BROOKDALE NORTH TUCSON

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

Findings include:

1. A review of facility quality management reports revealed one incident in December involving the facility calling 911 on behalf of a resident.

2. A review of facility documentation revealed one incident report in which a caregiver discovered R2 on the floor. It was determined R2 had suffered an injury, 9-1-1 was called and R2 was ultimately transported to the hospital.

3. A request was made to review the standardized form and documented information pertaining to R2 which was provided to the emergency responder. However, evidence of such documentation was not available for review.

4. In an interview, E1 acknowledged being aware of the implementation of A.R.S. 36-420.02, and the documentation required to be provided to emergency responders. E1 advised R2's medical information, such as a list of medications and basic health information, had been provided to the emergency responders who transported R2 to the hospital. However, E1 reported a standardized form had not yet been developed, and a copy of documentation to include the standardized form or required information provided to the emergency responders was unavailable for review.

Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in an inspection of the health care institution in an effort to ascertain if they were in substantial compliance with the requirements of this chapter and the rules established, during the term of the license. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of the Department documentation revealed the facility's perpetual license was effective on March 14, 2024.

2. The Compliance Officer arrived at the facility on October 29, 2024, at approximately 2:00 p.m., to conduct a complaint investigation. The Compliance Officer was informed the licensed manager and Executive Director E1 was in a meeting. The Compliance Officer was escorted into E1's office where he waited approximately 10-15 minutes whereupon E1 entered.

3. At approximately 2:25 p.m., the Compliance Officer and E1 began discussing the reason for the inspection. The Compliance Officer requested to review the incident report and investigative report pertaining to the complaint. E1 opened a document on her desktop computer, and advised the document represented a "summary" of the investigation into the matter. E1 provided the document as evidence of documentation of E1's investigation into the matter. E1 also provided a charting note as evidence of the requested incident report. The Compliance Officer made a second request for production of the incident report and investigative report, however E1 refused to provide the documents, citing company policy. The Compliance Officer reminded E1 of State statute and rules governing and regulating health care institutions required such facilities to comply with producing requested documents (see A.R.S. 36-406.1.c and A.A.C. R9-10-803.E). The Compliance Officer made another request for E1 to produce the documents, and again the licensed manager refused, indicating it was the company ' s policy such documents were internal records and were not to be made available for review. The Compliance Officer requested E1 call her supervisor to discuss the matter further, however she refused to do so.

4. At 2:35 p.m., the Compliance Officer made a formal written request to review all incident reports for the month of October, 2024, any investigative reports pertaining to alleged abuse neglect or exploitation of a resident, the facility ' s fall prevention and recovery program, the facility's Quality Management report to the governing authority and the facility's Quality Management program.

5. In an interview, E1 identified the caregiver, E2, involved in the complaint and confirmed the identity of the resident involved, R1. The Compliance Officer made an additional request to review the resident's service plan and E2's personnel record. In addition, the Compliance Officer requested to review E2's caregiver certificate and verification of skills and knowledge, the facility's "Quality Management Plan" as identified in the facility's Quality Management policy, the facility's policy on verifying a caregiver's skills and knowledge, and R1's progress notes for October 12 through 20, 2024.

6. The Compliance Officer made another request of E1 to produce the incident report and investigative report. E1 again refused to produce the records upon advice of counsel. At 3:20 p.m., the Bureau of Assisted Living Facilities Licensing Deputy Bureau Chief, O1, spoke with E1 telephonically, informing E1 of the Arizona Revised Statutes requiring health care institutions to produce documents requested by the licensing department (see A.R.S. 36-406.1.c and A.A.C. R9-10-803.E). O1 also advised E1 of the statute pertaining to acquiescence, and the potential consequences of total acquiescence, up to and including formal enforcement action. E1 indicated she would contact her supervisor and the facility's legal counsel to request they give permission to produce the requested records.

7. At approximately 4:40 p.m., E1 advised that E1 was given permission to produce the requested incident report and investigative report pertaining to the investigation. The Compliance Officer informed E1 that the exit interview would commence and conclude the portion of the investigation, but would wait while E1 retrieved the records. However, at 4:55 p.m., E1 had still not produced the requested reports, nor had E1 produced the Quality Management report to the governing authority, the Quality Management Plan, all incident reports for the month of October, all investigative reports pertaining to any allegations of abuse, neglect or exploitation of a resident for the month of October.

8. Shortly after 4:55 p.m., the Compliance officer approached E1 outside E1's office where E1 was observed making photocopies. The Compliance Officer advised the exit interview would commence as E1 had still not produced the requested information. The exit interview was conducted, E1 was informed of the Compliance Officer's findings and the investigation was concluded at approximately 5:05 p.m. on October, 29, 2024.

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. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On October 29, 2024, the Compliance Officer requested the following documents during the on-site inspection:

- documented investigation information as required per A.A.C R9-10-803.J.3 and 803.J.5
- documented incident report as noted in facility policy pertaining to Quality Management
- documented Quality Management report to the governing authority per A.A.C. R9-10-804.3
- documented Quality Management program as required in A.A.C. R9-10-804.1
- documented incident reports for the month of October 2024
- documented investigative reports pertaining to, and compliant with A.A.C R9-10-803.J
- documented skills and knowledge verified for E2;

However, this documentation was not provided.

2. In an interview, E1 and E8 acknowledged this information was not provided to the Compliance Officer within two hours after a Department request.

Based on interview and documentation review, the manager failed to provide documentation required by this Chapter to be submitted on behalf of an assisted living facility to the Bureau of Assisted Living Facilities Licensing after a Department request. The deficient practice posed a risk as the Department was unable to verify required documentation required by this Article.

Findings include:

1. On October 29, 2024 at approximately 2:25 p.m., the Compliance Officer made a verbal request to review the incident report and investigative report pertaining to Department complaint AZ00217577.

2. In an interview, E1 refused to provide copies of the requested reports. Rather, E1 provided an undated, unsigned "summary," of E1's investigation as well as a charting note, dated October 15, 2024, as evidence of the incident report.

3. At approximately 2:35 p.m. the Compliance Officer submitted a written request for the following:

- documented Quality Management report to the governing authority per A.A.C. R9-10-804.3
- documented Quality Management program as required in A.A.C. R9-10-804.1
- documented incident reports for the month of October 2024
- documented investigative reports pertaining to, and compliant with A.A.C R9-10-803.J

4. In an interview at approximately 4:40 p.m., E1 advised they would provide copies of the incident report and investigative report pertaining to Department complaint AZ00217577. However, as of 5:05 p.m., copies of the reports were not produced, nor were evidence of documentation of the facility's Quality Management report to the governing authority per A.A.C. R9-10-804.3, quality management program as required in A.A.C. R9-10-804.1, or incident reports for the month of October 2024 or documented investigative reports pertaining to, and compliant with A.A.C R9-10-803.J. E1 acknowledged the requested documentation had not been provided to the Department as required.

Based on document review and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the residents, document the report made, initiate an investigation of the suspected abuse, neglect or exploitation and document the information required in A.A.C. R9-10-803(J)(5). The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported, stopped, and investigated as required.

Findings include:

1. A review of facility documentation revealed a charting note, dated October 15, 2024, which documented R1's report of bruising to their left and right hand, believed to have occurred "3-4 days prior."

2. In an interview, E1 reported R1 approached a nurse and reported E2 had grabbed R1's hand's and hurt R1, causing bruising to their hands. E1 advised they were informed of the incident on October 15, 2024, and determined the incident to have occurred on October 13, 2024. E1 denied making any report to law enforcement or adult protective services, but acknowledged adult protective services did respond to investigate the incident. A verbal request was made by the Compliance Officer to review E1's investigative report and the facility's incident report pertaining to the allegation, however E1 refused to comply with the request.

3. A written request to review documentation of the manager's investigation of the alleged abuse required in R9-10-806(J)(5), and the corresponding incident report was made at approximately 2:35 p.m. However, at the conclusion of the investigation at approximately 5:05 p.m., E1 failed to provide the investigative report.

4. A review of documentation provided by E1, purported to be an investigation summary. However, the summary did not include documentation of notification of law enforcement or adult protective services. Nor did the summary include the date and time of the suspected abuse, a description of the injury to the resident or the names of any witnesses to the suspected abuse. The summary did include evidence of documentation of actions taken to prevent the suspected abuse which read "Community is scheduling a transfer training for the entire care staff." However, that entry was only made by E1, in the presence of the Compliance Officer, after E1 signed the written request for the investigative report.

5. In an interview, E1 acknowledged an investigation into the incident was conducted, however an investigation into the incident was not documented as required, and law enforcement or adult protective services were not immediately notified as required in A.R.S. 46-454.

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Quality Management Plan," which was last reviewed in September 2022. The Policy stated, "A Quality Management Plan will be implemented and documented by the assisted living Executive Director/Health and Wellness Director/manager on an on-going basis. The Plan, Do, Study, Act (PDSA) process is used as the quality improvement methodology." The policy continued as follows:

"1. A quality management plan may address the following:
Incident documentation and evaluation
Resident services quality assessment
Monitoring of clinical indicators that reflect the needs of the resident population
Conducting of a Brookdale Excellence Standard Tool (BEST) audit on an annual basis
Feedback on the state survey results
Resident satisfaction feed back
Review of opioid related incidents
Other indicators as needed

2. The quality management plan should include the development and implementation of measures to address the resident services needing improvement that are identified during the periodic review and evaluation.

3. The quality management plan should include an evaluation of the quality management program at least once every 12 months.

4. Documentation in a report of those resident services requiring improvement and the proposed actions will be submitted to the governing authority. The governing authority at the community is considered the Executive Director."

2. The Compliance Officer requested the quality management plan as noted in the policy. However, evidence of documentation of the quality management plan was unavailable for review.

3. In an interview, E1 acknowledged the facility's ongoing quality management plan as noted in the policy was not available for review. E1 acknowledged the policy provided did not satisfy the requirements as required in A.A.C R9-10-804.1.

Based on documention review and interview, the manager failed to ensure the quality management report required in R9-10-804(2) and the supporting documentation for the report was maintained for at least 12 months after the date the report was submitted to the governing authority. 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 to review the facility's quality management report submitted to the governing authority. However, evidence of documentation of such a quality management report was not available for review.

2. In an interview, E1 acknowledged a quality management report submitted to the governing authority had not been provided for review within two hours after a Department request.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, and according to policies and procedures. The deficient practice posed a risk if E2 did not have the qualifications, skills and knowledge necessary to provide the assisted living services, meet the needs of residents, and ensure their health and safety.

Findings include:

1. A documentation review of the facility's policies and procedures revealed a policy titled, "Skills & Competency Evaluation Policy" The policy stated, "Upon hire and as needed, the skills sets or competencies will be assessed/evaluated ..." The policy continued, "The assessment/evaluation may include skills, tasks or competencies identified in the associate's job description (e.g. bathing, handwashing, ambulatin, transfer, etc.)..."

2. A review of staffing schedules for October 2024 revealed E2 worked numerous shifts as a caregiver and medication technician during the month, including October 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 16, 17, and 27, 2024.

3. A review of E2's personnel record revealed E2' was hired as a caregiver and medication technician on August 8, 2024. However, evidence of documentation of verification of E2's skills and knowledge prior to providing physical health services was unavailable for review.

4. In an interview, E1 acknowledged E2's skills and knowledge were not verified and documented prior to providing physical health services and according to policies and procedures.

Based on document review, record review and interview, the manager failed to ensure the facility caregivers had the qualifications, experience, skills, and knowledge necessary to provide the assisted living services, meet the needs of a residents and ensure the health and safety of a resident. The deficient practice posed a health and safety risk if employees were unable to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a charting note, dated October 15, 2024, indicating R1 had been bruised on their right and left hand, apparently by a caregiver. The note indicated the incident "occurred 3-4 days ago."

2. A review of the quality management documentation revealed an incident report pertaining to the report made October 15, 2024 was unavailable for review.

3. A review of facility documentation, purported by E1 to be an investigations summary, revealed and undated and unsigned report which stated, "On 10/15/24 resident shared with HWD that a caregiver used his thumbs when grabbing [R1's] hands to transfer [R1] even though [R1] asked he does not because it cause [R1] blood vessels to break. Caregiver did not respect [R1]'s request and used his thumbs when he transferred [R1]." The report also stated "ED found that the team member used his thumbs to help transfer the resident..." and "Team member will be provided a written warning and removed form the resident's hall for care and medications. Team member will participate in resident rights and transfer training...Team member stated he is unsure how he is supposed to transfer someone with the use of his thumb for grip."

4. A review of R1's medical record revealed a service plan dated October 24, 2024 for personal care services. The service plan indicated "Resident uses a walker as mobility aid."

5. A review of E2's personnel record revealed E2' was hired as a caregiver and medication technician on August 8, 2024. However, evidence of documentation of verification of E2's skills and knowledge prior to providing physical health services was unavailable for review. Further review revealed a "Corrective Action" document, dated October 23, 2024. The document stated, "As a caregiver/med tech, you are expected to provide care per resident request. However, on 10/13/2024, you failed to meet the expectations of your position by transferring a resident in a manner that did not meet their preference or was the safest option."

6. In an interview, E1 reported R1 requested assistance from E2 in getting out of bed on the morning of October 13, 2024. E1 advised E2 used their thumbs to assist in gripping R1's hands in order to assist R1 to there feet, even though R1 had requested E2 not lift R1 in such a manner, as it would cause bruising to R1's skin. E1 advised R1 was a heavy resident, who prefers to be lifted from under their arms, rather than by their hands. E1 advised E2 was no longer providing services to residents in R1's wing of the facility. E1 acknowledged E2 did not have the skills and knowledge necessary to meet the needs of the resident.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a potential resident rights violation if the resident was subject to abuse or injury caused by negligent acts or omissions.

Findings include:

A.R.S. 46-451 "Abuse" means: (a) Intentional infliction of physical harm; (b) Injury caused by negligent acts or omissions; (c) Unreasonable confinement; (d) Sexual abuse or sexual assault; (e) Emotional abuse.

1. A review of facility internal documentation, purported by E1 to be an investigations summary, revealed and undated and unsigned report which stated, "On 10/15/24 resident shared with HWD that a caregiver used his thumbs when grabbing [R1's] hands to transfer [R1] even though [R1] asked he does not because it cause [R1] blood vessels to break. Caregiver did not respect [R1] request and used his thumbs when he transferred [R1]." The report also stated "ED found that the team member used his thumbs to help transfer the resident..." and "Team member will be provided a written warning and removed form the resident's hall for care and medications. Team member will participate in resident rights and transfer training...Team member stated he is unsure how he is supposed to transfer someone with the use of his thumb for grip."

2. In an interview, E1,acknowledged E2 was given corrective action due to E2 not treating a resident with respect and consideration and not meeting company expectations. E1 also acknowledged an investigation into the incident was not documented as required, and law enforcement or adult protective services were not immediately notified as required in A.R.S. 46-454.

This is a repeat deficiency from the on-site complaint inspection conducted on July 22, 2024, and an on-site complaint inspection conducted on October 15, 2024.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, or the nurse who reviewed the service plan, when initially developed and when updated, for three of five residents sampled.


Findings include:

1. A review of R2's medical record revealed a current service plan, dated May 21, 2024. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. Based on R2's date of admission, the service plan was required.

2. A review of R3's medical record revealed a current service plan, dated May 28, 2024. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. Based on R3's date of admission, the service plan was required.

3. A review of R4's medical record revealed a current service plan, dated May 28, 2024. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. Based on R4's date of admission, the service plan was required.

4. In an interview, E1, E2, and E3 acknowledged the service plans provided for R2, R3 and R4 did not include all required signatures.

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 if services were not provided to meet a residents needs.

Findings include:

1. A review of R1's, R2's, R3's, R4's and R5's medical record revealed current service plans for each resident which detailed the services to be provided to each.

2. A review of R1's and R2's medical records revealed documents titled, "Resident Personalized Service Plan Signature Sheet," (ADL) dated July through September. These sheets included three spaces per day for a caregiver to initial having provided services to the resident during each shift. However, both R1's and R2's ADL included multiple omissions or gaps where services had not been documented to have been provided. Both ADL's also included an initial in the box for September 31st, 2024 on the day shift.

3. A review of R3's, R4's and R5's medical record revealed ADL documentation for the requested timeframe was not available for review.

4. In an interview, E1, E2, and E3 acknowledged the services provided to R1, R2, R3, R4, and R5 had not been accurately documented in each resident's medical record.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a potential resident rights violation if the resident was subject to abuse, and was subjected to ridicule, demeaning, or derogatory remarks.

Findings include:

A.R.S. 46-451 "Abuse" means: (a) Intentional infliction of physical harm; (b) Injury caused by negligent acts or omissions; (c) Unreasonable confinement; (d) Sexual abuse or sexual assault; (e) Emotional abuse.

1. A review of facility internal investigations revealed and undated and unsigned report which stated, "Incident Investigation Recap: [E4] (caregiver) was reported to have been verbally abusive to [R1]. It was alleged that the staff member was using loud voice demining (sic) tone and was eating resident's food without permission. Incident occurred on 9/19/2024 and was reported on 09/23/2024, Employee was suspended on 09/23/2024 pending investigation on the matter. As to the claim of verbal abuse, staff member did not use suitable approach as trained in the caregiver certification and by Brookdale's standard. This behavior is not acceptable by the company. As to the claim of theft, it is seen that the staff member took food fromt he resident without permission and is against company policy."

2. In an interview, E1, E2, and E3 acknowledged E4 was terminated due to not meeting company standards.

This is a repeat deficiency from the on-site complaint inspection conducted on July 22, 2024.

Based on documentation review, observation and interview the manager failed to ensure a resident is treated with dignity, respect, and consideration. The deficient practice posed a potential resident rights violation if the resident was subject to abuse, and was subjected to ridicule, demeaning, or derogatory remarks.

Findings include:

A.R.S. 46-451 "Abuse" means: (a) Intentional infliction of physical harm; (b) Injury caused by negligent acts or omissions; (c) Unreasonable confinement; (d) Sexual abuse or sexual assault; (e) Emotional abuse.

1. A review of documentation dated July 15, 2024, revealed the following: "Victim reports being shouted at and verbally/emotionally abused by a third shift staff member named [E5]. Victim expressed feeling fearful of the aforementioned staff member and states that the caregiver will not respond to [R1's] calls throughout the night when assistance is needed".

2. A review of documentation Title "Resident Complaint/Response Form". The form was a statement from R1 reporting verbal abuse by E5. In a section of the form it stated, "Based on Brookdale investigation staff member termed for company standards".

3. A review of documentation dated July 12, @ 2:47 pm, revealed the facility's notes from a telephonic interview with E6. E6 was asked if E6 had been in a room where another caregiver was demeaning to a resident. E6 stated "Yes". E6 overheard R1 request care from E5. E5 stated no I don't have time I'm running late. E6 was asked if E6 had heard anything else. E6 reported being in R1's room with E5 changing a brief. E5 made a statement to R1 "You don't have to belittle me". Another time a friend of R1's from church was visiting and asked for R1 to be changed due to urine being in the brief. The person talked to E5 to help. That night on night shift E6 was with E5. E6 overheard E5 tell R1 "Why are you lying saying there is urine all over the place". In the statement there was a question to E6, "Do you think E5 stated it rudely? E6's response "I think so, I didn't think [E5] needed to bring it up. I didn't mean for [E5] to bring it up to R1. E6 reported E5 also said "You pissed your brief on purpose that way I'd have to change you ..." Also something like "Are you serious you can't feel that you're peeing right now?" R1 replied "No I can't" [E5] said, "yes you can".

4. In an interview, E1 reported E5 was terminated due to not meeting company standards.

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

Findings include:

1. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in April 2024.

2. A review of E4's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The document stated " Standard - First-Aid". The course was taken on August 22, 2023.

3. An online search of the National CPR Foundation revealed this is an online course. No hands-on CPR training is included.

4. A review of documentation on policy and procedures revealed "CPR and First Aid Training Requirements. Policy Details 1. Nurses, caregivers, managers or volunteers who provide direct care to residents will be required to complete CPR and first aid training as required by Arizona regulations. This training will be provided by an approved trainer. ....5. The photocopies of CPR and first aid certificates will be maintained in the nurse's, caregiver's, manager's or volunteer's files".

5. In an interview, E1 and O1 reported being unable to locate a current CPR documentation for E4. E1 and O1 acknowledged E4 did not have current documentation on cardiopulmonary resuscitation (CPR) training before providing assisted living services.

Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensures that a resident maintained the highest practicable level of independence when toileting, for five of five residents sampled receiving personal care services.

Findings include:

1. A review of R1's medical records revealed documentation of their current written service plan for personal care services did not contain the following:

- Offering sufficient fluids to maintain hydration; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

2. A review of R2's medical records revealed documentation of their current written service plan for personal care services did not contain the following:

- Offering sufficient fluids to maintain hydration; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

3. A review of R3's medical records revealed documentation of their current written service plan for personal care services did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Offering sufficient fluids to maintain hydration; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

4. A review of R4's medical records revealed documentation of their current written service plan for personal care services did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

5. A review of R5's medical records revealed documentation of their current written service plan for personal care services did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Offering sufficient fluids to maintain hydration; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

6. In an interview, E1 and O1 acknowledged the service plans were missing some of the requirements in R9-10-814.F.1-4 for personal care services which included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; and offering sufficient fluids to maintain hydration.

Based on record review, documentation review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of five residents sampled.

Findings include:

1. A review of R5's medical record revealed no evidence of any documentation of medication administered to R5 on April 18, 2024. This medication is to be administered at 0800 am, 1200 pm and 1700 pm. However, the Compliance Officer observed the following medication was not documented:

- At 1200 pm "Gabapentin Oral Tablet 600 MG, give 1 tablet by mouth three times a day for nerve pain".

2. A review of documentation tilted "Current Ordered Medications" revealed the following medication R5 was prescribed:

- Gabapentin Oral Tablet 600 MG, Take 1 tablet by mouth three times a day for pain".

3. A review of documentation revealed a policy and procedure titled "Medication & Treatment - Administration Assistance. Policy Detail .... 3. Medication assistance and administration should be in accordance with the prescriber's order". Another policy titled " Medications & treatments Medication Error" revealed "Policy Overview, Associates providing assisting or administering medication to residents are expected to follow the 7 Rights of Medication Administration, that includes-right medication, right person, right dose, right time, right route, right to refuse and right documentation". .... Policy Detail 1. The types of medication errors include: .... b) Incorrect time (i.e. failure to administer a medication at the prescribed time .... f) Missed dose (i.e. failure to administer a medication)".

4. In an interview, E1 and O1 acknowledged the medication for R5 had not been documented as administered in R5 medical record.