BROOKDALE UNION HILLS

<p>Based on documentation review, observation, and interview, the governing authority failed to notify the Department immediately when there was a change in the manager. The deficient practice posed a risk as the Department was unaware as to whether the facility maintained a qualified manager.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of Department documentation revealed a letter from E3 dated May 23, 2025, which indicated E3 was the manager effective immediately. The review revealed no other notification to the Department of a change in the manager thereafter.</p><p><br></p><p>2. The Compliance Officer did not observe E3's manager certificate posted in the facility.</p><p><br></p><p>3. In an interview, E2 reported the following:</p><p>- E1 was the manager from February 13, 2023, through May 25, 2025;</p><p>- E3 was not the manager effective May 23, 2025, and had not been the manager at this facility;</p><p>- E4 was the manager from May 25, 2025, through August 2, 2025;</p><p>- E1 was again the manager from August 3, 2025, through the present; and</p><p>- E2 would be taking over as the manager once E2 passed the certification test and had E2’s manager’s certificate.</p><p><br></p><p>4. A secondary review of Department documentation confirmed the Department received no notification of the change in manager between E1 and E4 in May 2025 or between E4 and E1 in August 2025.</p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspections conducted on October 6, 2025, and June 19, 2025.</p><p><br></p>

Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454.

Findings include:

1. A.R.S. \'a7 46-454(A) stated "...other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online."

2. A.R.S. \'a7 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..."

3. R9-10-101.110 stated "Immediate" means without delay.

4. E1 reported on July 19, 2024, R1's POA was in the facility on a visit. E1 reported being told by R1's POA "by the way, mention being raped and has skin issue with her leg". The progress notes dated July 19, 2024 revealed POA in the facility to visit R1. The progress notes stated R1 "became very agitated, yelling at them...waited to calm down...leakage on right lower leg. Nurse wrapped it...". E1 reported to have talked to R1 regarding what the POA just mentioned and R1 stated "I'm fine". E1 indicated APS and/or police were not notified.

5. In an interview, E2 reported not being aware of the aforementioned until returning from vacation. E2 reported upon return to the facility on August 1, 2024, R1 made same allegation and an internal investigation was conducted along with notification to APS and Police on August 1, 2024. E1 and E2 acknowledged documentation was not available that showed the incident on July 19, 2024 for R1 was reported immediately according to A.R.S. \'a7 46-454.

This is an uncorrected deficiency from the complaint investigation conducted on May 8, 2024.

Based on documentation review, record review, and interview, a manager who had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises failed to immediately report the suspected abuse, neglect, or exploitation of the resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk to the health and safety of a resident.

Findings include:

1. A.R.S. \'a7 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online."

2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay."

3. In an interview, E2 reported E2 believed R1 was abused while on the premises.

4. A review of R1's medical record revealed a series of progress notes detailing the suspected abuse. The review revealed the suspected abuse first occurred on April 30, 2024.

5. In an interview, E2 confirmed the suspected abuse first occurred on April 30, 2024. However, E2 reported E2 did not report the suspected abuse until May 2, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of facility documentation revealed a document titled "Fall Management Policy" that stated "1. The Executive Director (ED) is responsible for verifying that associated have completed the Brookdale Foundations Falls Management training course during orientation and should review annually thereafter..."

2. Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of December 16, 2021. The personnel record revealed no documentation of completing fall prevention and fall recovery training.

3. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of June 1, 2016. The personnel record revealed no documentation of completing fall prevention and fall recovery training.

4. In an interview, E1, E2, and E3 acknowledged documentation was not available that showed E5 and E6 completed training for fall prevention and fall recovery.

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

Findings include:

1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... 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..."

2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution.

3. In an interview, E1, E2, and E3 acknowledged documentation was not available that showed E2's work references were obtained upon hire at the facility.

4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of five employees reviewed. The deficient practice posed a TB exposure risk to residents.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. Review of E2's personnel record revealed no documentation of freedom from infectious TB. Based on E2's hire date, this documentation was required.

4. Review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required.

5. In an interview, E1, E2, and E3 acknowledged E2 and E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

6. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.

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

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "CPR and First Aid Training" that stated "1. Nurses, caregiver, managers or volunteers who provide direct care to residents will be required to complete CPR and first aid training as required by Arizona regulations...2. This training will be validated by a demonstration of the nurse's, caregiver's, manager's or volunteer's ability to perform CPR and first aid. 3. The CPR and first aid certificates will be renewed according to the approved trainer guidelines but no later that 2 years from the issued date of the certificates..."

2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record revealed no documentation of CPR training.

3. Review of E5's personnel record revealed a CPR and first aid card with an expiration date of September 1, 2023. There was no other documentation of CPR and first aid training in E5's record.

4. Review of E7's personnel record revealed E7 worked as a caregiver and had a hire date of July 6, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on April 13, 2022, and valid for two years. There was no other current documentation of CPR training available for review that documented E7 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR.

5. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only."

6. In an interview, E1, E2, and E3 acknowledged E2 and E5 did not have current documentation of first aid and CPR training and E7 did not have current documentation of CPR training, that included a demonstration of the individual's ability to perform CPR.

7. This is a repeat deficiency from the compliance inspections conducted on January 27, 2022, and January 19, 2023.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of five residents reviewed. The deficient practice posed a TB exposure risk to residents.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. Review of R8's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R8 had signs or symptoms of TB. Based on R8's acceptance date, this documentation was required.

3. In an interview, E1, E2, and E3 acknowledged R8 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of eight residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated August 3, 2023. This service plan stated "Skin is intact".

2. Review of R2's medical record revealed a document titled "Home Health/Hospice/Third Party Provider Collaboration Notes" dated October 2, 2023. This document stated "...1 open right heel blister..."

3. Review of R2's medical record revealed R2's service plan was not updated to show this skin issue.

4. In an interview, E2 and E3 acknowledged R2 had a wound to the right heel and E1, E2, and E3 acknowledged R2's service plan was not updated after this significant change of condition.

5. This is a repeat deficiency from the complaint investigation conducted June 13, 2023.

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, and if a review was required in subsection A(3)(d), the nurse or medical practitioner who reviewed the service plan, for two of eight residents reviewed. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided.

Findings include:

1. R9-10-808.A(3)(d) states "For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner."

2. Review of R5's medical record revealed a current written service plan dated August 17, 2023. This service plan indicated R5 received medication administration. However, the service plan did not include a signature and date by the resident or resident's representative, the manager, and the nurse or medical practitioner.

3. Review of R8's medical record revealed a current written service plan dated July 9, 2023. This service plan indicated R8 received medication administration. However, the service plan did not include a signature and date by the nurse or medical practitioner.

4. In an interview, E1, E2, and E3 acknowledged R5's and R8's service plans were not signed and dated by the required individuals.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to two of four residents reviewed. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R2's medical record revealed R2 received the flu vaccination September 28, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. In addition, documentation was not available that showed the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required.

3. Review of R3's medical record revealed R3 received the flu vaccination September 28, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. In addition, documentation was not available that showed the pneumonia vaccination was offered or received. Based on R3's acceptance date, this documentation was required.

4. In an interview, E1, E2, and E3 acknowledged R2's and R3's medical records did not include current documentation that showed the flu and pneumonia vaccinations were offered or received.

Based on record review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R3's medical record revealed a current written service plan for directed care services dated September 14, 2023. This service plan stated "...requires 2 person and a hoyer for transfers".

2. Review of R3's medical record revealed a written determination from R3's medical practitioner signed and dated February 3, 2023. However, documentation was not available that stated R3's needs could be met by the facility and R3's needs were within the facility's scope of services, at least once every six months.

3. In an interview, E2 reported R3 was unable to ambulate even with assistance and E1, E2, and E3 acknowledged R3's medical practitioner did not provide a written determination at least once every six months.

4. This is a repeat deficiency from the compliance inspections conducted February 4, 2021, January 27, 2022, and January 19, 2023.

Based on record review and interview, the manager failed to ensure the facility did not retain a resident who had a stage 3 or stage 4 pressure sore, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who had a stage 3 or stage 4 pressure sore. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R7's medical record revealed a document titled "Home Health/Hospice/Third Party Provider Collaboration Notes" dated August 1, 2023. This document was signed by a nurse and stated "Stage III coccyx".

2. Review of R7's medical record revealed no documentation indicating R7's medical practitioner examined R7 upon the onset of the condition and every six months thereafter, signed and dated a determination that stated R7's needs could be met by the facility, and reviewed the facility's scope of services.

3. In an interview, E1, E2, and E3 acknowledged R7's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of eight residents reviewed that received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed a signed order dated October 4, 2023. This order stated "Decubitus/Pressure Ulcer/Inner Buttocks Coccyx..."

2. Review of R1's medical record revealed a current written service plan dated October 5, 2023. This service plan stated " ...(R1) has a wound on (R1's) back, left foot bottom..." This service plan revealed no documentation of skin maintenance to treat the skin issue on the inner buttocks coccyx.

3. In an interview, E1, E2, and E3 acknowledged R1's service plan did not include skin maintenance to treat the skin issue on the inner buttocks coccyx.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated October 5, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated August 27, 2023. This medication order stated "Dilitiazem Hydrochloride 60mg oral tablet; Take 1 tab(s) oral 3 times a day for hypertension; Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 65".

3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated "Dilitiazem HCL Tablet 60mg take 1 tablet by mouth three times a day for increased BP, Hold for SBP less than 110 or HR less than 65" and indicated the following:
-R1's HR was less than 65 at 8am on October 16th, 22nd, 25th, 28th, and 30th, however, indicated one tab was administered.
-R1's HR was less than 65 at 1pm on October 2nd, however, indicated one tab was administered.
-R1's HR was less than 65 at 6pm on October 15th, however, indicated one tab was administered.

4. During an observation of R1's medications, Dilitiazem HCL 60mg was observed.

5. Review of R4's medical record revealed a current written service plan dated August 13, 2023. This service plan indicated R4 received medication administration.

6. Review of R4's medical record revealed a signed medication order dated October 18, 2023. This medication order stated "Midodrine HCL Oral Tablet 5mg Give 0.5 tablet by mouth three times a day for hypotension hold if SBP higher > 120".

7. Review of R4's medical record revealed an October 2023 MAR. This MAR stated "Midodrine HCL Oral Tablet 5mg Give 0.5 tablet by mouth three times a day for hypotension hold if SBP higher > 120" and indicated the following:
-R4's SBP was higher than 120 at 8am on October 14th, 16th, 23rd, 25th-27th, and 30th, however, indicated 1/2 tab was administered.
-R4's SBP was higher than 120 at 1pm on October 14th, 16th, 23rd, 25th-27th, and 30th, however, indicated 1/2 tab was administered.
-R4's SBP was higher than 120 at 6pm on October 3rd, 7th, 9th-10th, 15th-16th, 22nd-24th, and 29th-30th, however, indicated 1/2 tab was administered.

8. During an observation of R4's medications, Midodrine HCL 5mg was observed.

9. In an interview, E1, E2, and E3 reported the medications were administered per the MAR and acknowledged R1's and R4's medications were not administered in compliance with the available medication order.

10. This is a repeat deficiency from the compliance inspection conducted January 27, 2022 and the complaint investigation conducted on January 19, 2023.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of four residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R7's medical record revealed a document from Banner Boswell Medical Center dated November 16, 2022. This document stated "Fracture of unspecific part of neck of right femur". In addition, R7's service plan dated May 25, 2023 stated "(R7) recently had a fall and broke (R7's) hip..." However, documentation was not available that showed R7's emergency contact and primary care provider were notified of this incident.

2. In an interview, E1 reported E1, E2, and E3 were not working at the facility when this incident occurred. E1, E2, and E3 acknowledged R7's medical record did not include documentation that showed a caregiver immediately notified the resident's emergency contact and primary care provider.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of four residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R7's medical record revealed a document from Banner Boswell Medical Center dated November 16, 2022. This document stated "Fracture of unspecific part of neck of right femur". In addition, R7's service plan dated May 25, 2023 stated "(R7) recently had a fall and broke (R7's) hip..." However, documentation was not available that showed the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

2. In an interview, E1 reported E1, E2, and E3 were not working at the facility when this incident occurred. E1, E2, and E3 acknowledged R7's medical record did not include documentation that showed the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

3. This is a repeat deficiency from the compliance inspection conducted January 19, 2023.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance.

Findings include:

1. Review of facility's documentation revealed a policy titled "Tuberculosis (TB) Associate Requirements by State - Reference" that stated "AZ...Annual Facility Risk assessment & TB education..."

2. Review of E2's personnel record revealed E2 worked as a nurse and had a hire date of August 7, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB.

3. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of July 6, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB.

4. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of June 1, 2016. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB.

5. Review of E7's personnel record revealed E7 worked as a caregiver and had a hire date of July 6, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB.

6. In an interview, E1, E2, and E3 acknowledged E2's, E4's, E6's, and E7's personnel records did not include documentation of completing training and education related to recognizing the signs and symptoms of TB.

7. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff.

Findings include:

1. Review of facility's documentation revealed a policy titled "Tuberculosis (TB) Associate Requirements by State - Reference" that stated "AZ...Annual Facility Risk assessment & TB education..."

2. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB.

3. In an interview, E1, E2, and E3 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted.

4. Technical assistance was provided on this Rule during the compliance inspection conducted January 19, 2023.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of six residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R5's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R5's acceptance date, this documentation was required.

2. During an interview, E1 and E2 acknowledged R5 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of six residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R3's medical record revealed written service plans dated December 23, 2022 and March 24, 2023. These service plans stated " ...Skin is intact. No visible wounds..."

2. Review of R3's medical record revealed a document titled "Summary of Visit Findings" from United Hospice dated January 8, 2023. This document stated "...Skin: 2.5 x 3 cm wound to left hip..." Additionally, R3's medical record revealed a document titled "Physician Orders" dated January 8, 2023. This document stated "1. Wound Care: Cleanse wound and pat dry. Apply Medihoney to left hip and cover with 3 x 3 foam dressing 3x weekly."

3. During an interview, E2 reported the left hip wound started approximately two month ago.

4. Review of R3's medical record revealed R3's service plan was not updated to show this change.

5. During an interview, E1 and E2 acknowledged R3's service plan was not updated after a significant change of condition.

Based on document review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.

Findings include:

1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Plan" with a revision date of September 2022. This 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...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..."

2. The quality management reports reviewed did not include the development and implementation of measures to address the resident services needing improvement and an evaluation of the quality management program.

3. During an interview, E1 reported the quality management documentation was not completed per policy.

4. This is a repeat deficiency from the compliance inspection conducted January 27, 2022.

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

Findings include:

1. Review of E1's personnel record revealed E1 worked as the facility manager and had a hire date of September 21, 2020. The personnel record revealed a first aid and CPR card with an expiration date of September 30, 2022. There was no other documentation of first aid and CPR training in E1's personnel record.

2. Review of the facility's policy and procedure revealed a policy titled "CPR and First Aid Training" with a revision date of November 2022. This policy stated "...3. The CPR and first aid certificates will be renewed according to the approved trainer guidelines...4. The community Assisted Living Executive Director/Manager/designee will verify the certificates are current..."

3. During an interview, E1 acknowledged documentation was not available showing E1 had current documentation of first aid and CPR training.

4. This is a repeat deficiency from the compliance inspection conducted January 27, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for two of two resident reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents.

Findings include:

1. Review of R2's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination:
-The primary condition for which the individual needs assisted living services is a behavioral health issue; and
-The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual.
Based on R2's acceptance date, this documentation was required.

2. Review of R5's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination:
-The primary condition for which the individual needs assisted living services is a behavioral health issue; and
-The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual.
Based on R5's acceptance date, this documentation was required.

3. Rule review of R9-10-807(G) on or after October 1, 2019 and the facility's policy and procedure titled "Admission/Discharge Policy" with a revision date of February 2021 indicated the manager may discharge as follows:
A manager may terminate residency of a resident as follows:
1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility;
2. With a 14 calendar day written notice of termination of residency:
a. For nonpayment of fees, charges or deposits; or
b. Under any of the conditions in subsection (C); or
3. With a 30 calendar day written notice of termination of residency, for any other reason.
Review of subsection (C) stated:
1. The individual requires continuous:
a. Medical services;
b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or
c. Behavioral Health Services;
2. The primary condition for which the individual needs assisted living services is a behavioral health issue;
3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual;
4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or
5. The individual requires restraints, including the use of bedrails.

4. During an interview, E1 and E2 acknowledged R2's and R5's residency agreements did not include the correct policy and procedure for an assisted living facility to terminate residency.

5. This is a repeat deficiency from the compliance inspections conducted February 4, 2021 and January 27, 2022.

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

Findings include:

1. Review of R1's medical record revealed a current written service plan for directed care services dated November 1, 2022. This service plan indicated the following services were needed:
-provide prompting/cueing to encourage optimal intake
-requires full physical assistance with all dressing and grooming tasks
-requires full physical assistance with showering
-incontinent of bladder and bowel...requires full physical assistance regularly
-uses w/c to get to all destinations with full assist
-requires full physical assist with 2 people to transfer and the use of a gait belt
-required cueing and reminders for meals and activities
-fluids are encouraged
However, documentation was not available indicating these services were provided in October 2022, November 2022, December 2022, and January 2023.

2. Review of R2's medical record revealed a current written service plan for directed care services dated October 27, 2022. This service plan indicated the following services were needed:
-water is encouraged throughout the day
-standby assist with dressing and grooming
-assist (R2) to put on (R2's) ted hose daily
-standby assist with showering...showers will be given twice a week and as needed
However, documentation was not available indicating these services were provided in January 2023.

3. Review of R5's medical record revealed a current written service plan for directed care services dated November 7, 2022. This service plan indicated the following services were needed:
-encourage fluid intake
-requires assistance with layout and 1 person assist with dressing grooming 2x daily
-showering...provided at least twice weekly and as needed
-assist...to restroom before and after each meal, at bedtime and as needed. Peri-care provided at time of bathroom assistance
However, documentation was not available indicating these services were provided in October 2022, November 2022, December 2022, and January 2023.

4. During an interview, E1 and E2 acknowledged R1's, R2's, and R5's medical records did not include documentation of the above listed services and reported the services were provided as indicated in the service plans.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for two of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed a current written service plan for directed care services dated November 1, 2022. This service plan stated "...requires full physical assist with 2 people to transfer and the use of a gait belt..."

2. Review of R1's medical record revealed a written determination from R1's medical practitioner signed and dated February 17, 2022. However, documentation was not available stating R1's needs were met by the facility and R1's needs were within the facility's scope of services, at least once every six months.

3. Review of R4's medical record revealed a current written service plan for directed care services dated December 28, 2022. This service plan stated "...needs assist to transfer to and from wheelchair and bed..."

4. Review of R4's medical record revealed no documentation indicating R4's medical practitioner examined R4 upon acceptance and every six months thereafter, signed and dated a determination stating R4's needs were met by the facility, and reviewed the facility's scope of services.

5. During an interview, E1 and E2 reported R1 had been unable to ambulate even with assistance for at least one and a half years and E4 had been unable to ambulate even with assistance for approximately two months. E1 and E2 acknowledged R1's and R4's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

6. This is a repeat deficiency from the compliance inspections conducted February 4, 2021 and January 27, 2022.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R3's medical record revealed a document titled "Incident Report" dated October 29, 2022. This document indicated the time of incident was 5:30pm and stated "...Nature of Incident: Fall, Unwitnessed, Type(s) of Injury/Impairment: Cut/Laceration, Body Part(s) Injured: Skull/Scalp, Initial Actions taken: call 911..." However, the documentation did not include any action taken to prevent the incident from occurring in the future.

2. During an interview, E1 and E2 acknowledged R3's medical record did not include documentation of the any action taken to prevent the incident from occurring in the future.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented for assisting a resident in procuring medications for three of five residents reviewed. The deficient practice posed a risk if a resident did not have the prescribed medications available for administration.

Findings include:

1. Review of the facility's policies and procedures revealed a policy titled "Medications & Treatment - Storage, Handling, Distribution, Disposition and Payment" with a revision date of March 31, 2022. This policy stated "It is Brookdale's policy that all currently ordered medications will be available to the resident...1. The Community is responsible for obtaining newly ordered medication or refills for medications and treatment orders, unless otherwise agreed upon with the resident, family, or legally responsible party...2. In the event the resident or legally responsible party have signed...stating that they will have the responsibility for obtaining new ordered medication or re-ordering medications, but the medications are not delivered within two days prior to the depletion of the medication stock, the community will order or reorder the medications with the 'preferred provider' to insure no disruption takes place..."

2. Review of R1's medical record revealed a current written service plan dated November 1, 2022. This service plan indicated R1 received medication administration.

3. Review of R1's medical record revealed signed medication orders dated December 7, 2022. These medication orders stated the following:
"Hydralazine HCL oral tablet 100mg take 1 tablet by mouth q 8 hours"
"Amlodipine Besylate oral tablet 10mg take 1 tablet by mouth daily"

4. Review of R1's January 2023 medication administration record (MAR) showed the following:
"Hydralazine HCL oral tablet 100mg by mouth three times a day" however, indicated the following:
-The medication was administered at 8am January 1st - 2nd, 1pm January 1st - 2nd, and 6pm January 1st - 3rd.
-The code "05" was documented at 8am January 3rd - 7th, 1pm January 3rd - 7th, and 6pm January 4th - 6th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "H" was documented at 8am January 8th - 27th, 1pm January 8th - 27th, and 6pm January 7th - 26th. Review of the MAR showed the "H" code meant "On Hold By Physician".
"Amlodipine Besylate oral tablet 10mg tablet by mouth one time a day" however, indicated the following:
-The medication was administered at 8am January 1st, 2nd, 7th -10th.
-The code "05" was documented at 8am January 3rd - 6th and 12th - 14th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "09" was documented at 8am January 15th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 8am January 11th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".

5. During an observation of R1's medications, the following was observed:
Hydralazine HCL 100mg was not available.
Amlodipine Besylate 10mg was not available.

6. Review of R4's medical record revealed a current written service plan dated December 28, 2022. This service plan indicated R4 received medication administration.

7. Review of R4's medical record revealed the following:
-A verbal medication order- was available dated October 10, 2022. This order stated "Lotrimin AF (tolnaftate) 1% topical powder; Take 1 application applied topically 2 times a day; Apply on the sacrum". However, documentation was not available showing a written order was obtained from the medical practitioner within 14 days.
-A signed medication order was available dated September 8, 2022. This medication order stated "Diltiazem Hydrochloride 60mg oral tablet; Take 1 tab(s) oral 3 times a day hold for SBP less that 110 or HR less than 65." However, documentation was not available showing R4's systolic blood pressure (SBP) or heart rate (HR) were assessed three times a day to evaluate if the medication was needed.

8. Review of R4's medical record revealed a January 2023 MAR. This MAR showed the following:
"Clotrimazole External Cream 1% (topical) apply to sacrum topically two times a day" however, indicated the following:
-The medication was administered at 8am January 1st - present and 8pm January 1st - 12th and 14th - 18th.
-The code "16" was documented at 8pm January 13th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".
"Diltiazem HCL Tablet 60mg 1 tablet by mouth three times a day, Hold for SBP less than 110 or HR less than 65" however, indicated the following:
-The medication was administered at 8am January 1st - 11th, 14th, 15th, and 19th, 1pm January 1st and 3rd - 10th, and 6pm January 1st -10th, 14th, and 18th.
-The code "05" was documented at 8am and 1pm January 12th and 13th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "09" was documented at 8am January 16th - 18th, 1pm January 2nd and 15th - 18th, and 6pm January 12th and 15th - 17th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 1pm January 11th and 6pm January 11th and 13th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".

9. During an observation of R4's medications, the following was observed:
Clotrimazole 1% was not available.
Diltiazem HCL 60mg was not available.

10. Review of R5's medical record revealed a current written service plan dated November 7, 2022. This service plan indicated R5 received medication administration.

11. Review of R5's medical record revealed signed medication orders dated January 5, 2023. These medication orders stated the following:
"Donepezil HCL Oral Tablet 10mg Give 1 tablet by mouth one time a day"
"Tamsulosin HCL Oral Capsule 0.4mg Give 2 capsules by mouth one time a day"

12. Review of R5's January 2023 MAR showed the following:
"Donepezil HCL Oral Tablet 10mg Give 1 tablet by mouth one time a day" however, indicated the following:
-The medication was administered at 8am January 1st - 4th and 6th - 11th.
-The code "09" was documented at 8am January 5th and 12th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
"Tamsulosin HCL Oral Capsule 0.4mg 2 capsules by mouth one time a day" however indicated the following:
-The medication was administered at 8am January 6th.
-The code "09" was documented at 8am January 1st - 5th, 7th, and 9th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 8am January 8th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".

13. During an observation of R5's medications, the following was observed:
Donepezil HCL 10mg was not available.
Tamsulosin HCL 0.4mg was not available.

14. During an interview, E6 reported the facility was working with hospice to obtain the medications. E1 and E2 acknowledged the facility's medication policies and procedures were not implemented for assisting a resident in procuring medications.

Based on record review, observation, and interview, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receipt of the verbal order, for one of five residents reviewed. The deficient practice posed a health risk to the resident.

Findings include:

1. Review of R4's medical record revealed a current written service plan dated December 28, 2022. This service plan indicated R4 received medication administration.

2. Review of R4's medical record revealed a verbal medication order dated October 10, 2022. This order stated the following:
"Lotrimin AF (tolnaftate) 1% topical powder; Take 1 application applied topically 2 times a day; Apply on the sacrum". However, documentation was not available showing a written order was obtained from the medical practitioner.

3. Review of R4's medical record revealed a January 2023 medication administration record (MAR). This MAR showed the following:
"Clotrimazole External Cream 1% (topical) apply to sacrum topically two times a day" however, indicated the following:
-The medication was administered at 8am January 1st - present and 8pm January 1st - 12th and 14th - 18th.
-The code "16" was documented at 8pm January 13th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".

4. During an observation of R4's medications, Clotrimazole 1% was not available.

5. During an interview, E6 reported the medication was not available and did not know the length of time it had been unavailable. E1 and E2 acknowledged R4's record did not include a written order from the medical practitioner within 14 days.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for four of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated November 1, 2022. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed signed medication orders dated December 7, 2022. These medication orders stated the following:
"Hydralazine HCL oral tablet 100mg take 1 tablet by mouth q 8 hours"
"Amlodipine Besylate oral tablet 10mg take 1 tablet by mouth daily

3. Review of R1's January 2023 medication administration record (MAR) showed the following:
"Hydralazine HCL oral tablet 100mg by mouth three times a day" however, indicated the following:
-The medication was administered at 8am January 1st - 2nd, 1pm January 1st - 2nd, and 6pm January 1st - 3rd.
-The code "05" was documented at 8am January 3rd - 7th, 1pm January 3rd - 7th, and 6pm January 4th - 6th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "H" was documented at 8am January 8th - 27th, 1pm January 8th - 27th, and 6pm January 7th - 26th. Review of the MAR showed the "H" code meant "On Hold By Physician".
"Amlodipine Besylate oral tablet 10mg tablet by mouth one time a day" however, indicated the following:
-The medication was administered at 8am January 1st, 2nd, 7th -10th.
-The code "05" was documented at 8am January 3rd - 6th and 12th - 14th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "09" was documented at 8am January 15th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 8am January 11th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".

4. During an observation of R1's medications, the following was observed:
Hydralazine HCL 100mg was not available.
Amlodipine Besylate 10mg was not available.

5. Review of R3's medical record revealed a current written service plan dated November 12, 2022. This service plan indicated R3 received medication administration.

6. Review of R3's medical record revealed no documentation of a signed medication order or a verbal medication order for Lorazepam 2mg/ml (0.25ml) three times a day.

7. Review of R3's medical record revealed a January 2023 MAR. This MAR showed the following:
"Lorazepam Intensol Oral Concentrate 2mg/ml Give 0.25ml by mouth three times a day" and indicated Lorazepam was administered at 8am, 1pm, and 6pm January 1st - present.

8. During an observation of R3's medications, Lorazepam 2mg/ml (0.25ml) was available.

9. Review of R4's medical record revealed a current written service plan dated December 28, 2022. This service plan indicated R4 received medication administration.

10. Review of R4's medical record revealed the following:
-A verbal medication order was available dated October 10, 2022. This order stated "Lotrimin AF (tolnaftate) 1% topical powder; Take 1 application applied topically 2 times a day; Apply on the sacrum". However, documentation was not available showing a written order was obtained from the medical practitioner.
-A signed medication order was available dated September 8, 2022. This order stated "Diltiazem Hydrochloride 60mg oral tablet; Take 1 tab(s) oral 3 times a day hold for SBP less that 110 or HR less than 65". However, documentation was not available showing R4's systolic blood pressure (SBP) or heart rate (HR) were assessed three times a day to evaluate if the medication was needed.
-A signed medication order or verbal medication order was not available for Lorazepam 2mg/ml (0.25ml) two times a day.

11. Review of R4's medical record revealed a January 2023 MAR. This MAR showed the following:
"Clotrimazole External Cream 1% (topical) apply to sacrum topically two times a day" however, indicated the following:
-The medication was administered at 8am January 1st - present and 8pm January 1st - 12th and 14th - 18th.
-The code "16" was documented at 8pm January 13th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".
"Diltiazem HCL Tablet 60mg 1 tablet by mouth three times a day, Hold for SBP less than 110 or HR less than 65" however, indicated the following:
-The medication was administered at 8am January 1st - 11th, 14th, 15th, and 19th, 1pm January 1st and 3rd - 10th, and 6pm January 1st -10th, 14th, and 18th.
-The code "05" was documented at 8am and 1pm January 12th and 13th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "09" was documented at 8am January 16th - 18th, 1pm January 2nd and 15th - 18th, and 6pm January 12th and 15th - 17th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 1pm January 11th and 6pm January 11th and 13th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".
"Lorazepam Oral Concentrate 2mg/ml Give 0.25ml by mouth two times a day" however, indicated the following:
-The medication was administered at 8am January 1st - 11th and 13th - 19th and 6pm January 1st - 11th and 13th - 18th.
-The code "05" was documented at 8am January 12th. Review of the MAR showed the "05" code meant "Hold/See Nurse Notes".
-The code "09" was documented at 8pm January 12th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".

12. During an observation of R4's medications, the following was observed:
Clotrimazole 1% was not available.
Diltiazem HCL 60mg was not available.
Lorazepam 2mg/ml (0.25ml) was available.

13. Review of R5's medical record revealed a current written service plan dated November 7, 2022. This service plan indicated R5 received medication administration.

14. Review of R5's medical record revealed signed medication orders dated January 5, 2023. These medication orders stated the following:
"Donepezil HCL Oral Tablet 10mg Give 1 tablet by mouth one time a day"
"Tamsulosin HCL Oral Capsule 0.4mg Give 2 capsules by mouth one time a day"
"Hydralazine HCL Oral Tablet 50mg Give 1 tablet by mouth four times a day"
"Lantus Solution 100units/ml inject 14 units subcutaneously two times a day, Hold if BG is less than 120" However, documentation was not available showing R5's blood glucose (BG) was assessed two times a day to evaluate if the medication was needed.

15. Review of R5's January 2023 MAR showed the following:
"Donepezil HCL Oral Tablet 10mg Give 1 tablet by mouth one time a day" however, indicated the following:
-The medication was administered at 8am January 1st - 4th and 6th - 11th.
-The code "09" was documented at 8am January 5th and 12th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
"Tamsulosin HCL Oral Capsule 0.4mg 2 capsules by mouth one time a day" however, indicated the following:
-The medication was administered at 8am January 6th.
-The code "09" was documented at 8am January 1st - 5th, 7th, and 9th - 19th. Review of the MAR showed the "09" code meant "Other/See Nurse Notes".
-The code "16" was documented at 8am January 8th. Review of the MAR showed the "16" code meant "Pharmacy Action Required".
"Hydralazine HCL Oral Tablet 50mg Give 1 tablet by mouth four times a day" however, indicated the following:
-The medication was administered at 8am, 12pm, 4pm, and 8pm January 1st -13th.
-The medications was administered at 8am, 1pm, and 6pm January 14th - 19th.
"Lantus Sol

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of five residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R4's medical record revealed a current written service plan dated December 28, 2022. This service plan indicated R4 received medication administration.

2. Review of R4's medical record revealed a signed medication order dated September 8, 2022. This medication order stated the following:
"Diltiazem Hydrochloride 60mg oral tablet; Take 1 tab(s) oral 3 times a day hold for SBP less that 110 or HR less than 65". However, documentation was not available showing R4's systolic blood pressure (SBP) or heart rate (HR) were assessed three times a day to evaluate if the medication was needed.

3. Review of R4's medical record revealed a January 2023 medication administration record (MAR). This MAR showed the following:
"Diltiazem HCL Tablet 60mg 1 tablet by mouth three times a day, Hold for SBP less than 110 or HR less than 65" however, did not include documentation the medication was administered at 1pm January 14th.

4. During an observation of R4's medications, the following was observed:
Diltiazem HCL 60mg was not available.

5. During an interview, E1 and E2 were unsure if the medication was administered at 1pm on January 14th and acknowledged R4's medical record did not include documentation the medication was administered on January 14th.