A Caring Manor

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program." This policy stated, "...2. Quality Management program will consist off the following items:...2. Review and evaluate the effectiveness of the quality management program once every 12 months...the manager shall ensure the following: 1. A plan is established, documented, and implemented for an ongoing quality management program..." 2. The Compliance Officer requested to review the facility's quality management program and supporting documentation. However, no documentation was provided for review. 3. During an interview, E1 and E2 acknowledged a quality management report was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of three personnel records sampled. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. A review of facility documentation revealed a policy titled "New Employee Orientation." The policy stated, "…before providing assisted living services to a resident, a manager…receives orientation that is specific to the duties to be performed by the manager…” 2. A review of E3's personnel record revealed no documentation of completed orientation. Based on E3's hire date orientation was required. 3. In an interview, E1 and E2 acknowledged E3's personnel record did not include documentation of orientation.

Based on documentation review, 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 one of two residents sampled. 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. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. In an interview, E1 and E2 acknowledged R1's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1’s medical record revealed a document titled "Admission Orders or Consent to Continue Residency." This document was signed by a medical practitioner. However, the documentation was signed after R1’s move-in date. 2. In an interview, E1 acknowledged R1’s medical record did not contain the required documentation that was dated 90 days before R1 was accepted by the facility.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of a medication administered to the resident that included the correct strength, for one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a medication order (dated February 7, 2025) which stated "Trazodone HCL Oral Tablet 100 MG; 1 tab by mouth at bedtime for chronic insomnia." 2. A review of R1's medication revealed a container of Trazodone 100 mg Tablets. 3. A review of R1's medication administration record (MAR) showed "Trazodone 50mg tablet" recorded as administered at bedtime from March 1, 2025 - April 1, 2025. 4. In an interview, E1 acknowledged R1's medical record did not contain documentation of a medication administered to the resident that included the correct strength.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During the environmental tour of the facility, the Compliance Officer observed an unlocked door leading to the backyard. The backdoor was equipped with an alarm to alert employees of egress; however, the alarm was not turned on at the time of inspection. 3. In an interview, E1 and E2 acknowledged that there was no means of exiting the facility that controlled or alerted employees of the resident's egress.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk to the health and safety of residents as medications were not administered as ordered. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order for the following medication: -Trazodone Hydrochloride; 100mg tablet, 1 tab by mouth at bedtime for chronic insomnia 3. A review of R1’s medications revealed a bottle of Trazodone labeled 100 mg tablets. Further review revealed R1’s medication administration record (MAR) for March 2025 and April 2025 documented Trazodone; 50 mg; take one tab at bedtime for sleep..." 4. In an interview, E1 reported the medication was administered per the MAR and acknowledged R1’s medication was not administered in compliance with a medication order. This is a repeat deficiency from the inspections completed on August 18, 2023 and May 11, 2022.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1) During the environmental inspection of the facility, the Compliance Officer observed a Ziploc bag that contained insulin pens in R1’s bedroom. 2) A review of R1's medication orders revealed R1 received insulin glargine (Lantus); 20 units SubCutaneous; Once every day. 3) In an interview, E1 reported E1 administered the insulin per medication orders. 4) In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. 

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed Lysol All Purpose Cleaner, Cascade detergent pods, Rug Doctor Pet Deep Carpet Cleaner, and Finish Jet-Dry rinse aid in an unlocked cabinet under the kitchen sink. 2. In an interview, E1 and E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. In an on-site compliance and complaint investigation, the Compliance Officer requested the facility's fall prevention and recovery policy and procedure and staff training documentation for review. 2. After a brief search of facility documentation, E1 stated, "I know I wrote it up." However, E1 was unable to locate the fall prevention and fall recovery policy and procedure. 3. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed no documentation to indicate E1, E2, E3, E4, and E5 completed fall prevention and fall recovery training. 4. In an interview, E1 acknowledged E1 was unable to provide documentation of the facility's fall prevention and fall recovery policy and procedure as well as documentation of staff training. This is a repeat deficiency from the on-site inspection completed May 11, 2022.

Based on documentation review and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered staffing. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Staffing - Awake Staff." The policy stated, "Currently at A Caring Manor employees are live-in caregivers and staff sleeps during night time hours. The following procedure outlines how resident's health and safety is and will be maintained." 2. Under the title, "Procedure," the policy stated, "1. Staffing patterns will be maintained to meet all residents: a. cognitive, b. functional condition c. physical condition d. scheduled and unscheduled needs. 2. Residents residing in the home are capable of sleeping at night and live-in staff frequently makes routine checks through-out the night on those who reside at the home. 3. Bed alarms and monitors can be used if deemed necessary and as noted on the individual service plan. 4. If resident is at directed care level every 2 hour checks and monitoring will be initiated and documented on the service plan. 5. Should a resident move-in who's needs indicate that more frequent night time supervision is or would be required or if a current resident's condition change that would require such care, the home would employee [sic] a night time awake employee to meet those needs. 6. The Manager will be on call 24 hours a day to assist the staff in areas of emergencies and problem solving." 3. Further review of the facility's policies and procedures revealed a hand-written statement that stated, "When needed, A Caring Manor I will provide wake staff for residents awake during evening hours." 4. In an interview, E1 revealed R3 frequently wandered at night and for safety reasons required an awake staff at night. 5. A review of Department documentation revealed O1 was informed that R3 required awake staff at night, and O1 was to hire someone to sit with R3 from 11:00 PM to 5:00 AM. 6. In an interview, E1 reported O1 and E1 "talked about" hiring awake night staff with the expectation that O1 would pay for 5 nights a week, and A Caring Manor would pay for 2 nights a week. 7. In an interview, E1 acknowledged the facility's policy on providing awake staff was not implemented according to the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for three of five sampled caregivers. The deficient practice posed a risk to the health and safety of residents if E3, E4, and E5 were not qualified to provide caregiver services. Findings include: 1. A review of facility documentation revealed E3, E4, and E5 were listed on one or more of the January 2023 through August 2023 "Caregiver Monthly Schedule" as caregivers. 2. A review of E3's, E4's, and E5's personnel records revealed no documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 3. In an interview, E1 acknowledged E3's, E4's, and E5's personnel records did not include documentation of completion of a caregiver training program. E1 reported E1 used a temporary employment agency to hire E4 and E5. E1 reported E1 trusted the temporary agency to ensure E4 and E5 had the required documentation.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A), for four of five personnel records sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E1, E2, E3, and E5 were fit to work at the assisted living facility. Findings include: A.R.S. \'a7 36-411(A) states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 1. A review of E1's personnel record revealed a fingerprint clearance card from the Arizona Department of Public Safety. However, E1's fingerprint clearance card expired on July 11, 2023. 2. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website, using the fingerprint clearance card number provided in E1's personnel record, revealed E1's fingerprint clearance card was expired. 3. A review of E2's, E3's, and E5's personnel record revealed no documentation of a fingerprint clearance card. 4. In an interview, E1 acknowledged E1, E2, E3, and E5 did not have documentation of a valid fingerprint clearance card.

Based on documentation review, record review, and interview, the manager failed to ensure a complete personnel record was available for five of five employees sampled. The deficient practice posed a risk as required information could not be verified for E1, E2, E3, E4, and E5. Findings include: 1. A review of facility documentation revealed a policy and procedure titled, "Staff Records," reviewed and approved November 5, 2020. The policy stated, "The manager shall ensure that a personnel record for each staff member or volunteer is initiated upon hire and maintained throughout the staff member's or volunteer's period of providing services in or for A Caring Manor I..." 2. Upon arrival, the Compliance Officer observed E1 and E3 on the premises, providing services in or for A Caring Manor I. 3. During the compliance and complaint inspection, the Compliance Officer requested all personnel records for review. The Compliance Officer did not observe a personnel record for E2, E3, E4, or E5. However, the compliance officer did observe E2, E3, E4, and E5 listed as caregivers on one or more of the following personnel schedules: -January 2023; -February 2023; -March 2023; -April 2023; -May 2023; -June 2023; -July 2023; and -August 2023. 4. In an interview, E1 reported E2, E3, and E5 did not have a personnel record on the premises for review. E1 was able to provide minimal personnel information for E1 and E4. E1 reported E4 and E5 were agency personnel. 5. In an interview, E1 acknowledged there was not a complete personnel record available for E1, E2, E3, E4, and E5. E1 did not provide any additional documentation for review.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 days before the individual was accepted by an assisted living facility, and, if the individual was requesting or was expecting to receive supervisory care services, personal care services, or directed care services, included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician's assistant, for two of three residents sampled. The deficient practice posed a risk if a resident was not assessed and determined to be within the scope of an assisted living facility prior to receiving services. Findings include: 1. A review of R2's medical record revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints was available for review. 2. A review of R3's medical record revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints was available for review. 3. In an interview, E1 acknowledged R2's and R3's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant. This is a repeat deficiency from the on-site inspection completed May 11, 2022.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)( 1-10) for one of three residents sampled . The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R3's medical record revealed no documented residency agreement dated before or at the time of R3's acceptance into the facility. 2. In an interview, E1 acknowledged there was no documented residency agreement dated before or at the time of R3's acceptance into the facility. E1 reported the residency agreement was completed. However, E1 believed the original may have been given to R3's family and a copy was not made. This is a repeat deficiency from the on-site inspection completed May 11, 2022.

Based on record review and interview, the manager failed to ensure, before or at the time of acceptance by the assisted living facility, the resident or resident's representative was provided a copy of resident rights for three of three residents sampled. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed no documentation to indicate the residents or residents' representatives received a copy of the resident's rights at the time of admission, nor anytime since. 2. In an interview, E1 acknowledged there was no documentation to verify the sampled residents or their representatives had received a copy of the resident's rights. E1 reported the residents or residents' representatives received a a copy of the residency agreement, the resident rights, a copy of the house rules, and important phone numbers.

Based on record review and interview, the manager failed to ensure three of three residents sampled received a copy of the policy and procedure on health care directives at the time of acceptance. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed no documentation indicating the residents received a copy of the facility's policy and procedure on health care directives. 2. In an interview, E1 acknowledged R1, R2, and R3 did not receive a copy of the facility's policy and procedure on health care directives. E1 reported the residents or residents' representatives received a a copy of the residency agreement, the resident rights, a copy of the house rules, and important phone numbers.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed no service plan was available for review. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged R3's medical record did not include a service plan. E1 reported R3's service plan did not get completed because the facility was "waiting for hospice."

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated July 7, 2023. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. In an interview, E1 acknowledged R1's service plan did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of three residents sampled. The deficient practice posed a risk to the health and safety of residents as medications were not administered as ordered. 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed signed medication orders for the following medications: -Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate), 3 ml three times a day; -Fluticasone Proprionate Nasal Suspension 50MCG/ACT, 1 spray into each nostril two times a day; and -Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone Salmeterol), 1 puff every 12 hours. 3. A review of R1's medication administration record (MAR) revealed all of the aformentioned medications were documented on the MAR to be administered as needed (not scheduled). 4. A review of R1's MAR revealed R1 had not received medication administration of any of the aforementioned medications in July 2023 or August 2023. 5. In an interview, E1 acknowledged the aformentioned medications were not being administered in compliance with a medication order. E1 reported E1 thought the aforementioned medications were on the MAR as routine medications. E1 reported R1 "sometimes" refused the medications, but the refusal was not documented. 6. A review of R2's medical record revealed R2 received medication administration. 7. A review of R2's medical record revealed a signed medication order for Temazapam 15 milligrams (mg), one capsule at bedtime. 8. A review of R2's medication administration record (MAR) revealed R2 received Temazapam 15 mg from August 1, 2023-August 17, 2023. 9. A review of R2's medications revealed no Temazapam available for use. 10. In an interview, E1 reported R2 had been out of Temazapam since August 13, 2023. However, a documentation error indicated R2 received the medication August 14, 2023-August 17, 2023. 11. A review of R2's medication administration record (MAR) revealed R2 was administered the following scheduled medications: -Trazodone 150 milligrams (mg), one tablet at bedtime; -Pantoprazole 40 mg every day, one tablet every day; -Docusate 100 mg, two capsules every day; -Bethanechol 25 mg, 1/2 tablet twice a day; and -Tamsulosin 0.4 mg, one tablet at bedtime. 12. A review of R2's medical record revealed no signed medication orders for the aforementioned medications. 13. In an interview, E1 acknowledged R2's medications were not administered in compliance with a medication order, as there were no medication orders for review. E1 reported in the future, E1 would "call each month and get an updated medlist." 14. In an interview, E1 reported R3 received medication administration. 15. A review of R3's medical record revealed a signed medication list dated July 28, 2023. The medication list included the follo

Based on interview and record review, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of three residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) revealed R2 received medication administration of Midodrine 10 milligrams (mg), three times daily, if diastolic blood pressure was higher than 90. 3. In an interview, the Compliance Officer requested R2's blood pressure readings for review. E2 was unable to provide the documentation for review, stating R2's diastolic blood pressure was "usually not above 90, it is usually low." 4. A review of R2's MAR revealed R2 received Midodrine 10 mg three times daily at 8:00 AM, 3:00 PM, and 8:00 PM from August 1, 2023 to August 17, 2023. 5. In an interview, E1 reported the MAR documentation was incorrect. R2 had not received Midodrine 10 mg three times a day as documented in the MAR. 6. In an interview, E1 reported R3 received medication administration. 7. A review of R3's medical record revealed a signed medication list dated July 28, 2023. The medication list included the following medications: -Bupropion ER (XL) Tab ER 24 hr 300 milligrams (mg), 1 tablet daily; -Calcitriol Cap 0.25 mcg, 1 capsule daily; -Cholestyramine Powder, 1/2 scoop daily in water; -Depakote Sprinkles capsule delayed release 125 mg, 1 capsule 2 times daily; -Donepezil Tab 10 mg, 1 tablet at bedtime; -Duloxetine cap delayed release 60 mg, 1 capsule daily; -Keppra Tab 1000 mg, 1 tablet every 12 hours; -Losartan Potassium Tab 50 mg, 1 tablet daily; -Pepcid Tab 20 mg, 1 tablet daily; and -Quetiapine Fumarate Tab 50 mg, one tablet twice daily. 8. A review of R3's medical record revealed a verbal order dated August 7, 2023 with the following instructions: -Lorazepam 0.5 mg every 6 hours as needed; -Discontinue Calcitriol; and -Discontinue Donepezil. 9. A review of R3's medical record revealed a medication administration record (MAR) dated August 2023. The MAR included the following medications: -Bupropion ER (XL) Tab ER 24 hr 300 mg; -Divalproex Sprinkles capsule delayed release 125 mg; -Quetiapine Fumarate Tab 50 mg; -Losartan Potassium Tab 50 mg; -Lorazepam 50 mg; -Tylenol PM 500 mg; -Acetaminophen 25-500 mg; and -Imodium 2 mg. 10. A review of R3's MAR revealed none of the aforementioned medications (in numbers 2, 3, and 4 above) were administered to R3 in the month of August 2023. 11. In an interview, E1 reported there was no documentation of medication administered in August 2023 because the original documentation was handed to O1 to take to the doctor. 12. In an interview, E1 acknowledged medication administration provided to R3 was not documented in R3's medical record as required.

Based on documentation review and interview, the manager failed to ensure the facility had a disaster plan that was developed, documented, maintained in a location accessible to caregivers and assistant caregivers, and, if necessary, implemented that included when, how, and where residents would be relocated, how a resident's medical record would be available to individuals providing services to the resident during a disaster, a plan to ensure each resident's medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility's relocation site during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. During the facility inspection, the Compliance Officer requested the facility's disaster plan. E1 was unable to locate and provide the disaster plan for review. 2. In an interview, E1 acknowledged the facility did not have a disaster plan maintained in a location accessible to caregivers.

Based on documentation review and interview, the manager failed to ensure the disaster plan review included the date and time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. The deficient practice posed a risk to the health and safety of residents if the disaster plan was not current to meet the needs in a disaster. Findings include: 1. In an on-site compliance and complaint investigation, the Compliance Officer requested the facility's disaster plan review. 2. After a brief search of facility documentation, E1 reported E1 could not find documentation of a disaster plan review. 3. In an interview, E1 acknowledged a disaster plan review was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or assistant caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a risk as critical information needed in an investigation regarding a resident's urgent medical needs were not obtained as required. Findings include: 1. A review of Department documentation revealed paramedics were called to the facility on August 13, 2023, after R3 had a fall. 2. In an on-site compliance and complaint investigation, the Compliance Officer requested R3's medical record for review, including any incident reports. 3. A review of R3's medical record revealed one incident report dated August 13, 2023. However, the aforementioned incident report did not indicate a call was made to emergency services regarding this incident. 4. In an interview, E1 reported E1 called the paramedics the night of August 13, 2023 after R3 had another fall. However, E1 reported there was no documentation of the incident and no documentation that emergency services were called. 5. In an interview, E1 acknowledged there was no documentation of R3's emergency that resulted in E1 calling emergency medical services. The compliance officer asked why there was no documentation of the aforementioned fall. E1 stated, "I don't know why."

Based on observation, documentation review, and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R3's medical record revealed an incident report dated August 13, 2023. The report reported R3 stood up from the couch and fell into the caregiver's arms. 2. A review of Department documentation revealed R3's family reported R3 was a fall risk. 3. In an interview, E1 reported R3 tended to wander throughout the facility and would often wander into R1's bedroom. R1 was uncomfortable with this. However, R1 did not want R1's door closed. 4. In order to prevent R3 from wandering into R1's bedroom, E1 reported a baby gate was placed in R1's door to restrict access. 5. In an interview, O1 reported R3 fell over the baby gate and had three additional falls on August 13, 2023. 6. In an interview, E1 reported R3 "never fell on it" but R3 pushed the the gate down and walked over it. 7. In an interview, E1 acknowledged placing a baby gate in a resident's doorway may cause a resident or other individual to suffer physical injury.