GROVERS ASSISTED LIVING LLC

Based on observation, interview, and documentation review, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection (J)(2), including the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse; and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if the facility did not take any action to stop suspected abuse of a resident.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R1 to have a bandage on top of R1's head and a black eye.

2. In an interview, R1 reported E2 dragged R1 out of bed, and as a result R1's head hit the floor. R1 stated the incident was reported to the other caregivers E3 and E4.

3. A review of facility documentation revealed there was no documentation that included the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse.

4. In an interview, E3 reported R1 reported the aforementioned incident. E3 acknowledged there was no report submitted to Adult Protective Services (APS) regarding R1's allegations nor documentation of an investigation.

5. In an interview, E2 denied the allegations reported by R1. E2 acknowledged R1 reported the allegations to E3 and E4. E2 acknowledged there was no report submitted to APS regarding R1's allegations nor documentation of an investigation

Based on record review and interview, the manager failed to ensure a resident's medical record included the correct dosage for a medication administered, for one of two sampled residents. The deficient practice posed a risk if a resident was administered an incorrect dosage of medication.

Findings include:

1. A review of R1's medical record revealed a service plan dated June 27, 2023 which reflected R1 received medication administration services.

2. A review of R1's medical record revealed a medication order dated January 20, 2023 for "Omeprazole 20 mg (milligrams) one tablet daily."

3. A review of R1's medical record revealed a medication administration record (MAR) dated November 2023. R1's November 2023 MAR reflected R1 was administered "Omeprazole 50 mg" tablets once daily.

4. The Compliance Officer observed R1's medication container for "Omeprazole", which contained 20 mg tablets.

5. In interview, E2 reported R1's "Omeprazole" medication dosage was documented incorrectly on the MAR.

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 two 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 service plan dated November 8, 2023 reflected R2 recieved medication administration services.

2. A review of R2's medical record revealed a medication order dated June 1, 2021 for "Lisinopril 40 mg (milligrams) take one tablet by mouth once daily, hold if systolic blood pressure less than 110."

3. A review of R2's medical record revealed a medication administration record (MAR) dated November 2023. R2's November 2023 MAR did not indicate whether R2's "Lisinopril" was administered or withheld, and R2's blood pressure was not documented.

4. In an interview, E2 acknowledged there was no documentation of R2's blood pressure available for review. E2 acknowledged there was no documentation to indicate whether R2's "Lisinopril" was administered or withheld.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration services. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. A review of R1's medical record revealed a service plan dated June 27, 2023. R1's service plan reflected R1 received medication administration services.

2. A review of R1's medical record revealed a medication order November 14, 2023 for "Microbid 100 mg (milligrams) take one tablet by mouth twice daily for seven days."

3. A review of R1's medical record revealed a medication administration record (MAR) dated November 2023. R1's November 2023 MAR did not list "Microbid" as a medication administered to R1.

4. In an interview, E2 reported R1 was administered "Microbid" for seven days as ordered, however the administration was not documented.