THE GROVES ASSISTED LIVING PLACE LLC-APPLE

<p>Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><ol><li>A review of R1's medical record revealed a service plan, dated June 6, 2025, for directed care services including medication administration.</li><li>A review of R1's medical record revealed an order, dated June 18, 2025 for "Metoprolol, Hold for SBP <110 or HR <60, 12.5 mg / 1-PO / BID."</li><li>A review of R1's medical record revealed a medication administration record (MAR) dated June 2025. The MAR included the following entries:<ol><li>On June 1, 2025 at 8 PM, R1's systolic blood pressure (SBP) was 108, however, metoprolol had been administered;</li><li>On June 2, 2025 at 8 AM, R1's SBP was 103, however, metoprolol had been administered;</li><li>On June 10, 2025 at 8 PM, R1's SBP was 103, however, metoprolol had been administered;</li><li>On June 22, 2025 at 8 AM, R1's SBP was 108, however, metoprolol had been administered; and</li><li>On June 23, 2025 at 8 AM, R1's SBP was 104, however, metoprolol had been administered.</li></ol></li><li>In an interview, E1 acknowledged a medication administered to R1 had not been administered as ordered.</li></ol>

Based on documentation review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of two residents reviewed who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

1. A review of R1's medical record revealed a document, dated January 2025, which documented R1's temperature, blood pressure, pulse, and oxygen saturation. This log included the following dates and times when R1's systolic blood pressure was over 180, indicating R1 was having a hypertensive crisis, an emergency requiring immediate medical services:
- January 1, 2025 (time not documented), 195;
- January 5, 2025 (time not documented), 193;
- January 7, 2025 (time not documented), 204;
- January 8, 2025 (time not documented), 194;
- January 9, 2025 (time not documented), 225;
- January 11, 2025 (time not documented), 193;
- January 12, 2025 (time not documented), 195; and
- January 16, 2025 (time not documented), 190.

2. A review of R1's medical record revealed documentation of incident reports or medical services provided to R1 on the aforementioned dates and times, related to R1's blood pressure, were not available for review.

3. In an interview, E1 acknowledged documentation of the immediate notification of R1's emergency contact and primary care provider, when R1 had an emergency, were not available for review.

Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for one of one sampled residents for whom an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed an incident report dated May 12, 2024 for R2. The incident report stated, "Around 3:15 AM I heard a noise, at [R2's] room. Went to see and [R2] was on the floor. I asked what happened, [R2] said [they] tried to get up from the bed by themselves without calling and slipped between bed and wheelchair and fell to the floor......Call to 911 immediately, and while waiting notified [E1] Manager."

2. The Compliance Officer requested to review the facility's copy of the documentation which had been provided to the emergency responder after R2's incident. However, the documentation was not provided for review.

3. In an interview, E1 acknowledged a copy of the documentation given to the emergency responder for each resident was not available for review as required by ARS 36-420.04.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.

Findings include:

1. A review of facility documentation revealed an incident report dated May 12, 2024 for R2. The incident report stated, "Around 3:15 AM I heard a noise, at [R2's] room. Went to see and [R2] was on the floor. I asked what happened, [R2] said [they] tried to get up from the bed by themselves without calling and slipped between bed and wheelchair and fell to the floor......Call to 911 immediately, and while waiting notified [E1] Manager." The incident report indicated 911 was called at 3:20 AM, The resident's emergency was contacted at 6:00 AM, and R2's primary care provider was not notified of the incident.

2. In an interview, E1 reported E1 emailed R2's primary care provider at around 6:00 AM, the same time as the notification of the emergency contact. E1 acknowledged the incident report documentation indicated the caregiver had not immediately notified the emergency contact and primary care physician when R2 had an accident and required medical services.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officer observed the hot water temperature measured at 125.8\'b0 F in a shared bathroom adjacent to the living room.

2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F.

Based on observation and interview, the manager failed to ensure each sleeping area had adjustable window covers that provided resident privacy.

Findings include:

1. During an environmental tour of the facility, the Compliance Officer observed a resident bedroom, marked bedroom #2 on the facility floor plan, had two resident beds. However, the bedroom did not have adjustable window covers.

2. During an environmental tour of the facility, the Compliance Officer observed a resident bedroom, marked bedroom #3 on the facility floor plan, had two resident beds. However, the bedroom did not have adjustable window covers.

3. During an environmental tour of the facility, the Compliance Officer observed a resident bedroom, marked bedroom #5 on the facility floor plan, had two resident beds. However, the bedroom did not have adjustable window covers.

4. In an interview, E1 reported the facility was in the process of replacing window blinds in the facility. E1 acknowledged the three bedrooms did not have adjustable window covers for resident privacy.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area and inaccessible to residents.

Findings include:

1. During a facility tour, the Compliance Officer observed three five-gallon paint buckets in the back yard of the facility.

2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.