ANTHEM SENIOR LIVING

<p>Based on documentation review, interview, and record review, the governing authority failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “Fall Prevention.” The P&P stated, “Manager will conduct a Fall Prevention Training upon hiring and in routine team meetings.” However, the P&P did not clearly include a time frame for continued competency training.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported E1 was the manager. E1 reported the fall training included both fall prevention and fall recovery and not just fall prevention as stated in the P&P. E1 clarified facility personnel received the training upon hire and annually thereafter instead of upon hire and in routine team meetings as stated in the P&P. E1 reported the manager provided the training during orientation for new hires. However, E1 reported O1 provided the annual training through a third party. E1 confirmed E1 did not provide the fall training annually.</p><p><br></p><p><br></p><p>3. A review of E1’s personnel record revealed E3 was hired in 2016 and promoted to manager in August 2024. The review revealed documentation demonstrating E1 received training regarding fall prevention and fall recovery through O1’s third party company on September 17-18, 2023, and September 16-17, 2024, and not through the facility manager as stated in the P&P.</p><p><br></p><p><br></p><p>4. A review of E3’s personnel record revealed E3 was hired as an assistant caregiver in April 2023 then promoted to caregiver in June 2023. The review revealed an “EMPLOYEE ORIENTATION CHECKLIST” which indicated E3 did not receive training regarding fall prevention and fall recovery until June 25, 2023. The review revealed documentation demonstrating E3 received training regarding fall prevention and fall recovery through O1’s third party company on July 10-11, 2024, and July 18-19, 2025, and not through the facility manager as stated in the P&P. The review further revealed more than one year between the trainings on June 25, 2023, and July 10-11, 2024, as well as between the trainings on July 10-11, 2024, and July 18-19, 2025.</p><p><br></p><p><br></p><p>5. A review of E5’s personnel record revealed E3 was hired as an assistant caregiver in September 2023. The review revealed an “EMPLOYEE ORIENTATION CHECKLIST” which indicated E5 did not receive training regarding fall prevention and fall recovery upon hire. The review revealed documentation demonstrating E5 received training regarding fall prevention and fall recovery through O1’s third party company on September 19, 2023, and February 10, 2025, and not through the facility manager as stated in the P&P. The review further revealed more than one year between the trainings on September 19, 2023, and February 10, 2025.</p>

<p>Based on interview, documentation review, and record review, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder (EMS) which included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9).</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, E1 reported R2 had an accident, emergency, or injury on June 9, 2025, that resulted in facility personnel contacting EMS on behalf of R2.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed an “INCIDENT REPORT” dated June 9, 2025. However, the incident report did not include the individuals notified by the caregiver or assistant caregiver.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported E2 contacted R2’s primary care provider (PCP) the morning of the incident.</p><p><br></p><p><br></p><p>4. A review of E2’s phone records revealed a series of text messages between E2 and R2’s PCP. In the messages, E2 explained the incident and R2’s PCP stated, “Send [R2].” E2 stated, “911?” to which R2’s PCP replied, “Yes.”</p><p><br></p><p><br></p><p>5. A review of E1’s phone records revealed a call to EMS shortly after the aforementioned text message exchange.</p><p><br></p><p><br></p><p>6. A review of R2’s medical record revealed no copy of the document provided to EMS in compliance with A.R.S. § 36-420.04(A)(1-9).</p><p><br></p><p><br></p><p>7. In an interview, E1 reported facility personnel did not maintain a copy of the document provided to EMS for the aforementioned incident, stating, “We weren’t doing that.”</p>

<p>Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for four of four sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A.R.S. § 36-411(C)(4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.”</p><p><br></p><p><br></p><p>2. A review of E1's, E3’s, E4’s, and E5’s personnel records revealed E1, E3, E4, and E5 were hired before March 31, 2025. However, the review revealed no documentation demonstrating compliance with A.R.S. § 36-411(C)(4).</p><p><br></p><p><br></p><p>3. A review of the Adult Protective Services (APS) registry website revealed E1, E3, E4, and E5 were not on the registry.</p><p><br></p><p><br></p><p>4. In an interview, E1 and E2 reported not knowing about this statute. E1 and E2 confirmed E1 and E2 did not make documented, good faith efforts to verify that each current employee was not on the adult protective services registry.</p>

<p>Based on interview and documentation review, the manager failed to report alleged or suspected abuse, neglect, or exploitation of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454 when abuse, neglect, or exploitation of a resident was alleged or suspected to have occurred before the resident was accepted or while the resident was not on the premises and not receiving services from an assisted living facility’s manager, caregiver, or assistant caregiver.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, E1 reported E1 received a phone call on August 4, 2025. E1 reported the caller informed E1 that the caller was worried R2 may have been abused while R2 was not on the premises and not receiving services from an assisted living facility’s manager, caregiver, or assistant caregiver.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed no report of the alleged or suspected abuse to a peace officer or to the adult protective services central intake unit as required by this rule and A.R.S. § 46-454.</p><p><br></p><p><br></p><p>3. In an interview, E1 and E2 reported E1 and E2 did not report the alleged or suspected abuse. E1 and E2 reported E1 and E2 had not noticed any issues brought up by the caller and did not have a reason to believe the allegations shared by the caller. E1 and E2 reported not knowing this rule required reporting to a peace officer or to the adult protective services central intake unit when abuse, neglect, or exploitation of a resident was alleged or suspected to have occurred, even if the manager does not have a reasonable basis to believe it occurred.</p>

<p>Based on documentation review, observation, interview, and record review, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of two sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “Cardiopulmonary Resuscitation (CPR) and First Aid Trainings” The P&P stated; “1. Manager, caregivers, assistant caregivers and volunteers must acquire the CPR and First Aid Trainings before providing direct and indirect care to the elderly…7. The time-frame for renewal of cardiopulmonary resuscitation training and first aid should be: a. The trainees are responsible for keeping their cards current and not letting them lapse.”</p><p><br></p><p><br></p><p>2. The Compliance Officer observed E1 making changes to the August 2025 personnel schedule.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported E1 was updating the schedule because E3 no longer worked at the facility. When the Compliance Officer asked for E3’s date of termination of employment, E1 reported E1 did not know and would have to contact E3 to find out. However, documentation of E3's date <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">of termination of employment was not provided. </span></p><p><br></p><p><br></p><p>5. A review of facility documentation revealed a personnel schedule dated August 2025 which indicated E3 worked on August 4 and 6, 2025. </p><p><br></p><p><br></p><p>6. In an interview, the Compliance Officer pointed out the personnel schedule had E3 working on August 4 and 6, 2025, and again asked for E3’s date of termination of employment. E1 reported E1 found out that E3 last worked on August 4, 2025. E1 reported the schedule was incorrect and had not been updated. When the Compliance Officer asked if the facility kept track of hours worked in a way other than the personnel schedule, E1 reported facility personnel clocked in and out on an app. However no other documentation of hours work by E3 was provided.</p><p><br></p><p><br></p><p>7. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed first aid and CPR training certification dated as expired at the end of July 2025. The review revealed no current first aid and CPR training certification.</p><p><br></p><p><br></p><p>8. In an interview, E1 reported E1 obtained E3’s current first aid and CPR training certification via email on E1’s cell phone and presented it to the Compliance Officer.</p><p><br></p><p><br></p><p>9. A review of E1’s cell phone revealed a first aid and CPR training certification titled “[E3] CPR.pdf.” The certification reported E3 completed the course through HSI on January 29, 2025. However, a review of the HSI Student Card Validation website revealed the certification presented to the Compliance Officer belonged to O2 and not to E3.</p><p><br></p><p><br></p><p>10. In an interview, the Compliance Officer informed E1 that E3’s first aid and CPR training certification was invalid and belonged to O2 and not E3.</p><p><br></p><p><br></p><p>11. In an interview, the Compliance Officer asked who created the invalid first aid and CPR training certification. E1 did not answer. When the Compliance Officer asked who had sent the email with the invalid certification, E1 reported the owner sent it.</p>

<p>Based on observation, documentation review, interview, and record review, the manager failed to ensure a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for two of three sampled applicable personnel. The deficient practice posed a risk if a caregiver or assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed E5 working at the facility.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed no policy and procedure (P&P) covering how the manager would verify and document a caregiver’s or assistant caregiver's skills and knowledge.</p><p><br></p><p><br></p><p>3. In an interview, E2 acknowledged the facility did not have a P&P covering this rule.</p><p><br></p><p><br></p><p>4. A review of E3's personnel record revealed E3 was hired as an assistant caregiver in April 2023 then promoted to caregiver in June 2023. The review revealed an “EMPLOYEE ORIENTATION CHECKLIST” which included a section titled “Verification of skills and knowledge.” However, the checklist revealed the manager did not verify and document E3’s skills and knowledge until June 25, 2023.</p><p><br></p><p><br></p><p>5. A review of E5's personnel record revealed E2 was hired as an assistant caregiver. The review revealed an “EMPLOYEE ORIENTATION CHECKLIST” which included a section titled “Verification of skills and knowledge.” However, the checklist revealed the manager did not verify and document E5’s skills and knowledge.</p><p><br></p><p><br></p><p>6. In an interview, E1 reported E5 had not worked at the facility for quite some time but had just come back to work the week of the inspection. However, E1 confirmed the manager did not verify and document E5’s skills and knowledge.</p>

<p>Based on observation, interview, and documentation review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed E1 making changes to the August 2025 personnel schedule.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported E1 was updating the schedule because E3 no longer worked at the facility. When the Compliance Officer asked for E3’s date of termination of employment, E1 reported E1 did not know and would have to contact E3 to find out.</p><p><br></p><p><br></p><p>3. A review of facility documentation revealed a personnel schedule dated August 2025 which indicated E3 worked on August 4 and 6, 2025. </p><p><br></p><p><br></p><p>4. In an interview, the Compliance Officer pointed out the personnel schedule had E3 working on August 4 and 6, 2025, and again asked for E3’s date of termination of employment. E1 reported E1 found out that E3 last worked on August 4, 2025. E1 reported the schedule was incorrect and had not been updated. When the Compliance Officer asked if the facility kept track of hours worked in a way other than the personnel schedule, E1 reported facility personnel clocked in and out on an app. E1 reported E1 could log in to the app on a laptop and view the timecards there. However, no timecards or other documentation of the hours worked for each caregiver and assistant caregiver was provided. </p><p><br></p><p><br></p><p><br></p><p>5. The Compliance Officer observed E4 working at the facility.</p><p><br></p><p><br></p><p>6. A review of facility documentation revealed a series of personnel schedules dated between June 2025 and August 2025. The schedules revealed documentation demonstrating the following:</p><p><br></p><p>- E4 worked between 7:00 PM and 7:00 AM on June 1 and 5-6, 2025;</p><p><br></p><p>- E4 did not work any other shifts in June;</p><p><br></p><p>- E4 worked between 7:00 AM and 7:00 PM on July 5, 2025;</p><p><br></p><p>- E4 worked between 7:00 PM and 7:00 AM on July 3, 6, and 10-11, 2025;</p><p><br></p><p>- E4 did not work any other shifts in July;</p><p><br></p><p>- E4 worked between 7:00 AM and 7:00 PM on August 1, 2025;</p><p><br></p><p>- E4 worked between 7:00 PM and 7:00 AM on August 3, 2025; and</p><p><br></p><p>- E4 did not work any other shifts between August 1, 2025, and the date and time of the inspection.</p><p><br></p><p><br></p><p>7. In an interview, when the Compliance Officer asked if E4 worked nights, E4 stated, “No, I don’t.” E4 reported E4 was usually off work before 7:00 PM. When the Compliance Officer requested to view E4’s time records on the aforementioned app, E4 provided the time records.</p><p><br></p><p><br></p><p>8. A review of the time records on E4’s phone revealed the following:</p><p><br></p><p>- E4 worked no earlier than 6:21 AM and no later than 7:46 PM on any day between May 12, 2025, and the date of the inspection;</p><p><br></p><p>- E4 was off work before 7:00 PM on 49 of the 56 dates E4 worked between May 12, 2025, and the date of the inspection;</p><p><br></p><p>- E4 worked the day shift on June 2-6, 9-11, 15-19, 23, 26-28, and 30, 2025, with the start and end times varying as stated above;</p><p><br></p><p>- E4 worked the day shift on July 1-4, 7-12, 14-18, 21-25, and 28-31, 2025, with the start and end times varying as stated above;</p><p><br></p><p>- E4 worked the day shift on August 1 and 4-7, 2025, with the start and end times varying as stated above;</p><p><br></p><p>- E4 did not work on June 1, 2025, as reported on the paper schedule;</p><p><br></p><p>- E4 did not work on July 5-6, 2025, as reported on the paper schedule; and</p><p><br></p><p>- E4 did not work on August 3, 2025, as reported on the paper schedule.</p>

<p>Based on documentation review, observation, interview, and record review, the manager failed to maintain a personnel record for each employee that contained a contact telephone number and<span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);"> ending date of employment</span>, for one of four sampled employees. The deficient practice posed a risk as required information could not be verified.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “Personnel.” The P&P stated: “The manager of Anthem Senior Homes shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number [and] b. The starting date of employment or volunteer service and, if applicable, the ending date.”</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a personnel schedule dated August 2025 which indicated E3 worked on August 4 and 6, 2025. </p><p><br></p><p><br></p><p>3. In an interview, the Compliance Officer pointed out the personnel schedule had E3 working on August 4 and 6, 2025, and again asked for E3’s date of termination of employment. E1 reported E1 found out that E3 last worked on August 4, 2025. E1 reported the schedule was incorrect and had not been updated.</p><p><br></p><p><br></p><p>4. A review of E3’s personnel record revealed E3 was hired as a caregiver. However, the review revealed no documentation of E3’s contact telephone number and ending date of employment.</p><p><br></p><p><br></p><p>5. In an interview, E1 acknowledged that E3's personnel record did not contain E3's <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">contact telephone number and ending date of employment.</span></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. R9-10-113(A)(2)(a)(i-iii) 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…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)."</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled “Resident’s Physical and Electronic Medical Records.” The P&P stated: “A. Each resident will have a physical records [<em>sic</em>] including but not limited to the following information: h. Documentation of freedom from infectious tuberculosis as required in R9-10-807(A).”</p><p><br></p><p><br></p><p>3. A review of R2's medical record revealed documentation assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB, dated June 14, 2025. However, the assessment was dated more than seven days after R2’s date of occupancy. The review further revealed documentation of a negative TB blood test, dated June 12, 2025. However, the test was dated as read more than seven days after R2’s date of occupancy.</p><p><br></p><p><br></p><p>4. In an interview, E2 confirmed R2 did not receive baseline screening before or within seven calendar days after R2’s date of occupancy.</p>

<p>Based on documentation review, observation, interview, and record review, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for two of eight total residents. The deficient practice posed a risk as the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “Resident’s Physical and Electronic Medical Records.” The P&P stated: “A. Each resident will have a physical records [<em>sic</em>] including but not limited to the following information: l. Documentation of assisted living services provided to the resident.”</p><p><br></p><p><br></p><p>2. The Compliance Officer observed E1 making changes to the August 2025 personnel schedule.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported E1 was updating the schedule because E3 no longer worked at the facility. E1 reported the schedule was incorrect and had not been updated. When the Compliance Officer asked if the facility kept track of hours worked in a way other than the personnel schedule, E1 reported facility personnel clocked in and out on an app. E1 reported E1 could log in to the app on a laptop and view the timecards there.</p><p><br></p><p><br></p><p>4. The Compliance Officer observed E1 attempt to log in to the app via a laptop. The Compliance Officer observed E1’s login failed and the page reported E1 did not have access to view the timecards.</p><p><br></p><p><br></p><p>5. In an interview, when the Compliance Officer asked who else had access to the app to view the accurate personnel schedule, E1 reported the owner had access. However, E1 reported the owner was not available to log in.</p><p><br></p><p><br></p><p>6. A review of R1’s medical record revealed documentation of assisted living services provided to R1 (ADLs) dated between June 2025 and August 2025. The ADLs revealed documentation demonstrating the following:</p><p><br></p><p>- On June 18-19, 2025, between the hours of 9:00 PM and 7:00 AM, E4 checked R1’s briefs four times and changed R1’s briefs two times;</p><p><br></p><p>- On July 2-4, 16-17, and 30-31, 2025, between the hours of 9:00 PM and 7:00 AM, E4 checked R1’s briefs four times and changed R1’s briefs two times; and</p><p><br></p><p>- On August 1, 2025, between the hours of 9:00 PM and 7:00 AM, E4 checked R1’s briefs four times and changed R1’s briefs two times.</p><p><br></p><p><br></p><p>7. A review of R8’s medical record revealed ADLs dated between June 2025 and August 2025. The ADLs revealed documentation demonstrating the following:</p><p><br></p><p>- On June 18-19, 2025, between the hours of 9:00 PM and 7:00 AM, E4 checked R8’s briefs eight times and changed R8’s briefs four times; and</p><p><br></p><p>- On August 1, 2025, between the hours of 9:00 PM and 7:00 AM, E4 checked R8’s briefs eight times and changed R8’s briefs five times.</p><p><br></p><p><br></p><p>8. In an interview, when the Compliance Officer asked if E4 worked nights, E4 stated, “No, I don’t.” E4 reported E4 was usually off work before 7:00 PM. When the Compliance Officer requested to view E4’s time records on the aforementioned app, E4 provided the time records.</p><p><br></p><p><br></p><p>9. A review of the time records on E4’s phone revealed E4 worked no earlier than 6:21 AM and no later than 7:46 PM on any day between May 12, 2025, and the date of the inspection. The review revealed E4 did not provide incontinence care to R1 and R8 on the aforementioned dates and times as E4 was not working.</p><p><br></p><p><br></p><p>10. In an interview, E4 reported E4 had forgotten to log out of the program used to document the ADLs a few times several months before the inspection. E4 reported E4 had been reminded to log off before finishing E4’s shift at that time and had done so since. When the Compliance Officer asked why another individual was using E4’s login to document ADLs, E4 reported not knowing.</p><p><br></p><p><br></p><p>11. In an interview, when the Compliance Officer pointed out someone had been logging into the program used to document ADLs as E4, E1 stated caregivers were “Not signing in and out.”</p>

<p>Based on documentation review, observation, interview, and record review, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering the medication, for eight of eight total residents. The deficient practice posed a risk as the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “Resident’s Physical and Electronic Medical Records.” The P&P stated: “A. Each resident will have a physical records [<em>sic</em>] including but not limited to the following information: n. Documentation of a medication administered to the resident or for which the resident received assistance in the self-administration of the medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of the medication.”</p><p><br></p><p><br></p><p>2. The Compliance Officer observed E1 making changes to the August 2025 personnel schedule.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported E1 was updating the schedule because E3 no longer worked at the facility. E1 reported the schedule was incorrect and had not been updated. When the Compliance Officer asked if the facility kept track of hours worked in a way other than the personnel schedule, E1 reported facility personnel clocked in and out on an app. E1 reported E1 could log in to the app on a laptop and view the timecards there.</p><p><br></p><p><br></p><p>4. The Compliance Officer observed E1 attempt to log in to the app via a laptop. The Compliance Officer observed E1’s login failed and the page reported E1 did not have access to view the timecards.</p><p><br></p><p><br></p><p>5. In an interview, when the Compliance Officer asked who else had access to the app to view the accurate personnel schedule, E1 reported the owner had access. However, E1 reported the owner was not available to log in.</p><p><br></p><p><br></p><p>6. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) for each of the three residents dated July 2025. The MARs revealed E4 administered medication to each of the three residents on July 2-3, 16-17, and 30-31, 2025, between the hours of 8:00 PM and 9:00 PM.</p><p><br></p><p><br></p><p>7. In an interview, when the Compliance Officer asked if E4 worked nights, E4 stated, “No, I don’t.” E4 reported E4 was usually off work before 7:00 PM. When the Compliance Officer requested to view E4’s time records on the aforementioned app, E4 provided the time records.</p><p><br></p><p><br></p><p>8. A review of the time records on E4’s phone revealed E4 worked no earlier than 6:21 AM and no later than 7:46 PM on any day between May 12, 2025, and the date of the inspection. The review revealed E4 was off work before 7:00 PM on 49 of the 56 dates E4 worked between May 12, 2025, and the date of the inspection. The review further revealed E4 did not administer medication to any residents on the aforementioned dates and times as E4 was not working.</p><p><br></p><p><br></p><p>9. In an interview, E4 reported E4 had forgotten to log out of the program used to document the MARs a few times several months before the inspection. E4 reported E4 had been reminded to log off before finishing E4’s shift at that time and had done so since. When the Compliance Officer asked why another individual was using E4’s login to document medication administration, E4 reported not knowing.</p><p><br></p><p><br></p><p>10. In an interview, when the Compliance Officer pointed out someone had been logging into the program used to document medication administration as E4, E1 stated caregivers were “Not signing in and out.”</p>