OLIVE GROVE ASSISTED LIVING

<p><span style="font-size: 18pt;">Based record review and interview, the manager failed to ensure that a written notice of termination included the contact information for the State Long-Term Care Ombudsman.</span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;">Findings include:</span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;">1. A review of R1’s medical record revealed a document titled “Formal Notice of Termination” dated April 7, 2025 due to nonpayment of rent. R1’s termination letter reflected “Should you have any questions or need further assistance, you may contact the state long-term care ombudsman at [Ombudsman Phone Number] or [Ombudsman Phone Number]”. R1’s notice of termination did not include the contact information</span><span style="font-size: 10.5pt;"> for the </span><span style="font-size: 18pt;">State Long-Term Care Ombudsman.</span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;">2. In an interview, E1 acknowledged that the notice of termination provided to R1 did not include the contact information</span><span style="font-size: 10.5pt;"> for the </span><span style="font-size: 18pt;">State Long-Term Care Ombudsman.</span></p>

<p><span style="font-size: 14px;">Based on documentation review and interview, the manager failed to ensure that the facility conducted an investigation and created an incident report for an allegation of sexual assault. The deficient practice posed a potential danger to the health and safety of residents.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">Findings include:</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">1. Documentation review established that the facility had not conducted an investigation and did not have an incident report for the incident involving R1.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">2. In an interview, E1 confirmed that the facility had not conducted an investigation and did not have an incident report for the incident involving R1.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">3. In an interview, R1 confirmed to the Compliance Officer that R1 was reportedly raped by an employee about nine to ten months ago and R1 also did not want this employee’s identity to be known. R1 reported the rape to E2 who then reported it to E3. </span></p><p><br></p><p><br></p><p>4. <span style="background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(68, 68, 68);">In an interview, </span>E2 reported that R1 told E2 about the sexual assault in February. E1 <span style="font-size: 14px;">confirmed that the alleged perpetrator had been put on administrative leave pending a full investigation.</span></p>

<p><span style="font-size: 14px;">Based on documentation review and interview, the manager failed to ensure that the facility was treating residents with dignity, respect, and consideration. The deficient practice posed a potential risk to the health and safety of residents.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">Findings include:</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">1. Documentation review established that the facility had not conducted an investigation and did not have an incident report for the incident involving R1.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">2. In an interview, E1 confirmed that the facility had not conducted an investigation and did not have an incident report for the incident involving R1. E1 confirmed that this was not in accordance with treating R1 with dignity, respect, and consideration.</span></p>

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type and frequency of assisted living services to be provided to the resident, for one of four sampled residents. The deficient practice posed a risk if a resident did not receive sufficient services as necessary.

Findings include:

1. A review of R1's medical record revealed a service plan dated January 27, 2025, for personal care services. The service plan indicated R1 required assistance with dressing and nail care. However, the service plan did not indicate the amount or frequency at which the services would be provided.

2. In an interview, E1 reviewed R1's service plan and acknowledged R1's service plan did not reflect the amount or frequency of oral care or toileting provided to R1.

Based on record review and interview, the manager failed to ensure two residents had medical records which contained all required documents in Arizona Administrative Code (A.A.C.) R9-10-811(C)(1)-(24).

Findings include:

1. The compliance officer requested R2's medical record for review. However, R2's medical record was not provided.

2. In an interview, E1 reported R2's medical record was unavailable for review at the time of the survey.

3. In an interview, E1 acknowledged R2's medical record was not available for review, and acknowledged R2's medical record.

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 two of seven sampled residents who received medication administration services. 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 records revealed a service plan dated January 27, 2025 which reflected R1 received medication administration services.

2. A review of R1's medical record revealed a medication order for Lispro INS 100 unit/ml pen inject as per sliding scale: if 71 -150 administer zero units inject before meals record blood sugar before injecting: 151 through 200 administer three units; 201 through 250 administer five units; 251 through 300 administer seven units; 301 through 350 administer ten units; 351+ administer 12 units and call primary physician.

3. A review of R1's medical record revealed a medication administration record dated January 2025, which reflected R1 administered Lispro insulin from January 1, 2025 through January 30, 2025, however R1's blood sugar was not check before every administration, and R1's MAR did not document every amount of insulin administered to R1.

4. In an interview, E1 acknowledge R1's blood sugar was not check before every administration, and R1's MAR did not document every amount of insulin administered to R1.

Based on record review and interview, the manager failed to ensure that a caregiver documented the names of individuals who observed the accident, emergency, or injury, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.

Findings include:

1. A review of R2's medical record revealed an incident report, dated December 15, 2024, which resulted in R2 being transported to the hospital. However, the incident report did not contain the names of individuals who observed the accident, emergency, or injury.

2. A review of R2's medical record revealed an incident report, dated December 17, 2024, which resulted in R2 being transported to the hospital. However, the incident report did not contain the names of individuals who observed the accident, emergency, or injury.

3. In an interview, E1 acknowledged that when a resident had an accident, emergency, or injury that required medical services, a caregiver did not document the names of the individuals who observed the accident, emergency, or injury.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked.

Findings include:

1. The compliance officer requested to see the facility's work schedule from November 1, 2024 to November 10, 2024 of each caregiver and assisted caregiver that worked each day. There was documentation to reflect all the caregiver and assistant caregivers who worked each day from November 1, 2024 to November 10, 2024.

2. A review of facility documentation revealed documents titled "Time Punch Correction Request" reflected E2 worked November 8, 2024 from 1pm to 9pm, November 9, 2024 from 1pm to 9pm, and December 16, 2024 from 1pm to 9pm.

3. A review of facility's documentation revealed document titled "Detailed Calculated Time Weekly Punch Report" which reflected a report of employees and their start time and end time while at the facility.

4. In an interview E6 reported the "Detailed Calculated report only reflect the employees who are entered in their system, and acknowledged E2 would have not been included in the report due to E2 not being entered into the system.

5. A review of the facility's work schedule dated November 10, 2024 through November 16, 2024 which reflected "Agency" on November 16, 2024 on 2:30pm to 10:30pm shift.

6. A review of the facility's work schedule dated November 24, 2024 to November 30, 2024 which reflected "Agency" on 6:30am to 2:30am shift, November 25, 2024 on 6:30am to 2:30am shift, November 29, 2024 on 6:30 am to 2:30 am shift, November 30, 2024 on 6:30 am to 2:30 am shift and on 2:30 pm to 10:30pm shift. The schedule did not reflect the caregivers or assistant caregiver from the "agency" scheduled to work.

7. In an interview, E6 reported caregivers are obtained from an agency to work at the facility, and acknowledged the work schedule did not reflect the caregivers and assistant caregivers who worked each day on the aforementioned schedules.

Based on record review and interview, the manager failed to ensure a written service plan was documented for one of eight sampled residents reviewed.

Findings include:

1. Review of R1's medical record revealed no documentation of a written service plan. Based on R1's date of acceptance and date of termination of residency, a service plan was required.

2. In an interview, E1 acknowledged R1's medical record did not contain a service plan due to R1 being discharged and a service plan could not be generated.

This is a repeat deficiency from the compliance and complaint survey conducted on June 24, 2024.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided assisted living services according to the resident's service plan, for one of two sampled residents.

Findings include:

1. A review of R2's medical record revealed a document titled "Active Cares for [R2]"service plan dated November 3, 2023. R2's service plan reflected R2 required assistance with housekeeping weekly, medication administration, bathing assistance via set up. There was no documentation to reflect R2 was provided the above assistance.

2. In an interview, E1 acknowledged there was no documentation to reflected R2 was provided the above required assistance while residing at the facility.

This is a repeat deficiency from the compliance and complaint survey conducted on June 24, 2024, and the complaint investigation conducted on September 27, 2024.

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 two of two sampled residents who received medication administration services. 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 records revealed a service plan which reflected R1 received medication administration services

2. A review of R1's record revealed a medication order November 11, 2024 for Cephalexin one tablet twice daily for seven days. R1's November 2024 medication administration record reflected R1's Cephalexin was schedule to be administrated at 12pm and no other time, and was not administered Cephalexin between November 13, 2024 through November 17, 2024.

4. A review of R2's medical record revealed a document title "medication administration record (MAR)" dated November 2024, which reflected R2 was administered medications by various caregivers.

5. A review of R2's medical records revealed a medication order dated May 10, 2024 for Lispro insulin U-100 unit inject per sliding scale before meals if 70-150 administer zero units, 151 through 200 administer two units, 201 through 250 administer four units, 251 through 300 administer six units, 301 through 350 administer eight units, 351 through 400 inject ten units, and blood sugar more than 400 call physician.

6. A review of R2's November 2024 MAR reflected R2 was scheduled to be administered Lispro at 8am, 12pm and 4pm. R2 was administered Lispro on various times and dates in November, however R2's blood sugar was not taken or documented before R2's Lispro was administered as required by order. R2 was also not administered Lispro on various days in November.

7. In an interview, E1 reviewed and acknowledged there was no other documentation to reflect R1's and R2's medication was given according to R1's and R2's medication order.

This is a repeat deficiency from the compliance and complaint survey conducted on June 24, 2024, and the complaint investigation conducted on September 27, 2024.

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 one of six caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents.

Findings include:

1. A review of E5's personnel records revealed no documented verification of E5's skills and knowledge.

2. A review of the facility's documentation revealed a work schedule dated November 24, 2024 through November 30, 2024, reflected E5 was scheduled to work from 10:30pm to 6:30am on November 25, 2024, November 26, 2024, November 29, 2024 and November 30, 2024.

3. In an interview, E1 reviewed and acknowledged E5's personnel file did not contain documented verification of E5's skills and knowledge.

This is a repeat deficiency from the complaint and compliance investigation conducted on June 24, 2024.

Based on record review and interview, the manager failed to ensure a written service plan was documented for one of five sampled residents reviewed.

Findings include:

1. Review of R2's and R5's medical record revealed no documentation of a written service plan. Based on R2's and R5's and date of acceptance and date of termination of residency, a service plan was required.

2. In an interview, E1 acknowledged R2's and R5's medical record did not contain a service plan available for review.

This is a repeat deficiency from the complaint and compliance investigation conducted on June 24, 2024.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of five residents sampled.

Findings include:

1. A review of R1's medical record revealed a document titled "Service Plan Task" which reflected "scheduled dates July 4, 2024 - No end date ... R1 required a full assistance with bathing and showering, [R1] was dependent with dressing and required twice daily full dressing and undressing assistance." There was no documentation to reflect R1 was provided assistance with activities of daily living while residing at the facility.

2. A review of R3's medical record revealed a document titled "Service Plan Task" which reflected R3 required daily safety checks and shower set up assistance. There was no documentation to reflect R3 was provide with activities of daily living while residing at the facility.

3. In an interview, E1 acknowledged there was no documentation to reflect R1 and R3 were provided with activities of daily living.

This is a repeat deficiency from the complaint and compliance investigation conducted on June 24, 2024, and a compliant investigation on September 27, 2024.

Based on interview, the manager failed to ensure residents were treated with dignity, respect and consideration.

Findings include:

1. In an interview with R6, R6 reported it normally took six hours for staff to respond to the pull cord alert or pendant.

2. In an interview, R7 reported staff take a awhile to respond but did not specify a time frame or window.

3. In an interview, R8 reported pulling the cord or pushing the pendant and staff members would come in the room to stop call button and leave without assisting R8.

4. In an interview, R3 reported laying on the floor six hours and no one heard R3's screams, R3 reported R3's pendant didn't work. R3 reported falling recently on the floor and alerted staff 40 minutes before the fire department arrived. R3 reported getting medications late or not at all.

5. A review of facility's documentation revealed a document titled "Intake Information" November 7, 2024, which reflected "Fire Department reconnected oxygen. [R3] felt normal and didn't want any further care. [R3] states that the staff hasn't gave [R3] [R3's] medications and will not respond to [R3's] alert button."

6. A review of facility's documentation revealed a document titled "Intake Information" November 15, 2024, which reflected "[R1] does not get medication or insulin some days, and do not receive insulin shot until after eaten ... R1 has not been showered in four weeks ... room has not been cleaned in six weeks."

7. A review of R1's medical record revealed the following medication orders: Gabapentin 600 mg one tablet three times daily dated August 1, 2024, Ammonium Lactate 12% apply twice daily dated February 23, 2024, Atorvastatin 40mg one tablet prior to bedtime dated November 7, 2024; Bupropion 150mg one tablet twice daily dated April 4, 2024; Lantus solostar 50 units in the morning, and Lantus Solo Star 100 unit/ inject 35 units twice daily hold for glucose below 120 dated July 26, 2024, and Lisinopril 5mg one tablet daily dated August 19, 2024. R1's record revealed a document titled "Med Pass History for [R1]" revealed R1 was administered Gabapentin 600mg two times on November 20, 2024, November 18, 2024, November 11, 2024, November 5, 2024, October 30, 2024. R1 was administered Gabapentin 600mg one time on November 4, 2024; R1 was administered Ammonium lactate 12% one time on November 20, 2024, November 12, 2024, and November 4, 2024; R1 was not administered Atorvastatin 40mg on November 11, 2024 and November 10, 2024, R1 was not administered Bupropion 150 mg twice daily on November 20, 2024, November 11, 2024,November 4, 2024; R1 was not administered Lantus 50 units in the morning on November 20, 2024, November 19, 2024, November 18, 2024, November 12, 2024, November 9, 2024, November 10, 2024, November 5, 2024, and November 1, 2024; R1 was administered Lantus 35 units twice daily from November 20, 2024 through November 1, 2024, however R1's glucose was not documented to reflect if Lantus should've be held or administered; R1 was not administered Lisinopril 5mg on November 11, 2024.

8. A review of R1's medical record revealed a document titled "Service Plan Task" which reflected "scheduled dates July 4, 2024 - No end date ... R1 requires a full assist with bathing and showering, [R1] dependent with dressing and requires twice daily full dressing and undressing assist." There was no documentation to reflect R1 was not provided assistance with activities of a daily living while residing at the facility.

9. In an interview, E1 acknowledged the above concerns.

This is a repeat deficiency from the complaint and compliance investigation conducted on June 24, 2024.

Based on interview, the manager failed to ensure residents at the personal level of care had a bell, intercom, or other mechanical means to alert employees to the residents' needs or emergencies, and that staff responded appropriately.

Findings include:

1. In an interview with R6, R6 reported it normally took six hours for staff to respond to the pull cord alert or pendant.

2. In an interview, R7 reported staff take a awhile to respond but did not specify a time frame or window.

3. In an interview, R8 reported pulling the cord or pushing the pendant and staff members would come in the room to stop call button and leave without assisting R8.

4. In an interview, R3 reported laying on the floor six hours and no one heard R3's screams, R3 reported R3's pendant didn't work. R3 reported falling recently on the floor and alerted staff 40 minutes before the fire department arrived. R3 reported getting medications late or not at all.

5. A review of facility's documentation revealed a document titled "Intake Information" November 7, 2024, which reflected "Fire Department reconnected oxygen. [R3] felt normal and didn't want any further care. [R3] states that the staff hasn't gave [R3] [R3's] medications and will not respond to [R3's] alert button."

6. In an interview, E1 acknowledged the above concerns.

Based on record review , observation and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of five sampled residents.

Finding interview:

1. A review of R1's medical record revealed a document titled "Active Cares for [R1] Service Plan Task" "Medication management: Dependent Instructions: ... Status: Significant total assist: staff administer medications as delegated by a licensed health care professional according to service plan."

2. A review of R3's medical record revealed a document titled "Active Cares for [R3] Service Plan Task" "Medication management: Dependent Instructions: ... Status: Significant total assist: staff administer medications as delegated by a licensed health care professional according to service plan."

3. A review of R4's medical record revealed a document titled "Active Cares for [R4] Service Plan Task" "Medication management: Dependent Instructions: ... Status: Significant total assist: staff administer medications as delegated by a licensed health care professional according to service plan."

4. A review of R1's medical record revealed the following medication orders: Gabapentin 600 mg one tablet three times daily dated August 1, 2024, Ammonium Lactate 12% apply twice daily dated February 23, 2024, Atorvastatin 40mg one tablet prior to bedtime dated November 7, 2024; Bupropion 150mg one tablet twice daily dated April 4, 2024; Lantus solostar 50 units in the morning, and Lantus Solo Star 100 unit/ inject 35 units twice daily hold for glucose below 120 dated July 26, 2024, and Lisinopril 5mg one tablet daily dated August 19, 2024.

5. A review of R3's medical record revealed a document titled "Active Medications for [R3]", which reflected R3 would be administered the following medication: Atorvastatin calcium 20 mg, Bumetanide 1 mg, Folate 800 mg take in Monday, Wednesday and Friday, Gabapentin 400 mg take one twice a day , Levetiracetam 500 mg, and Metoprolol Succinate 25mg .

6. A review of R4's medical record revealed the following medication orders: Levothyroxine 50 mcg one tablet every morning dated February 24, 2024, Mirtazapine 15 mg one tablet at bedtime dated April 30, 2024, and Lorazepam 1 mg four times daily October 1, 2024.

7. A review of R1's medical record revealed a document titled "Med Pass History for [R1]" revealed R1 was administered Gabapentin 600mg two times on November 20, 2024, November 18, 2024, November 11, 2024, November 5, 2024, October 30, 2024. R1 was administered Gabapentin 600mg one time on November 4, 2024; R1 was administered Ammonium lactate 12% one time on November 20, 2024, November 12, 2024, and November 4, 2024; R1 was not administered Atorvastatin 40mg on November 11, 2024 and November 10, 2024, R1 was not administered Bupropion 150 mg twice daily on November 20, 2024, November 11, 2024, November 4, 2024; R1 was not administered Lantus 50 units in the morning on November 20, 2024, November 19, 2024, November 18, 2024, November 12, 2024, November 9, 2024, November 10, 2024, November 5, 2024, and November 1, 2024; R1 was administered Lantus 35 units twice daily from November 20, 2024 through November 1, 2024, however R1's glucose was not documented to reflect if Lantus should've been held or administered; R1 was not administered Lisinopril 5mg on November 11, 2024.

8. A review of R3's medical record revealed a document titled "Med Pass History for [R3]" revealed R3 was administered: Atorvastatin calcium 20 mg, Bumetanide 1 mg, Folate 800 mg, Gabapentin 400 mg take one twice a day, Levetiracetam 500 mg, and Metoprolol Succinate 25mg on various time and days in October 2024 and November 2024. However, there were no medication orders for the above medications available for review.

9. A review of R4's medical record revealed a document titled "Med Pass History for [R4]" revealed R4 was not administered Levothyroxine 50 mcg on October 7, 2024, October 6, 2024, October 3, 2024, September 28, 2024, September 26, 2024, and September 24, 2024; Lorazepam 1 mg was not administered four time a day on October 9, 2024, October 8, 2024, October 7, 2024, October 6, 2024, October 4, 2024, October 3, 2024, and September 30, 2024.

10. In an interview, E1 reviewed and acknowledged R1's, R3's, and R4's above medications were reflected as not administered in compliance with medication orders.

This is a repeat deficiency from the complaint and compliance investigation conducted on June 24, 2024, and a compliant investigation on September 27, 2024.

Based on record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of one resident reviewed. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall.

Findings include:

1. A review of R2's medical record revealed a document titled "Incident Report Form" dated September 21, 2024 which reflected "Found [R2] on the floor face down. Turned [R2] to side no blood or discoloration noted. I call 911 Resident transported to valley wise emergency room."

2. In an interview, E2 reported turning R2 to the side and waited to 911. E2 reported R2 was too heavy and couldn't be lifted by E2 by E2's self. E2 reported another staff member was is the facility but didn't call the other personnel.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident or resident's representative, the manager, and, if applicable, the nurse, medical practitioner or behavioral health professional who reviewed the service plan, for two of five sampled residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated July 4, 2021, indicating R1 received personal level of care, and was receiving medication administration services. R1's service plan was not signed by the resident or resident's representative, nurse or medical practitioner, or the manager.

2. A review of R3's medical record revealed a service plan dated July 6, 2024, indicating R3 received personal level of care and was receiving medication administration services. R3's service plan was not signed by the resident or resident's representative, nurse or medical practitioner, or the manager.

3. In an interview, E1 acknowledged R1's and R3's service plans were not signed by the resident or resident's representative, nurse or medical practitioner, or the manager.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of five residents sampled.

Findings include:

1. In an interview, R3 reported not regularly receiving showers and the last shower or bath R3 had was about three weeks ago.

2. A review of R3's medical record revealed a service plan dated July 6, 2024 which reflected R3 would be provided the following assistance from a caregiver: bathing every Wednesday and Friday of the week, toileting checks nine times daily, and require nightly safety checks three time daily.

3. A review of R3's medical record revealed for the month August 2024 and September 2024 the only documented bathing assistance provided to R3 was August 14, 2024 and September 14, 2024. There was no other documentation R3 was provided assistance with personal hygiene, toileting assistance, and nightly safety checks as required on service plan.

4. In an interview, E1 reviewed and acknowledged there was no other evidence to demonstrate compliance that R3 was provided services in R3's service plan.

This is an uncorrected deficiency from the complaint investigation and compliance inspection conducted on June 24, 2024.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for of three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R2's service plan dated July 6, 2024 revealed R2 would be provided the following assistance: bathing twice weekly, grooming reminders every morning and night, and toileting checks every night. A review of documentation of services provided to R2 reflected R2 was provided two showers on September 5, 2024 and September 4, 2024. There was no other documentation to reflect R2 was provide assistance with the above required services for the entire month of August 2024 and September 2024.

2. In an interview, E1 reviewed and acknowledged there was no documentation to reflect R2 was provided assistance with the services required in the R2's service plan. E1 reported E1 could not confirm or deny whether or not R2 was provided above services.

This is an uncorrected deficiency from the complaint investigation and compliance inspection conducted on June 24, 2024.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of four residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated July 4, 2024 which reflected R1 was personal level of care and would be provided medication administration services. R1's record contained the following medication orders:
-Divalproex 125 mg one tablet at bedtime dated July 4, 2024;
- Doxepin 25 mg one capsule at bedtime dated May 30, 2024;
- Levetiracetam 500 mg one tablet twice daily dated July 5, 2024;
-Mirtazapine 15 mg one tablet once daily at 5 pm and Mirtazapine 45 mg one tablet at bedtime dated March 25, 2024;
- Mirtazapine 45 mg one tablet at bedtime dated March 25, 2024;
-Quetiapine 100 mg one tablet once daily date May 22, 2024; and
-Quetiapine 25 mg one tablet once daily dated April 24, 2024.

3. A review of R1's September 2024 medication administration record revealed the following medication errors:
-R1's Divalproex 125 mg was scheduled to be given at 8 pm daily. R1 was administered Divalproex 125mg at 9:30 on September 11, 2024, 10pm on September 12, 2024, 5:56 pm on September 17, 2024, and 10:33 pm on September 19, 2024;
-R1's Levetiracetam 500mg was scheduled to be given at 8am and 8pm daily. R1's 8am dose was administered at 9:35 am on September 2, 2024, 10:10 am on September 5, 2024, 10:47 am on September 9, 2024, 9:36 am on September 10, 2024, 11:59 am on September 16, 2024, 11:07 am on September 19, 2024, 10:40 am on September 26, 2024, and 11:15am on September 27, 2024. R1's 8 pm dose was administered at 9 pm on September 8, 2024, 9:32 pm on September 11, 2024, 10 pm on September 12, 2024, 5:58 pm on September 17, 2024, and 10:34 pm on September 19, 2024. R1's Mirtazapine 15 mg was scheduled to be administered at 8 pm daily. R1's Mirtazapine 15 mg was administered at 5:58 pm on September 17, 2024, all other days R1 was administered Mirtazapine 15 mg between 7 pm to 10:35 pm

4. A review of R2's medical record revealed July 6, 2024 reflected R2 receive medication administration services. R2's record revealed the following medication orders: Fluoxetine 20mg one tablet daily dated August 12, 2024, Fluoxetine 40mg one tablet daily dated August 14, 2024, Mirtazapine 15mg one tablet daily dated July 1, 2024, and Trazadone 50mg one tablet at bedtime dated June 13, 2024. R2's August 2024 MAR reflected R2's Fluoxetine 40mg was not documented as administered on August 13, 2024, August 15, 2024, August 29, 2024 and August 31, 2024. R2's Fluoxetine 20mg was not administered on August 13, 2024, August 15, 2024, August 29, 2024 and August 30, 2024. R2's Mirtazapine 15mg was not administered on August 16, 2024, August 17, 2024 and August 28, 2024. R2's Trazadone 50mg was not administered on August 16, 2024, August 17, 2024 and August 28, 2024.

5. A review of R3's medical record revealed July 6, 2024 reflected R3 receive medication administration services. R3's record revealed the following medication orders: Tramadol 50 mg one tablet ever morning dated June 28, 2024, Montelukast 10mg one tablet every evening, Gabapentin 300 mg one tablet at bedtime dated June 25, 2024. R3's August 2024 MAR reflected R2's Tramadol 50 mg was not documented as administered on September 13, 2024, September 15, 2024, September 29, 2024 and September 31, 2024. R2's Montelukast 10 mg was not administered on September 20 2024 and September 25, 2024. R2's Mirtazapine 15 mg was not administered on September 16, 2024, September 17, 2024 and September 28, 2024. R3's Gabapentin 300 mg was scheduled to be given at 8 pm daily, however was administered at 9:12 pm on September 9, 2024, 9:25 pm on September 11, 2024, 9:26 pm on September 12, 2024.

6. In an interview, E1 reviewed and acknowledged R1's, R2's, and R3's MAR did not reflect their above medications were given in compliance with the above medication orders.

This is an uncorrected deficiency from the complaint investigation and compliance inspection conducted on June 24, 2024.

Based on interview, record review, observation, and documentation review, the governing authority failed to ensure that the certified manager had a personnel record maintained at the facility.

Finding include:

1 A review of Department documentation revealed O1 had been the facility manager; but O1 notified the Department that O1 was no longer the manager of the facility as of May 23, 2022.

2. A review of Department documentation revealed there was no notification of the facility's manager.

3. During observation of the facility's postings, no manager's certificate was posted in a conspicuous area.

4. A review of personnel records revealed there was no personnel record for the manager.

5. In an interview, E1 reported being the facility's administrator but not manager and reported there was no personnel record for the manager.

5. On August 12, 2024, E10 submitted documentation to the Department which showed the appointment of E11 as the certified manager.

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 two of nine caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents.

Findings include:

1. A review of E8's and E9's personnel records revealed no documented verification of E8's and E9's skills and knowledge.

2. A review of R7's medical record revealed a document titled "Task Administration record" date June 2024, which reflected "RT2 (Registry two)" completed the "follow up every shift for 72 hours, check vital signs and check pain at 12am and 2am on June 2, 2024."

3. In an interview, E1 reported E8 or E9 possibly provided the above service to R7. In an interview, E1 reported "RT2" are registry appointed caregivers who document the services provided to residents.

Based on record review and interview, the manager failed to ensure a written service plan was documented for one of eight sampled residents reviewed.

Findings include:

1. Review of R5's medical record revealed no documentation of a written service plan. Based on R5's date of acceptance and date of termination of residency, a service plan was required.

2. In an interview, E1 and E7 acknowledged R5's medical record did not contain a service plan due to R5 being discharged and a service plan could not be generated.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for five of eight residents sampled.

Findings include:

1. A review of R1's service plan dated November 4, 2023 reflected R1 would be provided the following services:
- grooming oral hygiene: set up and remind resident to complete oral care;
- weekly housekeeping;
- night safety check between 10pm and 6am;
- bathing stand by assistance;
- dressing assistance required for lower body;
- medication administration services;
- daytime safety checks;
- monthly vital and weight checks.

2. R1's medical record contained a document titled "Task Administration Record" dated June 2024, which reflected R1 was not assisted with the following services:
- bathing, dressing, grooming, and daytime safety check were not completed from June 1, 2024 to June 20, 2024.
- night time safety checks were not completed on June 1, 2024, June 3, 2024, June 7, 2024 through June 9, 2024 and June 13, 2024.

3. A review of R2's medical record revealed a service plan dated February 16, 2024 which reflected R2 would be provided the following services:
- bathing standby assistance;
- daily safety checks;
- weekly housekeeping;
- medication administration services;
- monthly vital and weight checks;
- two daily reminders to perform grooming;
- night safety checks;
- weekly laundry service.

4. R2's medical record contained a document titled "Task Administration Record" dated June 2024 which reflected R2 was not assisted with the following services:
- bathing, weekly, laundry, daily safety checks, monthly vitals, care and cleaning of nebulizer machine, and personal grooming from June 1, 2024 through June 20, 2024;
- night safety checks on June 1, 2024, June 3, 2024, June 7, 2024 through June 9, 2024 and June 13, 2024 through June 16, 2024.

5. A review of R3's service plan dated December 12, 2023, which reflected R3 would be provided the following services:
- housekeeping and laundry weekly;
- night shift safety checks at 2am;
- daytime safety checks;
- bathing requires standby assistance.

6. R3's medical record contained a document titled "Task Administration Record" dated May 2024, which reflected R3 was not provided assistance with weekly housing, daily safety checks, daily trash removal, reminders for hydration and bathing assistance between June 1, 2024 through June 21, 2024.

7. A review of R4's medical record revealed a service plan dated March 4, 2024, which reflected R4 would be provided the following services:
- daily safety checks
- weekly housekeeping;
- medication administration services;
- monthly vital and weight checks;
- meal escort three times daily;
- weekly laundry service;
- bathing assistance.

8. R4's medical record contained a document titled "Task Administration Record" dated April 2024 reflected was not provided the following scheduled services:
- bathing assistance on April 2, 2024, April 9, 2024, and April 16, 2024;
- daily safety checks from April 1, 2024 through April 4, 2024, and April 14, 2024 through April 17, 2024;
- weekly laundry April 1, 2024 through April 15, 2024
- escorts to breakfast and lunch from April 1, 2025 through April 4, 2024, April 7, 2024 through April 11, 2024, and April 14, 2024 through April 17, 2024.

9. A review of R6's medical record revealed a service plan December 14, 2023 reflected R6 would be provided the following services:
- daily safety checks;
- weekly housekeeping;
- medication administration services;
- monthly vital and weight checks;
- night safety checks; and
- weekly laundry service.

8. R6's medical record contained a document titled "Task Administration Record" dated April 2024 reflected was not provided the following scheduled services:
- daily safety checks from April 1, 2024 through April 4, 2024 and April 13, 2024 through April 15, 2024; and
- weekly laundry April 1, 2024 through April 15, 2024.

9. In an interview, E1 acknowledged the above documentation reflected the services were not provided as required by the residents' service plans.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of eight resident.

Findings include:

1. A review of R5's medical record revealed there was no documentation of services provided to R5.

2. In an interview, E1 reported the documentation of services provided to R5 was not available for review.

Based on interview, the manager failed to ensure a resident was treated with dignity, respect and consideration.

Findings include:

1. In an interview, R2 reported missing breakfast due to medications often given late, and reported often missing showers.

2. In an interview, R9 reported caregivers refused to help wheel R9 to meals, and often requested R9's roommate to assist. R9 reported the facility ran out of R9's medication often.

3. In an interview, R10 reported the facility often ran out of medication and reported clothes had been stolen from R10's unit, however reported the staff refused to investigate R10's concerns.

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for two of eight residents sampled. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance.

Findings include:

1. A review of R3's medical record revealed a document titled "Task Administration Record" dated May 2024 which reflected "OGR" provided safety checks to R3 on May 11, 2024 at 3:12am and May 12, 2024 at 2:16am. The record reflected "OCG" was assigned to "OG registry".

2. A review of R7's medical record revealed a document titled "Task Administration record" date June 2024, which reflected "RT2" (Registry two)" completed the "follow up every shift for 72 hours, check vital signs and check pain at 12am and 2am on June 2, 2024.

3. In an interview, E1 reported "OGR" and "RT2" are registry appointed caregivers who possibly documented the services provided. E1 acknowledged the documented services in R3's and R7's medical records were not authenticated by the individuals documenting the service.

4. A review of R1's and R2's medical records revealed a document titled "Activities of Daily Living (ADL sheet)" dated February 2020 and March 2020 for each resident. The ADL sheets of R1 and R2 contained check marks to reflect the services were provided to each resident. However, the entries on the ADL sheets were not authenticated by the individual(s) who provided the services to the residents.

5. In an interview, E1 reported being unaware the documentation of the services being provided to the residents required authentication.

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 two of seven sampled residents who received medication administration services. 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 and R2's medical records revealed a service plan which reflected R1 and R2 received medication administration services.

2. A review of R1's medical record revealed the following medication orders:
- Gabapentin 600mg take one tablet by mouth four times daily, take at the same time every day;
- Levothyroxine 175 mcg one tablet each morning;
- Insulin Lispro kwik pen inject one additional unit for every 50 over glucose of 150 for a max of 50 units daily.

3. A review of R1's medical record revealed a medication administration record (MAR) dated January 2024 which reflected:
- R1 was administered Lispro insulin on January 2, 2024 at 4:08pm with a blood glucose of 201, and 8:09pm with a blood glucose of 316. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin January 3, 2024 at 6:19pm with a blood glucose of 240, and 8:55pm with a blood glucose of 289. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin January 5, 2024 at 7:28pm with a blood glucose of 215. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 6, 2024 at 3:59pm with a blood glucose of 175, and 7:36pm with a blood glucose of 325. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 8, 2024 at 3:58pm with a blood glucose of 270, and 8:30pm with a blood glucose of 480. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 9, 2024 at 5:04pm with a blood glucose of 161, and 8:26 pm with a blood glucose of 261. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 10, 2024 at 4:28pm with a blood glucose of 256, and 8:40 pm with a blood glucose of 373. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 12, 2024 at 3:52pm with a blood glucose of 235, and 10:19 pm with a blood glucose of 234. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 13, 2024 at 4:13pm with a blood glucose of 295, and 7:12 pm with a blood glucose of 174. The amount of insulin administered to R1 was left blank;
- R1 was administered Lispro insulin on January 14, 2024 at 7:35am with a blood glucose of 146, 12:37pm with a blood glucose of 404 and 4:25pm with a blood glucose of 327. The amount of insulin administered or withheld was left blank; and
- R1 was administered Lispro insulin on January 15, 2024 at 3:52pm with a blood glucose of 258, and 10:19pm with a blood glucose of 202. The amount of insulin administered to R1 was left blank.

4. R1's January 2024 MAR reflected R1's Gabapentin 600mg was scheduled to be administered 8am, 12pm, 4pm and 8pm every day. R1's MAR reflected the following:
- R1's 8am dose was administered at 10:14am on January 1, 2024, 9:45am on January 3, 2024,10:04am on January 6, 2024, 9:20am on January 7, 2024, 9:42am January 15,2024, and 10:22am on January 27, 2024;
- R1's 12 noon dose was administered at 1:37pm on January 1, 2024, 1:27 on January 3, 2024, 1:32pm on January 3, 2024, 1:40pm on January 9, 2024, 1:47 on January 13, 2024, 2:19pm on January 29, 2024, and 2:32pm on January 31, 2024.

5. R1's January 2024 MAR reflected R1's Levothyroxine was not documented as administered on January 2, 2024 and January 20, 2024.

6. A review of R2's medical record revealed the following medication orders:
order dated June 6, 2024 for Gabapentin 400mg take one tablet by mouth three times daily, take at the same time every day, Losartan 50mg one tablet once daily, Verapamil 240mg one tablet daily, Oxybutynin 10mg one tablet daily, Duloxetine 40mg two capsules once daily, Glipizide 5mg one tablet once daily, and Nitrofurantoin 50mg one capsule by once daily.

7. R2's June 2024 MAR reflected R2's medications were not documented as administered:
- Gabapentin 400mg was not documented as administered a 6am dose on January 9, 2024, 6p dose on June 8, 2024, June 11, 2024, June 12, 2024, June 14, 2024, June 17, 2024, June 18, 2024 and June 21, 2024.
- Losartan 50mg was not documented as administered on June 8, 2024 and June 9, 2024 ;
- Verapamil 240mg was not documented as administered on June 8, 2024;
- Oxybutynin 10mg was not documented as administered on June 9, 2024;
- Duloxetine 40mg was not documented as administered on June 7, 2024; and
- Glipizide 5mg was not documented as administered on June 8, 2024 and June 9, 2024.

8. R2's June 2024 MAR reflected R1's Gabapentin 400mg was scheduled to be administered 6am, 12pm, 4pm and 6pm every day. R1's MAR reflected the following:
- R2's 12pm dose was administered at 1:29pm on June 7, 2024, 2:37pm on June 8, 2024, and 2:01pm on June 18, 2024.

9. In an interview, E1 reviewed R1's and R2's medical records and acknowledged the reviewed documentation did not reflect the residents' medications were administered in compliance with the medication orders.

Based on documentation review and interview, the manager failed to ensure a pest control program compliant with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was implemented.

Findings include:

1. A.A.C. R3-8-201(C)(4) states: "4. An individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator in the certification category for which services are being provided."

2. A review of facility documentation revealed a Pest Control Log, which reflected pest control was completed on a various dates ranging from October 2023 through June 2024 by the facility's maintenance staff. There was no documentation of individual conducting the pest control service being a certified applicator.

3. In an interview, E1 reported the maintenance staff provided pest control to the various locations in the facility, and there was no documentation available for review to reflect the individuals providing pest control services were certified applicators.

Based on observation, documentation review, and interview, the manager failed to ensure pets were licensed consistent with local ordinances.

Findings include:

1. The Compliance Officer observed O1 accompanying R10 around the facility on a motor chair.

2. A review of facility documentation for O1 revealed no documented evidence to indicate O1 was licensed consistent with local ordinances.

3. In an interview, E1 reported being unable to provide documentation of a pet license for O1.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies.

Findings include:

1. The Compliance Officer observed O1 accompanying R10 around the facility on a motor chair.

2. A review of facility documentation for O1 revealed no documented evidence to indicate a current rabies vaccination for O1.

3. In an interview, E1 reported being unable to provide documentation of a current rabies vaccination for O1.