EVERGREEN ASSISTED LIVING LLC GILBERT

<p>Based on documentation review and interview, the manager failed to ensure the report required in subsection (2) was maintained for at least 12 months after the date the report was submitted to the governing authority. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of the facility's quality management documentation revealed a monthly quality management report dated January 2025, February 2025, March 2025, and April 2025. However, documentation of additional reports was unavailable for review. </p><p><br></p><p><br></p><p>2. In an interview, E1 reported the facility's 2024 quality management documentation was stored at E1's home. E1 acknowledged the <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">report required in subsection (2) was not maintained for at least 12 months after the date the report was submitted to the governing authority. </span></p>

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of three residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order.

Findings include:

1. A review of R2's medical record revealed R2 received medication administration.

2. A review of R2's medical record revealed a medication list dated November 11, 2024, signed by a licensed practical nurse (LPN), which included Seroquel 25 milligrams (mg), 0.5 tablet by mouth (po) daily (qd) at bedtime. However, the medication list was not signed by a medical practitioner as required.

3. A review of R2's medication administration record (MAR) for November 2024 revealed R2 was administered Seroquel 25 mg 1 tablet po at 8:00 PM November 11, 2024 - present.

4. In an interview, E1 acknowledged R2's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of R1's, R2's, and R3's medical records revealed R1, R2, and R3 received directed care services.

2. During an environmental tour of the facility, the Compliance Officer observed the front door and sliding back door to the patio were equipped with an alarm to alert employees of egress; however, the alarms were not turned on at the time of inspection.

3. While on-site for the abbreviated inspection, the Compliance Officer observed R1 wandering in and out of the back patio door independently.

4. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.