Abella Manor Senior Care, LLC

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two sampled personnel. Findings include: A review of E2's personnel record revealed documented, good faith attempts to contact prior employers was not available for review. A review of E2's personnel record revealed documentation of verification E2 was not on the Adult Protective Services registry was not available for review. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to implement an ongoing quality management program which included a method to evaluate the data collected to identify a concern about the delivery of services related to resident care and the submission of reports to the governing authority. Findings include: A review of the facility's policies and procedures revealed a quality management policy which included monthly summary reports, and an annual review. However, the most recent monthly summary report was dated November 2024 and a 2024 Annual Review report was not available for review. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical Assistance for this rule was provided during the on-site compliance inspection conducted on June 16, 2024.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility which included whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints, and is dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two sampled residents. Findings include: A review of R2's medical record revealed documentation stating whether needed continuous medical services, continuous or intermittent nursing services, or restraints was not available for review. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or resident’s representative, and by the manager, when a service plan was updated, for one of two sampled residents. Findings include: A review of R1's medical record revealed a current service plan updated July 20, 2025. However, the service plan had not been signed by the manager or by the resident or resident's representative. Additionally, documentation of attempts to obtain the resident's representatives review and signature were not available for review. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or from a medical practitioner indicating that weighing the resident was contraindicated, for one of two residents sampled. Findings include: A review of R1’s medical record revealed a service plan updated January 20, 2025. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical Assistance for this rule was provided during the on-site compliance inspection conducted on July 15, 2024.

Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for one of two sampled residents for whom an emergency responder had been contacted. Findings include: 1. A review of R1's medical record revealed a progress note, dated December 16, 2024, which indicated emergency medical services had been contacted on R1's behalf and R1 was transported to a hospital. 2. A request was made to review the standardized form and documented information pertaining to R1 which was provided to the emergency responder. However, evidence of such documentation was not available for review. 3. In an interview, E1 acknowledged being unaware of the implementation of A.R.S. 36-420.04, and the documentation required to be provided to emergency responders.

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 two residents sampled. Findings include: 1. A review of R1's medical record revealed an acceptance date for R1 had not been documented. 2. A review of R1's medical records revealed a residency agreement, however, the residency agreement included R1's name only and was otherwise blank and did not include R1's acceptance date, fees, or any required signatures or dates. 3. In an interview, E1 acknowledged there was no documented residency agreement dated before or at the time of R1's acceptance into the facility.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated July 15, 2024, for personal care services. However, the service plan was not signed and dated by R1 or R1's representative. 2. In an interview, E1 acknowledged the service plan provided for R1 had not been signed and dated by R1 or their representative when the service plans were updated. E1 reported R1 refused to sign anything and did not have a representative.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the date of acceptance and date of termination of residency, for one of one sampled former residents. Findings include: 1. A review of R1's medical record revealed it did not contain the date of R1's acceptance or date of R1's termination of residency. 2. In an interview, E1 acknowledged R1's medical record did not include a date of acceptance or date of termination of residency.

Based on record review, observation, 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 who received medication administration. The deficient practice posed a risk if medication had not been administered correctly and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan, dated July 15, 2024, for personal care services including medication administration. 2. A review of R1's medical record revealed a prescription, dated September 12, 2024, for, "Hydrocodone 5 mg - acetaminophen 325 mg tablet, 1 tab every 6 hours as needed for pain." 3. A review of R1's medical record revealed a prescription, dated November 6, 2024, for, "Sertraline 50 mg tablet, take 1 tablet by mouth daily." 4. A review of R1's medical record revealed an Medication Administration Record (MAR) dated December, 2024. The MAR documented the following: - For "Hydrocodone Acetaminophen, take 1 tablet by hour every 4 hours," the MAR documented this medication had been administered four times per day, at "AM, Noon, PM, and HS," on each day between December 1, 2024, and December 16, 2024. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the order was for an as needed (PRN) medication, the MAR did not document the strength of the medication, and if the medication had been given every four hours as indicated on the MAR, it would need to be administered six times per day instead of four times; - For "Sertraline 50 mg, take 1 tab once a day," the MAR documented this medication had been refused on every day between December 1, 2024 and December 16, 2024. There were no marks to indicate if the medication had been administered after December 16, 2024. 5. A review of R1's medical record revealed a document titled, "Narcotic Record," dated December 2024. The narcotic record documented R1 had received, "Hydrocodone Acetaminophen 5-325 MG," five times per day between December 1, 2024 and December 16, 2024, at 6:00 AM, 11:00 AM, 4:00 PM, 9:00 PM, and 2:00 AM on each day. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the Narcotic record contradicted the MAR, which indicated the medication had only been administered four times per day. 6. A review of R1's medical record revealed a progress note dated December 16, 2024. The progress note stated, "Before this happened, [R1] was being aggressive for past few days. I call now 911 per [R1] request and base on Medics [R1] was all good, but still [R1] wanted to go ER." The progress note was initialed by E1. However, the progress note was false or misleading, as the MAR and Narcotic record both indicated medication had been provided at all times on December 16, 2024. 7. In an interview, E1 reported this incident happened around lunch time. E1

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 two residents sampled who received medication administration. The deficient practice posed a risk if medication administered to a resident was not accurately documented and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan, dated July 15, 2024, for personal care services including medication administration. 2. A review of R1's medical record revealed a prescription, dated September 12, 2024, for, "Hydrocodone 5 mg - acetaminophen 325 mg tablet, 1 tab every 6 hours as needed for pain." 3. A review of R1's medical record revealed a prescription, dated November 6, 2024, for, "Sertraline 50 mg tablet, take 1 tablet by mouth daily." 4. A review of R1's medical record revealed an Medication Administration Record (MAR) dated December, 2024. The MAR documented the following: - For "Hydrocodone Acetaminophen, take 1 tablet by hour every 4 hours," the MAR documented this medication had been administered four times per day, at "AM, Noon, PM, and HS," On each day between December 1, 2024, and December 16, 2024. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the order was for an as needed (PRN) medication, the MAR did not document the strength of the medication, and if the medication had been given every four hours as indicated on the MAR, it would need to be administered six times per day instead of four times; - For "Sertraline 50 mg, take 1 tab once a day," the MAR documented this medication had been refused on every day between December 1, 2024 and December 16, 2024. There were no marks to indicate if the medication had been administered after December 16, 2024. 5. A review of R1's medical record revealed a document titled, "Narcotic Record," dated December 2024. The narcotic record documented R1 had received, "Hydrocodone Acetaminophen 5-325 MG," five times per day between December 1, 2024 and December 16, 2024, at 6:00 AM, 11:00 AM, 4:00 PM, 9:00 PM, and 2:00 AM on each day. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the Narcotic record contradicted the MAR, which indicated the medication had only been administered four times per day. 6. A review of R1's medical record revealed a progress note dated December 16, 2024. The progress note stated, "Before this happened, [R1] was being aggressive for past few days. I call now 911 per [R1] request and base on Medics [R1] was all good, but still [R1] wanted to go ER." The progress note was initialed by E1. However, the progress note was false or misleading, as the MAR and Narcotic record both indicated medication had been provided at all times on December 16, 2024. 7. In an interview, E1 reported this incident happened around

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was was conspicuously posted at least one calendar day before the first meal on the food menu was served, included any food substitution no later than the morning of the day of meal service with a food substitution, and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: Arizona Administrative Code (A.A.C.) R9-10-101(54) states "conspicuously posted" means: "placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 1. The Compliance Officer observed a conspicuously posted menu in the kitchen was dated,. "December 17 - December 20." However, the on-site inspection was conducted on December 23, 2024. The posted menu did not include any substitutions. 2. During the on-site inspection, E1 provided a monthly menu for review. This menu did not include any substitutions and documented lunch for December 23, 2024 would include, "Roast Beef with Gravy, Mashed Potatoes, Caesar Salad, and Juice or Milk." 3. The Compliance Officer observed the food being served during the on-site inspection was not nutritious and included four crackers, a cupcake, and a scoop of a plain potato salad which did not include additional vegetables. 4. In an interview, E1 reported the residents don't have good teeth and will not eat protein or vegetables, only soft food, and if E1 puts a protein they won't eat it and E1 will have to throw it away. E1 reported none of the nine residents would eat meat, such as the roast on the menu, fruits, or vegetables so they were not being served. 5. In an interview, E1 acknowledged the facility had not posted a current menu, had not served the foods listed on the menu, and had not documented a substitution no later than the morning of the day of the meal service with a food substitution.

Based on documentation 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 one residents reviewed who had an accident, emergency, or injury resulting in the resident needing medical services. The deficient practice posed a risk if the resident did not receive adequate follow-up care. Findings include: 1. A review of facility incident reports revealed no incident reports for R1. 2. A review of R1's medical record revealed a progress note dated December 16, 2024. The progress note stated, "Before this happened, [R1] was being aggressive for past few days. I call now 911 per [R1] request and base on Medics [R1] was all good, but still [R1] wanted to go ER." The progress note was initialed by E1. 3. A review of facility incident reports revealed an incident report for R1, dated December 16, 2024, including documentation of the immediate notification of R1's primary care provider and emergency contact was not available for review. 4. In an interview, E1 acknowledged documentation of the immediate notification of R1's emergency contacts and primary care providers, when R1 had an emergency, was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Opioid Prescribing and Treatment," which stated, "Pain Management Scales....2. A numeric system, often using the numbers one through ten, can be used to measure pain. The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses shall be documented in the Resident's medical record." 2. A review of R1's medical record revealed a service plan, dated July 15, 2024, for personal care services including medication administration. 3. A review of R1's medical record revealed a prescription, dated September 12, 2024, for, "Hydrocodone 5 mg - acetaminophen 325 mg tablet, 1 tab every 6 hours as needed for pain." 4. A review of R1's medical record revealed an Medication Administration Record (MAR) dated December, 2024. The MAR documented the following: - For "Hydrocodone Acetaminophen, take 1 tablet by hour every 4 hours," the MAR documented this medication had been administered four times per day, at "AM, Noon, PM, and HS," On each day between December 1, 2024, and December 16, 2024. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the order was for an as needed (PRN) medication, the MAR did not document the strength of the medication, and if the medication had been given every four hours as indicated on the MAR, it would need to be administered six times per day instead of four times. 5. A review of R1's medical record revealed a document titled, "Narcotic Record," dated December 2024. The narcotic record documented R1 had received, "Hydrocodone Acetaminophen 5-325 MG," five times per day between December 1, 2024 and December 16, 2024, at 6:00 AM, 11:00 AM, 4:00 PM, 9:00 PM, and 2:00 AM on each day. There were no marks to indicate if the medication had been administered after December 16, 2024. However, the Narcotic record contradicted the MAR, which indicated the medication had only been administered four times per day. 6. A review of R1's medical record revealed documentation of R1's numeric rating of R1's level of pain prior to administration and R1's numeric rating of the effect of the opioid were not available for review. 7. In an interview, E1 acknowledged the caregivers administering opioids to R1 had not documented the identification of R1's need for the opioid before every administered dose and had not documented monitoring of the effectiveness of the opioid in the manner prescribed by the f

Based on documentation review, record review, and interview, the manager failed to ensure entries in the medical record were not changed to make the initial entry illegible for one of two resident records sampled. Findings include: 1. A review of R2's medical record revealed a form used for documenting activities of daily living (ADLs) for the month of November 2024. The form included a section titled "Shower," and white correction tape had been applied to the form in areas used for documenting the service on November 1, 2024 and November 5, 2024, in such a manner as to make the original entry illegible. Further review revealed a document titled "Narcotic Record," used for documenting the count of controlled substances administered to a resident. The record documented the count of liquid Lorazepam administered to R2 from August 6, 2024 through September 6, 2024, and indicated the medication was administered to R2 on September 6, 2024 and September 9, 2024. Two entries were made in between the September 6, 2024 and September 9, 2024 entries; however, those entries had been covered by white correction fluid, making the original entries illegible. 2. In an interview, E1 acknowledged the entry in R2's medical record had been changed to make the initial entry illegible.

Based on record review, and interview, 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 medication, for two of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a Medication Administration Record (MAR) dated December 2024. Entries were made on the MAR between December 6 and December 9 indicating E2 had administered "Amlodipine 10 MG," "Glipizide 10 MG," and "Haloperidol 0.5 mg" to R1 as ordered. The MAR contained a second, unique set of initials indicating these medications had been administered to R1 on December 10 through December 18, 2024. In addition, the same unique set of initials documented the administration of "Metformin 850 MG" to R1. The MAR included a section at the bottom for documenting the initials and signature of the caregiver administering medication to R1. The section was completed with the initials "NM," and the signature of E2, however the section did not include evidence of the second set of unique initials and the signature of the caregiver they belonged to. 2. A review of R2's medical record revealed a Medication Administration Record (MAR) dated November 2024. Entries of two unique sets of initials were made on the MAR throughout the month indicating the medications prescribed to R2 had been administered as ordered. One set of initials were clearly those of E2 as evidenced in the section at the bottom of the MAR for documenting the initials and signature of the caregiver administering medications to R2. The second set of initials was clearly the same as those entered into R1's MAR on December 10 through December 18, and as entered into R1's MAR for the administration of Metformin. However, the section at the bottom for documenting the initials and signature of the caregiver administering medication to R2 contained only the initials and signature of E2. 3. A review of staffing schedules for the month of November 2024 revealed E1 was not scheduled to work on November 6, 7, 13, 14, 21 or 22. In addition, the schedule reflected E2 was not scheduled to work on November 8, 11, 15, 18, 22, 15 or 29. A review of the schedule for December 2024 revealed E1 was not scheduled to work on December 4, 5, 11, 12 or 18, and E2 was not scheduled to work on December 3, 9, 13 and 16. 4. In an interview, E2 advised both sets of initials belonged to and were entered by E2. E2 reported the difference in style of the initials was due to the type of pen E2 had used to make the entries. E2 advised they lived at the facility and would administer medications to residents even when E2 was not scheduled to work. 5. In an interview, E1 agreed the two sets of initials in R1's and R2's MAR were uniquely different. E1 declared the second set of initials belonged to and had been ent

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), for one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk to R2's safety. Findings include: 1. A review of R2's medical record revealed a document titled "Residents Approval of Continued Residency," dated October 9, 2023. The document reflected R2 was last examined by a medical provider on October 3, 2023, and stated R2's "care exceeds the limit of custodial care at Abella Manor Senior Care, LLC," was "confined to a chair or bed and is unable to ambulate on their own." Further review revealed a current service plan for directed care which indicated R2 was "confined to a bed or chair." Evidence of documentation indicating R2 had been examined by a provider every six months since R2's date of admission, and R2's needs could be met by the facility was unavailable for review. 2. In an interview, E1 confirmed R2 was bedbound and had been admitted to the facility in the same condition. E1 agreed R2's medical record did not contain a determination indicating R2 had been examined at least once every six months, and R2's needs were being met by the facility.

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 and documented in the resident's medical record, for one of four residents sampled. Findings include: 1. A review of R2's medical record revealed a current service plan which indicated R2 received medication administration. Further review revealed a medication administration record (MAR) dated November 2024, which indicated R2 was being administered the following medications: -Aspirin 81 mg 1 tab daily; -Loratadine 10mg 1 tab daily; -Metoprolol Tartrate 25mg 1/2 tab twice daily; -Trazadone HCL 50mg 1 tab at bedtime; -Lorazepam 2mg/ml take 0.25ml at morning and noon; -Lorazepam 2mg/ml take 0.5ml at bedtime; -Mirtazapine 30mg 1 tab at bedtime; and -Acetaminophen 325 mg take 2 tabs three times a day. 2. A review of R2's medical record revealed a document titled "Client Medication Report," ordering Aspirin 81 mg 1 tab daily, Loratadine 10mg 1 tab daily, Metoprolol Tartrate 25mg 1/2 tab twice daily, Trazadone HCL 50mg 1 tab at bedtime, Lorazepam 2mg/ml take 0.25ml at morning and noon, Lorazepam 2mg/ml take 0.5ml at bedtime, Mirtazapine 30mg 1 tab at bedtime, and Acetaminophen 325 mg take 2 tabs three times a day. The document was electronically signed by a registered nurse on April 14, 2024 and again on May 10, 2024. However, evidence of an order signed by a medical provider for was unavailable for review. 3. In an interview, E1 acknowledged a valid order for medications to be administered to R2 was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure, for one of two sampled employees, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel records revealed CPR and First Aid training certifications dated March 1, 2021 with a marked expiration of March 31, 2023. E3's personnel record also included a "BLS" CPR only certification dated May 20, 2023 with a marked expiration on May 2025. However, current documentation of First Aid training for E3 was not available for review. 2. Following the survey, E1 provided a CPR and First Aid training certification for E3 dated May 29, 2024 with a 2 year expiration. 3. In an interview, E1 acknowledged E3's personnel record did not include documentation of current First Aid training certification.

Based on record review, documentation review, and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility including whether the individual required continuous nursing services or restraints, for one of two residents sampled. Findings include: 1. A review of R2's medical records revealed a document titled "Provider Approval for Admission." This document was signed by a medical practitioner within 90 calendar days before admission and stated R2 did not require Continuous Nursing Services and did not require restraints. However, the document did not state whether R2 resident required continuous medical services or intermittent nursing services. 2. In an interview, E1 acknowledged the admissions form provided by the facility for R2 had not been completely filled out prior to R2's admission.

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A review of R2's medical record revealed a service plan, updated April 10, 2024, for directed care services. The service plan stated, "[R2] continues to be chair bound. [R2] requires assistance with transport around the care home. [R2] is unable to physically participate with transfers." 2. A review of R2's medical record revealed a document titled, "Residents Approval of Continued Residency", dated October 9, 2023. However, R2's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months, to include an approval of continued residency dated on or before April 9, 2024. 3. In an interview, E1 reported R2 was not ambulatory. E1 acknowledged the statements required from a medical practitioner every six months during R2's residency, had not been provided for review.

Based on record review, observation, and interview, for two of two sampled residents, the manager failed to ensure medication was administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's and R2's medical records revealed signed orders for medications were available for each resident. 2. A review of R1's and R2's medical records revealed a Medication Administration Record (MAR), dated June 2024, for each resident. However, the MARs indicated some medications had not been administered in compliance with a medication order for each resident. 3. The Compliance Officer observed R1's and R2's boxes of medications included medications different from each resident's medication orders and some missing medications. 4. In an interview, E1 acknowledged mediation had not been administered in compliance with a medication order. This is a repeat deficiency from the on-site complaint inspection conducted on October 24, 2023.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen was accessible to residents. Inside the refrigerator, the Compliance Officer observed bottles of Guaifenesin and, "Systane" in the door, stored alongside food items. 2. During an environmental inspection of the facility, the Compliance Officer observed a cabinet in the laundry room did not have a lock. Inside the cabinet, the Compliance Officer observed bottles of Glucosamine, and "Walgreens Foot Powder." 3. In an interview, E1 acknowledged medication stored by the facility was not stored in a separate locked area 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 were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a chemical storage cabinet in the laundry room had a magnetic lock. However, the latch was loose and the cabinet could be opened without the magnet. Inside the cabinet, the Compliance Officer observed containers of, "Resolve," "Easy Off," and "Spirit II Disinfectant." 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on June 9, 2023.

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 two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan, updated September 10, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders, dated April 13, 2023, which included the following orders: - "Methocarbamol 500 mg tablet, take 1 or 2 tablets a day as needed for neck pain if Tylenol does not relieve." However, R1's medication orders did not include a current order for Tylenol. 3. A review of R1's medical record revealed a Medication Administration Records (MARs) dated October 2023. The MAR documented the following medication had been administered to R1 in October 2023: - "Methocarbamol Tablet 750 MG, Give 1 tablet by mouth every 6 hours as needed for muscle spasm," had been administered once daily on each day in October, 2023. However, this dosage did not match the order. Additionally, no Tylenol had been administered to R1 in October 2023. 4. The Compliance Officer observed a box containing R1's medications included a bottle of, "Methocarbamol 500 mg Tablets, take 1 to 2 tablets by mouth as needed for neck pain if Tylenol does not relieve." 5. In an interview, E1 reported R1 had been provided Methocarbamol as needed for neck pain, not as a secondary step when Tylenol was noted to be ineffective. 6. A review of R2's medical record revealed service plan was not available, however, based on R2's date of admission, a service plan was not yet required. 7. In an interview, E1 reported R2 has severe dementia and is directed care and requires medication administration. 8. A review of R2's medical record revealed a signed list of medication orders, dated October 9, 2023, which included the following orders: - "Alendronate NA, PO 70MG, QD on Mon;" - "Claritin, PO 10 MG, Daily;" and - "Melatonin PO 3 MG, Bedtime." 8. The Compliance Officer observed a box containing R2's medications did not include Alendronate or Claritin. 9. A review of R2's medical record revealed a Medication Administration Record (MAR) dated October 2023. The MAR documented the following medication had been administered to R2 in October 2023: - "Alendronate Sodium Oral Tablet 70 MG, Give 70 MG one time a day every MONDAY for Osteoporosis," had not been administered on October 16, 2023. The MAR had not been marked to indicate the reason the medication had not been administered; - "Claritin" was not listed on the MAR; and - "Melatonin Tablet 3 MG, Give 0.5 tablet by mouth two times a day," had been marked as administered at, "PM (4 pm to 7pm)" on each day in October, 2023. However, the dosage and frequency did not match the order, and the morning dosage had not b

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a hospice document dated April 21, 2023. This document indicated R1's effective date for hospice services was April 21, 2023. 2. A review of R1's medical record revealed a service plan, updated March 30, 2023, for personal care services. No subsequent service plan updates were available for review. However, the service plan did not include hospice services. 3. In an interview, E1 acknowledged R1's service plan had not been updated within 14 calendar days after R1 began receiving hospice services.

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 two of two residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a service plan, updated March 30, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated April 21, 2023. The list included: - "Levothyroxine Sodium Oral Tablet 50 MCG, Give 1 tablet by mouth daily for thyroid replacement." 3. The Compliance Officer observed a box containing R1's medications included a bottle of, "Levothyroxine 0.05MG (50MCG) tab, Take 1 tablet by mouth every day for hypothyroidism." 4. A review of R1's medical record revealed a Medication Administration Record (MAR) dated June, 2023. However, the MAR indicated the following: - For Levothyroxine, the MAR indicated R1 had received, "Levothyroxine 100 mcg," on each day between June 1, 2023 and June 8, 2023. 5. In an interview, E1 reported R1's MAR included an error and R1 had actually received the 50 microgram dosage of Levothyroxine as ordered. 6. A review of R2's medical record revealed a service plan, updated March 10, 2023, for directed care services including medication administration. 7. A review of R2's medical record revealed a signed list of medication orders dated October 25, 2022. The list included: - "Doxepin HCL oral capsule 25 mg, Give one capsule by mouth nightly at bedtime for anxiety/restlessness"; and - "Mirtazapine Oral Tablet 15 mg, Give one tablet by mouth at bedtime for sleep." 8. The Compliance Officer observed a box containing R2's medications included a bottle of, "Doxepin 25 MG," dispensed on June 5, 2023 with 8 of 15 tablets remaining. 9. The Compliance Officer observed a box containing R2's medications included a bottle of, "Mirtazapine 15 MG," dispensed on June 5, 2023 with 8 of 15 tablets remaining. 10. The Compliance Officer observed a weekly medi-set containing R2's medications contained Doxepin and Mirtazapine in each daily section. 11. A review of R2's medical record revealed a Medication Administration Record (MAR) dated June, 2023. However, the MAR did not include documentation of the administration of Doxepin or Mirtazapine to R2. 12. In an interview, E1 acknowledged the medications administered to R1 and R2 had not been accurately documented in each resident's medical record.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. Findings include: 1. A review of facility disaster drills conducted during the previous twelve months revealed the following drills: - March 25, 2023 at 3 pm; - March 26, 2023 at 8 pm; - June 26, 2023 at 3 pm; and - June 26, 2023 at 8 pm. However, disaster drills conducted in June of 2022, September of 2022, and December of 2022 on each shift were not available for review. 2. In an interview, E1 reported the drills dated June 26, 2023 were dated incorrectly and were for June 26, 2022. E1 acknowledged documentation of disaster drills conducted on each shift at least once every three months was not provided for review.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen sink had a lock, however, the key had been left in the lock. Inside the cabinet, the Compliance Officer observed a canister of, "Comet with Bleach." 2. During an environmental inspection of the facility, the Compliance Officer observed an aerosol paint can and a small can of paint on a table near the back door. 3. During an environmental inspection of the facility, the Compliance Officer observed a storage shed in the back yard. The storage shed had a lock, however, the shed had been left unlocked. Inside the shed, the Compliance Officer observed the following: - "Pine-Sol Multi-Surface Cleaner"; -"Cloralen No Splash Bleach"; - "Ortho Home Defense Insect Killer"; and - "Spectracide Weed and Grass Killer." 4. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.