COPPER CANYON ALZHEIMER'S SPECIAL CARE CENTER

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

Findings include:

1. A review of facility documentation revealed an incident report documenting an interaction between a E11 and R5. The report stated, "E11 was overheard raising E11's voice and using profanity when addressing this resident." The report further stated E11 was immediately placed on administrative leave and terminated five days later.

2. In an interview, E1 acknowledged R5 was treated without dignity, respect and consideration. E1 further acknowledged immediate action to prevent further occurrence by placing E11 on administrative leave and later terminating E11.

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for one of six resident records reviewed. The deficient practice posed a risk as the original entry was unable to be verified.

Findings include:

1. A review of R6's medical record revealed an untitled document, where caregivers document services provided to R6. However, correction fluid was used to obscure two original entries on July 14, 2024. The entries not legible were the caregiver who completed R6's activities of daily living, and the original caregiver assigned to R6 for the evening of July 14, 2024.

2. In an interview, E1 acknowledged entries in R6's medical record were changed to make the initial entries illegible.

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 six resident records reviewed.

Findings include:

1. A review of R6's medical record revealed a signed medication order, dated July 3, 2024, which stated:
- "DC Lasix 20mg Qd. Stop today 7/3/24";
- "DC KCI 10mg Qd. Stop today 7/3/24"
- "Start Lasix 20mg QOD. Start 7/7/24";
- "Start KCI 10meq QOD. Start 7/7/24"

2. A review of R6's medical record revealed a Medication Administration Record (MAR) dated July 2024. The MAR revealed "FUROSEMIDE 20 MG TABLET", also known as Lasix, and "Potassium CL ER 10 MEQ CAPS", also known as KCI, were stopped on July 3, 2024 as ordered, however they were not administered again until July 13, 2024.

3. In an interview, E1 acknowledged medications were not administered to R6 in compliance with medication orders.

Based on documentation review, record review, and interview, the manager failed to implement a policy and procedure to protect the health and safety of a resident that covered how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "9.2 Resisting Care - Memory Care". The policy stated, "1. All staff will be trained on resident rights and the Resident's entitlement to:...Freedom from restraints or physical or verbal force...3. Staff will apply approaches, invitations, and direction to best encourage residents' positive responses...Resident's preferences, lifestyles, and choices will be considered during care practices such as... bath or shower...staff will gently coax Residents through process during care practices....Attempt diversion if Resident appears uncomfortable such as playing music or singing songs....If resident becomes upset or agitated or indicates verbally or physically NO or STOP: Maintain calm demeanor, apologize for causing resident distress, cease personal care for that time, but do not leave the Resident alone if it is unsafe to do so, offer support, If a trigger is identified, re-assess situation, Re-attempt care after a few minutes if the Resident appears calm and willing, Seek co-caregiver assistance if necessary or implement, "Change of Face technique"..."

2. A review of the facility's policies and procedures revealed a policy titled, "Aggression - Memory Care." The policy stated, "2. Staff will follow the Alzheimer's Association's recommended interventions, including but not limited to:...h. Decrease level of anger..i. Remove self or other Residents out of the reach of the aggressive Resident...iv. Restraint or force are not used to manage behavioral challenges. If incident of aggression occurs...use "change of face" technique while removing self from direct sight of resident to promote resident refocus...contact the resident's physician or any order or treatment, notify the residents legal representative of occurrence and of physician orders, document incident information in the resident's record..."

3. A review of facility incident reports revealed an incident report dated April 1, 2024. The incident report included an incident date of March 31, 2024 at 8 PM. The incident report included a witness statement which stated,"...I was working on the floor as a caregiver. I was helping [R1]. I called over the radio for assistance with [R1]. [E4] came to assist. [R1] can be combative and tries to hit. I had [R1] in the bathroom. I got [R1's] brief off but needed assistance because [R1] was getting combative. We got [R1] changed in the bathroom, taking [R1] to bed. [R1] was getting angry and started to resist and fight. [E4] was fake fighting with [R1]. It was making [R1] angry. We got [R1] in bed. [R1] was struggling and trying to get up. I was standing next to the bed. [R1] tried to get up and [R1] took some swings at me. [E4] was at the foot of the bed, grabbing at [R1's] feet, then [E4] was next to me. [E4] slapped [R1] across [R1's] face, told [R1] to calm down, then [E4] walked out. [R1] had a cyst on [R1's] eyelid and when [E4] slapped [R1] it broke and later [R1] had a red mark on [R1's] face. I was totally shocked. When I told another caregiver, [they] said [E4] has done it before and was aggressive." However, the incident report did not document attempts to use any of the techniques listed in the facility's Policies and Procedures, and the aggressive behavior and resulting incident was not reported or documented until the following day.

4. In an interview, E1 acknowledged the facility policy covering how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual had not been implemented.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of five employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

A.R.S. \'a7 36-411 states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.

C. 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.

2. Verify the current status of a person's fingerprint clearance card.

D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.

E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.

F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.

G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.

H. For the purposes of this section:

1. "Direct supportive services":

(a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:

(i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.

(ii) Assistance with self-administration of medication.

Findings include:

1. A review of E4's personnel record revealed E4 had been hired as a caregiver in March of 2023. E4's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E4's personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E4's fitness to work in a residential care institution.

2. A review of E6's personnel record revealed E6 had been hired as a caregiver in August of 2023. E6's personnel record included a fingerprint clearance card. However the card had a marked expiration of March 7, 2024.

3. Online verification of E6's fingerprint clearance card revealed E6 did not have a valid fingerprint clearance card.

4. A review of the facility work schedule revealed E6 worked for the facility after the expiration of E6's fingerprint clearance card on the following days:
- March 8, 2024 from 6 AM to 10 PM;
- March 9, 2024 from 6 AM to 10 PM;
- March 10, 2024 from 6 AM to 10 PM;
- March 11, 2024 from 6 AM to 10 PM;
- March 14, 2024 from 2 PM to 10 PM;
- March 15, 2024 from 6 AM to 10 PM;
- March 16, 2024 from 6 AM to 10 PM;
- March 17, 2024 from 6 AM to 10 PM;
- March 29, 2024 from 6 AM to 10 PM;
- March 30, 2024 from 6 AM to 10 PM; and
- March 31, 2024 from 6 AM to 10 PM.

5. A review of E7's personnel record revealed E7 had been hired as a caregiver in November of 2023. E7's personnel record included a valid fingerprint clearance card and a list of previous employers. However, E7's personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E7's fitness to work in a residential care institution.

6. In an interview, E1 and E2 acknowledged the personnel records provided for review did not document compliance with all subsections of A.R.S. \'a7 36-411.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident covering staffing and recordkeeping.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "2.1 General Staffing and Supervision Principles," revised January 15, 2020. However, this policy referenced other policies, stating, "The community has developed and implemented staffing policies, which require personnel rations based upon the needs of the Residents, as identified in their Service Plans."

2. During the on-site inspection, the Compliance Officer requested to review the referenced resident assessment and staff ratio policy, to determine if the facility was staffed per policy. However, this policy was not provided for review.

3. In an interview, E1 and E2 acknowledged the provided staffing policy and procedure did not provide any means to determine if the facility had sufficient staff and referenced another, unavailable policy.

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

Findings include:

1. A review of R1's medical record revealed a service plan, dated February 14, 2024, for directed care services. R1's medical record did not include a discharge date.

2. A review of R1's medical record revealed an incident report dated March 1, 2024 at 4:10 AM. The incident report stated, "resident did not sleep at all in the night. [R1] been aggressive all night, in the morning [R1] got out through he back door. [R1] started to throw rocks at us. [R1] started to run after us. [R1] hit [two staff members.] I had to call 911. I also called [R1's representative] who said it's ok for ambulance to take [R1] out. [R1's representative] said [they] will be here this morning to call doctor." The incident report also stated, "talked with [R1's representative.] Psych eval done ASAP. Meds Changed. Continue to redirect and call EMS if needed."

3. In an interview, E1 reported R1 was evaluated in the emergency department and returned to the facility later that day.

4. A review of R1's medical record revealed an incident report dated March 27, 2024 at 3:50 AM. The incident report stated, "[a staff member] call[ed] me on the radio stating [R1] had just push[ed] down [R7]. [R7] had a wound on the back of [R7's] head. [R7] was bleeding from [their] head. I called nurse and 911. They took [R7] out to the hospital. I called [R1's representative] no answer left voicemail. [R1] is so aggressive and refused p.r.n." The incident report had the business card of a police officer attached, but no further details regarding the incident.

5. In an interview, E1 reported R1's representative came to stay with R1 and the police were contacted and responded to the facility but took no other immediate action. E1 reported R1 was removed from the facility by their representative later that day.

6. In an interview, E2 reported both R1 and R2 left the facility on March 29, 2024. E2 reported R1 is considered discharged and R2 is expected to return.

7. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR documented the following:
- R1 had not received medications at 7 AM or 8 AM on March 1, 2024, and the MAR was marked "LOA," or "OOF" for each medication;
- R1 had received medications at 2 PM, 5 PM, and 9 PM on March 1, 2024;
- R1 had received medications at 8 AM on March 29, 2024;
- R1 had not received medications at 12:00 PM, 2 PM, 5 PM, of 9 PM on March 29, 2024, and the MAR was marked "LOA," "OOF," or "--";
- R1 had not received medications at any time on March 30 or March 31, 2024, and the MAR was marked "LOA."

8. A review of R1's medical record revealed a form titled, "Service Checkoff List," (ADL) dated March 2024. The ADL form included false or misleading entries and documented R1 had received the following services:
- All services were provided on March 1, 2024 on the AM shift, while R1 was at the hospital;
- No services were provided on March 6, 2024 on the AM, PM, or Night shifts, while R1 was at the facility;
- All services were provided on March 29, 2024 on the PM and Night shifts, after R1 had discharged;
- All services were provided on March 30, 2024 on the AM, PM, and Night shifts, after R1 had discharged; and
- All services were provided on March 31, 2024 on the AM, PM, and Night shifts, after R1 had discharged.

9. A review of R2's medical record revealed a service plan, dated February 22, 2024, for directed care services.

10. A review of R2's medical record revealed an incident report dated March 23, 2024 at 6:54 PM. The incident report stated, "[R2] stated [R2] can hit whoever [R2] wants and do what [R2] wants." The incident report also stated, "APS report filled, needs frequent redirection at times challenging. PCP asked for UA to be done + Psych Eval if this agitation continues, 3/25/24. Send to [a geropsych facility] for eval." The incident report included two witness statements. One stated, "Resident was mean to other residents and [R2] got hit on the face." The second witness statement stated, "resident was getting aggressive and then [R2] hitting the other residents."

11. In an interview, E2 reported R2 was transported to another facility on March 29, 2024.

12. A review of R2's medical record revealed a MAR dated March 2024. The MAR documented the following:
- R2 had received medications at 8 AM on March 29, 2024;
- R2 had not received medications at 8 PM on March 29, 2024, and the MAR was marked "LOA;
- R2 had not received medications at any time on March 30 or March 31, 2024, and the MAR was marked "LOA."

13. A review of R2's medical record revealed an ADL form dated March 2024. The ADL included false or misleading entries and documented R2 had received the following services:
- No services were provided on March 6, 2024 on the AM, PM, or Night shifts, while R2 was at the facility;
- All services were provided on March 29, 2024 on the PM and Night shifts, after R2 left the facility;
- All services were provided on March 30, 2024 on the AM, PM, and Night shifts, including a shower, after R2 had left the facility; and
- All services were provided on March 31, 2024 on the AM, PM, and Night shifts, after R2 had left the facility.

14. A review of R3's medical record revealed an ADL dated March 2024, however, the ADL did not document any services provided on R3 on March 6, 2024.

15. A review of R4's medical record revealed an ADL dated March 2024, however, the ADL did not document any services provided on R4 on March 6, 2024.

16. A review of R5's medical record revealed an ADL dated March 2024, however, the ADL did not document any services provided on R5 on March 6, 2024.

17. In an interview, E1 and E2 acknowledged the "Service Checkoff List" documents provided did not accurately document the services provided to each resident.

Based on record review, observation, and interview, the manager failed to ensure a resident was provided a diet that met the resident's nutritional needs as specified in the resident's service plan, for two of five sampled residents.

Findings include:

1. A review of R3's medical record revealed a form titled, "Dietary Physicians Orders." The form had been signed by a physician on September 1, 2022 and stated, "Food Allergies: Soy, Soy products."

2. A review of R3's medical record revealed a service plan dated January 22, 2024 for directed care services. The service plan stated, "Allergies: Amoxicillin," and "Diet: Regular, soy soy products."

3. A review of R4's medical record revealed a form titled, "Dietary Physicians Orders." The form had been signed by a physician on July 20, 2023 and stated, "Food Allergies: Wheat."

4. A review of R4's medical record revealed a service plan dated January 24, 2024 for directed care services. The service plan stated, "Allergies: Bee Sting, Bee Venom Protein (Honey bee), Buckwheat, Lactose, Milk, Wheat," and "Diet: Lactose Free, Regular, weat allergie (sic)."

5. The Compliance Officer observed a cabinet in E8's office included a binder containing the "Dietary Physicians Orders" for each resident. The binder contained a copy of R4's order stating R4 had a wheat allergy, however, the binder did not contain a copy of R3's order stating R3 had a soy allergy.

6. The Compliance Officer observed a posted list of special diets on a bulletin board in the commercial kitchen. The list included R4's Lactose restriction. However, the posting did not list R3's soy allergy or R4's wheat allergy.

7. The Compliance Officer observed a clipboard hanging from the bulletin board in the commercial kitchen. The clipboard contained a document listing all residents, their special diets and allergies, and included spaces for staff to document whether each resident had eaten each daily meal. The document included R4's lactose restriction. However, the document did not list R3's soy allergy or R4's wheat allergy.

8. In an interview, E8 reported E8 receives the diet orders, maintains the binder, and creates the postings and checklists for the dietary staff to utilize. E8 reported a copy of the checklist is sent with the prepared food to the back dining room. E8 reported the kitchen prepares all snacks but the activity staff handle providing the snacks to residents and would also use the postings to know who has a dietary restriction. E8 reported additional snacks are in a refrigerator in the kitchen at all times and is always unlocked so off-shift staff can always get a snack for a resident. E8 reported all staff use the posted information to know if a resident has a dietary restriction. E8 acknowledged R3's and R4's allergies were not posted or included on the server checklists.

9. In an interview, E1 and E2 acknowledged R3 and R4 had not been provided a diet that met the resident's nutritional needs as specified in the resident's service plan.

Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for two of two sampled residents for whom an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed an incident report dated March 1, 2024. The incident report indicated R3 had been transported to the hospital after, "[R3] got out through the back door. [R3] started to throw rocks at us, [R3] started to run after us. [R3] hit [two staff]. I had to call 911, I also called POA, [they] said its okay for ambulance to take [R3] out.."

2. A review of R3's medical record revealed a copy of any documentation given to the emergency responder was not available for review.

3. A review of facility documentation revealed an incident report dated March 17, 2024. The incident report indicated R4 had been transported to the hospital after, "[R4] had seizing for couple minutes, care manager assisted [R4] and medtech call 911 and family member."
4. A review of R4's medical record revealed a copy of any documentation given to the emergency responder was not available for review.

5. In an interview, E1 acknowledged the documentation of what was given to the emergency responder for R3 and R4 was not provided for review.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident covering staffing and recordkeeping.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "2.1 General Staffing and Supervision Principles," revised January 15, 2020. However, this policy referenced other policies, stating, "The community has developed and implemented staffing policies, which require personnel rations based upon the needs of the Residents, as identified in their Service Plans."

2. During the on-site inspection, the Compliance Officer requested to review the referenced resident assessment and staff ratio policy, to determine if the facility was staffed per policy. However, this policy was not provided for review.

3. In an interview, E1 acknowledged the provided staffing policy and procedure did not provide any means to determine if the facility had sufficient staff and referenced another, unavailable policy.

Based on record review and interview, 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. On March 22, 2024 at 10:53 AM, the Compliance Officer requested the following documents during the on-site inspection:
- Complete medical records for R1, R2, R3, R4, R5, and R6.
However, partial records were provided for each resident within the two hour window and the remainder of the requested documentation was not provided for review within the two hour window.

2. On March 22, 2024 1:29 PM, the Compliance Officer was provided additional partial records for R3, R4, R5, and R6.

3. On March 25, 2024 at 1:30 PM, the Compliance Officer received three E-mails containing the remaining requested records.

4. In an interview, E1 acknowledged the requested documentation had not been provided for review within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the name, address, and telephone number of the resident's primary care provider, for one of six residents sampled.

Findings include:

1. A review of R3's medical record revealed the record included the address and telephone number of a primary care provider.

2. A review of R3's medical record revealed all orders on file were from a different primary care provider not listed in R3's medical record.

3. In an interview, E3 acknowledged R3's medical record did not contain the updated name, address or telephone number for R3's current primary care provider(s).

Based on record review and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency, for two of two sampled former residents.

Findings include:

1. A review of R1's medical record revealed it did not contain the date of R1's termination of residency.

2. A review of R2's medical record revealed it did not contain the date of R2's termination of residency.

3. In an interview, E1 acknowledged R1's and R2's medical records did not include each resident's date of termination of residency.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for six of six residents sampled who received directed care services.

Findings include:

1. A review of R1's, R2's, R3's, R4's, R5's and R6's medical records revealed each resident had a current service plan, for directed care services. However, the service plans did not include documentation of each resident's weight or documentation from a medical practitioner stating weighing each resident was contraindicated.

2. In an interview, E1 acknowledged the provided service plans did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover termination initiated by the manager of an assisted living facility and termination initiated by a resident or the resident's representative.


Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "3.7 Move Out," revised January 15, 2020. However, the policy was not in compliance with the termination rules found in R9-10-807.G, and the policy did not provide specific timeframes for termination. The policy stated, "Procedure: Move-out procedures will be in accordance with the Resident's signed Residency Agreement and state specific regulations."

2. In an interview, E1 reported each resident's residency agreement includes specific termination rules, however, E1 reported no residents have had their residency terminated by the facility since the change of ownership.

3. In an interview, E1 and E2 acknowledged the provided policy and procedure manual did not include a policy covering termination initiated by the manager of an assisted living facility and termination initiated by a resident or the resident's representative, compliant with the rules found in R9-10-807.G.

Based on observation, record review, and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for seven of seven residents sampled.

Findings include:

A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. A review of seven resident's medical records revealed each resident had a current service plan. However, the service plans did not state what level of service each resident was expected to receive, "Supervisory," "Personal," or "Directed." Each service plan included a section titled, "Assessment Information: Assessment: Copper Canyon Assessment AL/MC, and included a numeric score as the result. The seven resident's scores ranged from 15.614 for R1 to 145.294 for R3

2. In an interview, E2 reported all residents at the facility received Directed care services, and reported the assessment tool determined if a resident needed assisted living services or memory care services.

3. In an interview, E1 and E2 acknowledged the resident's service plans provided for review had not identified if each resident was expected to receive Supervisory care services, Personal Care services, or Directed care services.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, for two of seven sampled residents.

Findings include:

1. A review of R2's medical record revealed a service plan dated July 22, 2023. The service plan stated R2 would receive: "Diet: Regular."

2. A review of R2's medical record revealed a physician's order dated March 24, 2023 which stated, "Diabetic / low carb diet (to help aid in compliance of wife's diabetic diet orders)."

3. A review of R3's medical record revealed a service plan dated June 12, 2023. The service plan stated R3 would receive: "Diet: Puree advance as tolerated."

4. A review of R3's medical record revealed a physician's order dated June 9, 2023 which stated, "Change patient diet to chopped/soft mechanical."

5. In an interview, E1 reported R3 had just returned to a pureed diet the day of the inspection, however, E1 acknowledged the June 12, 2023 service plan update stating R3 would receive a pureed diet was dated immediately after the order for a mechanical soft diet had been received on June 9, 2023.

6. A review of R3's medical record revealed an order to provide a pureed diet was not available for review.

7. In an interview E1 and E2 acknowledged the diet specified in the service plans for R2 and R3 contradicted the dietary orders in each resident's medical record.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-7), for five of seven directed care residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated July 18, 2023. The service plan did not state R1's level of care. Additionally, the service plan did not include the following:
- Documentation of R1's weight or documentation from a medical practioner stating that weighing R1 was contraindicated;
- Incontinence care that ensured that R1 maintained the highest practicable level of independence when toileting; and
- Offering sufficient fluids to maintain hydration.

2. A review of R2's medical record revealed a service plan dated July 22, 2023. The service plan did not state R2's level of care. Additionally, the service plan did not include the following:
- Documentation of R2's weight or documentation from a medical practioner stating that weighing R2 was contraindicated;
- Incontinence care that ensured that R2 maintained the highest practicable level of independence when toileting; and
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

3. A review of R3's medical record revealed a service plan dated June 12, 2023. The service plan did not state R3's level of care. Additionally, the service plan did not include the following:
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

4. A review of R4's medical record revealed a service plan dated August 19, 2023. The service plan did not state R4's level of care. Additionally, the service plan did not include the following:
- Documentation of R4's weight or documentation from a medical practioner stating that weighing R4 was contraindicated; and
- Offering sufficient fluids to maintain hydration.

5. A review of R7's medical record revealed a service plan dated July 22, 2023. The service plan did not state R7's level of care. Additionally, the service plan did not include the following:
- Offering sufficient fluids to maintain hydration.

6. In an interview, E2 reported all residents at the facility receive directed care services.

7. In an interview, E1 and E2 acknowledged some of the service plans provided for review did not include all of the requirements in R9-10-815(C)(1-7).

Based on record review and interview, the manager failed to ensure a current therapeutic diet manual was available for use by personnel members. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review.

2. A review of R2's medical record revealed an order for a, "diabetic," diet.

3. A review of R3' medical record revealed an order for a, "chopped/soft mechanical," diet.

4. In an interview, E1 and E2 acknowledged the facility's therapeutic diet manual had not been provided for review within two hours after a Department request.