Agave Care Home of Scottsdale

Based on record review and interview, for one of three manager and caregiver records reviewed, the manager failed to ensure a caregiver provided documentation of first aid training (FA), and cardiopulmonary resuscitation training (CPR) certification specific to adults. The deficient practice posed a risk to residents if a caregiver did not have current training in FA and CPR. Findings include: 1. In record review, E1's personnel record included a CPR/FA card with an expiration date of October 26, 2023. 2. During an interview, E1 acknowledged not having provided documentation of current FA and CPR training.

Based on record review and interview, for one of three resident's medical records reviewed, and receiving medication administration services, the manager failed to ensure a resident's medical record included the time of medication administration. The deficient practice posed a health and safety risk to a resident if the time of medication administration was not documented. Findings include: 1. In record review, R2's medical record (received personal care and medication administration services) included a medication order for Oxycodone HCI 5 mg, one tab po every 6 hours as needed for pain 6-10. R2's medication administration record (MAR) documented R2 received Oxycodone medication once daily, November 1, through 30, 2023. The MAR did not include documentation of the time the medication was administered to R2. 2. During an interview, E2 reported R2 received the Oxycodone medication every 6 hours for pain. R2 acknowledged the resident's MAR did not include the time the medication was administered to R2.

Based on observation, record review, and interview, for one of three residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a medication administered to a resident was not documented as administered. Findings include: 1. In record review, R2's medical record (received personal care services) included medication orders for Alendronate sodium, 70 mg 1 tab po once a day every Friday, Aspirin, one tab po once a day, Cozaar 25 mg, one tab po once a day, for hypertension. Hold for Systolic BP <110, Carvedilol 6.25 mg one tab po bid, Metformin 1000 mg one tab po bid, Gabapentin 300 mg, one tab po QID, Insulin Glargine 100 units, inject 25 unit subcutaneously at bedtime, and Oxycodone HCI 5 mg, one tab po every 6 hours as needed for pain 6-10. 2. In record review, R2's medical record did not include documentation R2's blood pressure was measured on December 2 and 3, 2023. 3. In record review, R2's medication administration record (MAR) dated December, 2023, did not include documentation medications were administered to R2, as ordered, December 1 through 4, 2023. 4. In observation, R2's medications were observed on site. 5. During an interview, E2 reported the medications were administered to R2 as ordered; however, the medication administration was not documented on the MAR at the time of administration, as required. E2 reported R2's blood pressure was measured by E2 daily; however, E2 did not work on December 2 and 3, and was unaware if R2's blood pressure was measured on those days.

Based on observation, record review, documentation review, and interview, for two of three residents reviewed, who received controlled substances, the manager failed to ensure policies and procedures were established, documented, and implemented for storing, inventorying, and dispensing controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for, and the facility did not have the required policies and procedures. Findings include: 1. In observation R1's medications were observed to include the following controlled substances: - Oxycodone APAP 5-325 mg., 60 pills were dispensed on October 13, 2023, and 4 pills remained in the bottle. - Lorazepam, one syringe, not stored in the original packaging - Oxycodone, four syringes, not stored in the original packaging - Tramadol, sixty pills were dispensed on July 28, 2023, and 93 pills remained in the bottle. 2. In record review, R1's medical record did not include an inventory of the controlled substances. 3. In observation, R2's medications were observed to include Oxycodone, 120 pills dispensed on November 13, 2023, and 66 pills remained in the container. 4. In record review, R2's medical record did not include an inventory of the controlled substance. 5. In documentation review, the compliance officer was provided with the facility's policies and procedures, which did not include documentation of a policy for storing, inventorying, and dispensing controlled substances. 6. During an interview with E2 and E3, the compliance officer requested to review the policy for controlled substances, however, a policy for storing, inventorying, and dispensing controlled medication was not made available for review.

Based on observation and interview, the manager failed to ensure that equipment and food contact surfaces were clean. The deficient practice posed a health and safety risk to residents if food was not stored in a clean manner. Findings include: 1. During an environmental inspection, the compliance officer observed the kitchen refrigerator was not maintained in a clean manner. Two storage bins were soiled with food particles, and one bin bottom was covered with unknown liquid. 2. During an interview, E1 and E2 acknowledged the refrigerator surfaces were not maintained in a clean manner.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a health and safety risk to residents if the employees were not trained to implement the disaster plan, and if false and misleading documentation was provided to the Department. Findings include: 1. In documentation review, the facility had documentation disaster drills were conducted on September 1, 2023, June 1, 2023, March 1, 2023, and December 1, 2022, on two shifts each day. 2. During an interview, E1 and E2 reported E1 and E2 worked 24 hour shifts five days a week, and E3 worked two days a week. E1 and E2 reported disaster drills were not conducted with E1 and E2, (as documented) and acknowledged they were required to be conducted at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a health and safety risk to residents and employees, if the employees were unable to implement the evacuation plan, and the Department was provided false and misleading documentation. Findings include: . 1. In documentation review, the facility had documentation disaster drills were conducted on June 1, 2023, and December 1, 2022. 2. During an interview, E1 and E2 reported E1 and E2 worked 24 hour shifts five days a week, and E3 worked two days a week. E1 and E2 reported evacuation drills were not conducted (as documented), and acknowledged they were required to be conducted at least once every six months, to include an evacuation of residents, unless otherwise indicated.

Based on observation, record review, documentation review, and interview, for one of two residents reviewed, and receiving opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual, authorized to administer opioids, documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if the resident's level of pain was not documented, as required. Findings include: 1. In observation, R2 had Oxycodone medication (a schedule II controlled substance), on site and stored by the facility. The medication container indicated 120 pills were dispensed on November 13, 2023, and 60 pills remaining in the bottle. 2. In record review, R2's medical record (received personal care and medication administration services) included a medication order for Oxycodone HCI 5 mg, one tab po every 6 hours as needed for pain 6-10. R2's medication administration record (MAR) included documentation R2 received Oxycodone medication once daily, November 1, through 30, 2023. R2's record did not include documentation of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. 3. During an interview, E2 reported R2 received the Oxycodone medication every 6 hours for pain. R2 acknowledged the resident's need for the opioid and the monitoring of the effect of the opioid was not documented in the resident's medical record.