5. In an interview, E2 reported the registered nurse who conducted the TB test had to use a photocopy of another person's TB test results because they ran out of blank forms. In addition, E10 reported they should not have used a photocopy for E2's TB test.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's service plan was completed no later than 14 calendar days after the resident's date of acceptance; for one of five residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan. Based on R2's date of admittance, the service plan was completed 25 days after R2 was admitted into the facility.

2. A review of policies and procedures (P&P) revealed a P&P titled "Service Plan Policy & Procedure." The P&P stated, "The Service Plan along with the Assessment is reviewed . . . Upon admission . . . Within 30 days of admission . . . The Service Plan is reviewed with the Resident and/or Resident Representative upon completion." However, R9-10-808.A.1 states, "[A resident's service plan] Is completed no later than 14 calendar days after the resident's date of acceptance."

3. In an interview, E1 acknowledged R2's service plan was not completed within 14 calendar days after R2 was admitted into the facility.

Based on documentation review 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.

Findings include:

1. A review of the facility's staffing schedule revealed there were three shifts: 1st shift 6:00 AM - 2:30 PM, 2nd shift 2:00 PM - 10:30 PM, and a nocturnal (NOC) shift 10:00 AM - 6:30 AM.

2. A review of the "State Survey Binder" revealed facility disaster drills. The disaster drills were conducted on the following dates and times on the 1st shift:
- January 1, 2023 at 1:30 PM;
- November 2, 2022. The form had no documented time, but the form stated "1st shift";
- July 22, 2022 at 9:00 AM;
- February 25, 2022 at 11:30 AM; and
- January 28, 2022 at 11:30 AM.

However, the 1st shift disaster drills were not conducted every three months and no other disaster drills were provided for review.

A review of the facility disaster drills revealed disaster drills were conducted on the following dates and times on the 2nd shift:
- November 30, 2022 at 2:00 PM; and
- August 23, 2022 at 7:03 PM.

However, the 2nd shift disaster drills were not conducted every three months and no other disaster drills were provided for review.

A review of the facility disaster drills revealed disaster drills were conducted on the following dates and times on the NOC shift:
- February 1, 2023. The form had no documented time, but the form stated "NOC";
- October 29, 2022. The form had no documented time, but the form stated "NOC";
- September 28, 2022, at 5:10 AM;
- June 30, 2022. The form had no documented time, but the form stated "3rd Shift [NOC Shift]"; and
- February 25, 2022 at 5:30 AM.

However, the NOC shift drills were not completed every 3 months and no other disaster drills were provided for review.

In addition, the following drill was conducted, but the Compliance Officer was unable to determine which shift it was for:
- December 21, 2022, at 5:55 (The form did not identify AM or PM, or which shift it was for).

The "State Survey Binder" included "Elopement Drills." However, these were not disaster drills.

3. In an interview, E1 reported they thought elopement drills counted as disaster drills. In an interview, E1, E9, and E10 acknowledged the disaster drills were not conducted every three months.

This is a repeat deficiency from the compliance inspection conducted on September 9, 2021.