Deer Valley Care Home, LLC

Based on documentation review and interview, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed seven incident reports from February 2024 and March 2024 which indicated R1, R2, R4, R5, and R6 had accidents, emergencies, or injuries that resulted in the facility requesting emergency responders for R1, R2, R4, R5, and R6. The review revealed standardized forms for each resident which included some of the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). However, the forms did not include a space to write the reason or reasons the emergency responder was requested on behalf of a resident; the name, address and telephone number of the residents' current pharmacies; or the point-of-contact information for the assisted living home, including the email address. 2. In an interview, E2 acknowledged the forms did not include the aforementioned information. E2 reported the copies of the residents' health insurance portability and accountability act release forms authorizing receiving hospitals to communicate with the assisted living home to plan for the residents' discharge were not provided to emergency responders in the aforementioned cases.

Based on documentation review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). Findings include: 1. A review of facility documentation revealed standardized forms for each resident which included some of the information prescribed in A.R.S. \'a7 36-420.04(A)(1) through (9). However, the forms did not include a space to write the reason or reasons the emergency responder was requested on behalf of a resident; the name, address and telephone number of the residents' current pharmacies; or the point-of-contact information for the assisted living home, including the email address. 2. In an interview, E2 acknowledged the forms did not include the aforementioned information. E2 reported E2 had another form that could be used. 3. A review of facility documentation revealed a second standardized form. However, the form did not include the facility email address.

Based on documentation review and interview, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder which included the items listed in Arizona Revised Statutes (A.R.S.) \'a7 36-420.04(A)(1) through (9). Findings include: 1. A review of facility documentation revealed seven incident reports from February 2024 and March 2024 which indicated R1, R2, R4, R5, and R6 had accidents, emergencies, or injuries that resulted in the facility requesting emergency responders for R1, R2, R4, R5, and R6. However, the review revealed no copies of the documents provided to the emergency responders for the aforementioned incidents. 2. In an interview, E2 reported E2 did not have copies of the documents provided to the emergency responders in compliance with this statute.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Resident Medical Records (including electronic records) and Documentation" dated January 1, 2023. The policy and procedure stated, "Residents records are protected from loss, damage or unauthorized use." 2. During the environmental inspection of the facility, the Compliance Officer observed a binder sitting on a table in the front room. The Compliance Officer observed the binder contained documentation of medication administered to residents or for which residents received assistance in the self-administration of medication. 3. In an interview, the Compliance Officer informed E2 the documentation was part of the resident records and could not be left out. E2 reported the instruction having never been brought up in the past. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on December 28, 2023.

Based on documentation review, observation, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of one sampled resident. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Medication Administration, Records and Monitoring" dated January 1, 2023. The policy and procedure stated, "Medication administration is not documented until the resident is seen taking them." 2. During the environmental inspection of the facility conducted on May 7, 2024, at 9:45 AM, the Compliance Officer observed a binder sitting on a table in the front room. The Compliance Officer observed the binder contained medication administration records (MARs). 3. A review of R3's medical record (as observed in the aforementioned binder) revealed a MAR dated May 2024. The MAR revealed R3 received four medications at 12:00 PM and one medication at 5:00 PM on May 7, 2024. 4. In an interview, E2 confirmed a caregiver pre-signed the five medications for future times. E2 stated, "It was a mistake" and "[the caregiver] probably just didn't see the times." E2 reported the five medications were not administered yet. 5. The Compliance Officer observed R3's medication organizer with the five aforementioned medications still inside. This is a repeat/uncorrected deficiency from the complaint and compliance inspection conducted on December 28, 2023.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay." 2 A review of facility documentation revealed three incident reports from February 2024 which indicated R2, R4, and R6 had accidents, emergencies, or injuries that resulted in R2, R4, and R6 needing medical services. However, none of the three incident reports indicated R2's, R4's, and R6's primary care providers were notified of the accidents, emergencies, or injuries. 3. In an interview, E2 acknowledged R2's, R4's, and R6's primary care providers were not notified of the accidents, emergencies, or injuries. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on December 28, 2023.

Based on documentation 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 an assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury. Findings include: 1. A review of facility documentation revealed seven incident reports from February 2024 and March 2024 which indicated R1, R2, R4, R5, and R6 had accidents, emergencies, or injuries that resulted in R1, R2, R4, R5, and R6 needing medical services. However, the reports did not include any actions taken to prevent the accidents, emergencies, or injuries from occurring in the future, despite the reports having a place for such actions to be documented. 2. In an interview, E2 acknowledged the incident reports did not include any actions taken to prevent the accidents, emergencies, or injuries from occurring in the future.

Based on documentation review, record review, and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse or neglect had occurred on the premises, the manager complied with all the requirements in R9-10-803(J), which posed a health and safety risk. Findings include: 1. A.R.S. \'a7 46-454. stated, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures." 2. Review of R2's record revealed a document titled "Report of Unusual Occurrence" dated December 6, 2023. This document stated "I went to change (R2) and (R2) could not stand up as usual to be changed. Call hospice and POA [Power of Attorney]. POA came Hospice came prescribed Morphine and Lorazepam. The POA decided (the POA) wants to call 911...The hospital confirmed the emergency personnel test that (R2) was overdosed on Fentanyl. CG [caregiver] and facility owner explained to the hospital SW [social worker] there is impossible for (R2) to have that where no medications is admin to our residents without dr. order. (R2) has no prescription for such drug. No other resident in the facility has one." 3. Review of R2's medical record revealed no documentation of reporting this incident to Adult Protective Services (APS) or the police. Additionally, documentation was not available that showed an investigation of the suspected abuse or neglect. 4. In an interview, E1 reported E1 did not know how R2 could have had Fentanyl in R2's system. E1 reported R2 did not return to the facility. 5. In an interview, E2 reported E2 did not call APS or the police after this incident or document an investigation.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of six residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed no documentation of a November 2023 medication administration record (MAR) or a December 2023 MAR. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged R2 received medication administration and the November 2023 MAR and December 2023 MAR were not available for review.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1)-(2), for one of six personnel members sampled. The deficient practice posed a risk if the personnel member was unfit to work in a residential care institution. Findings include: 1. A.R.S. \'a7 36-411(C)(1)-(2) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency [and] 2. Verify the current status of a person's fingerprint clearance card." 2. A review of facility documentation revealed a policy and procedure titled "Staffing and Recordkeeping" dated January 16, 2023. The policy and procedure stated, "The facility manager shall ensure that a personnel record for each employee and volunteer includes documentation of...compliance with the fingerprinting requirements in A.R.S. \'a7 36-411." 3. A review of E7's personnel record revealed a photocopy of E7's fingerprint clearance card. However, the review revealed no documentation demonstrating compliance with A.R.S. \'a7 36-411(C)(1)-(2). 4. A review of the Department of Public Safety website revealed E7's fingerprint clearance card was valid. 5. In an interview, E3 reported not being told E7 started working until after the fact. E3 reported knowing all paperwork should have been done before E7 started working.

Based on documentation review, interview, and record review, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered assistance in the self-administration of medication. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Medications Including Opioids and Narcotics: Part VIII - Providing of Medications Offsite," dated January 1, 2023. The policy and procedure stated: "For residents going out of the facility for less than 24 hours and have medication to be administered: Narcotics will not be given to the resident for outings if supervision is not available." The review further revealed a sign out-sign in sheet for residents. The document revealed R2 left the facility for a few hours in the afternoon on December 18, 2023. 2. In an interview, E4 reported R2 left the facility to visit a family member, and E3 reported R2 left the facility to go to a doctor's appointment. 3. A review of R2's medical record revealed an incident report dated December 18, 2023. The report stated: "[R2] was given lunch meds to take. [R2] came back about 4:30 PM. [R2] did not take [R2's] pills or eat. CG got [R2] in bed and went to the kitchen to get [R2] something to eat and meds. When returned to the room, [R2] was passed out...911 was called. [R2] was taken to the hospital." The report revealed R2 returned to the facility at approximately 9:00 PM the same day. The review further revealed a narcotic administration record dated December 17-19, 2023. The document revealed E4 signed off on R2 having received R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023, even though R2 was not at the facility during those times. 4. In an interview, E4 confirmed R2 did not receive R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023. E4 reported E4 placed R2's "Oxycodone" in a tin and gave the tin to R2 when R2 left earlier in the day. E4 reported the "Oxycodone" was still in the tin when R2 returned several hours later. E4 reported E4 left the "Oxycodone" in the tin until E4 administered it to R2 when R2 returned from the hospital around 9:30 PM. E4 stated, "I signed four o'clock because that's the four o'clock pill." E4 acknowledged E4 did not implement the facility's procedures regarding assistance in the self-administration of medication.

Based on documentation review, interview, record review, and observation, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as residents were left alone with an individual who was not a certified caregiver. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(46) states "Supervision" means "direct overseeing and inspection of the act of accomplishing a function or activity." 2. A review of facility documentation revealed a policy and procedure titled "Employees and Volunteer Qualifications" dated January 1, 2023. The policy and procedure stated: "An assistant caregiver: Interacts with residents under the supervision of a manager or caregiver." The review revealed a policy and procedure titled "Staffing and Recordkeeping" dated January 16, 2023. The policy and procedure stated: "At least the manager or a caregiver is present at the facility when a resident is present." 3. In an interview, E3 and E5 reported E5 was an assistant caregiver. 4. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. 5. During an environmental inspection of the facility, the Compliance Officer observed E5 in the process of transferring R2 to R2's bed. The Compliance Officer observed no manager or caregiver were in the bedroom with E5 and R2 or within sight of E5 and R2. 6. In an interview, E5 reported E5 was the only personnel member at the facility with the residents for several hours in the evening/night on December 23-25, 2023. 7. In a telephonic interview, E1 reported leaving E5 at the facility alone with the residents. E3 stated to E1, "You're supposed to be here" to which E1 responded, "It's true." E3 stated, "You left [E5] assistant caregiver by [E5's] self, right?" and E1 responded, "Right."

Based on 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, and according to policies and procedures, for two of six personnel members sampled. The deficient practice posed a risk if the personnel members did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Employees and Volunteer Qualifications" dated January 1, 2023. The policy and procedure stated: "The hiring manager or individual will ensure, check and document that each caregiver, or assistant caregiver providing physical health services [has] the required skills and knowledge before providing any services to the residents." 2. In an interview, E3 reported E6 was hired as an assistant caregiver and E7 was hired as a caregiver. 3. A review of the personnel records of E6 and E7 revealed E6 was hired as an assistant caregiver and E7 was hired as a caregiver. The review revealed E6's skills and knowledge were verified and documented on December 19, 2023. The review revealed no documentation to indicate E7's skills and knowledge were verified. 4. A review of resident medical records revealed E6 provided physical health services on December 2, 4, 6, 11, 15, and 17, 2023, before E6's skills and knowledge were verified, and E7 provided physical health services on December 2-5, 2023. 5. In an interview, E3 reported not being told E7 started working until after the fact. E3 reported knowing all paperwork should have been done before E7 started working, but E7 refused to fill out all required hire paperwork.

Based on interview, record review, and documentation review, the manager failed to ensure an assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services and ancillary services in the assisted living facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. In an interview, E5 reported E5 was the only personnel member at the facility with the residents for several hours in the evening/night on December 23-25, 2023. E3 and E5 reported E5 was an assistant caregiver. 2. A review of E5's personnel record revealed E5 was an assistant caregiver. 3. In a telephonic interview, E1 reported leaving E5 at the facility alone with the residents. E3 stated to E1, "You're supposed to be here" to which E1 responded, "It's true." E3 stated, "You left [E5] assistant caregiver by [E5's]self, right?" and E1 responded, "Right." 4. A review of facility documentation revealed a policy and procedure titled "Employees and Volunteer Qualifications" dated January 1, 2023. The policy and procedure stated: "The hiring manager or individual will ensure, check and document that each caregiver, or assistant caregiver providing physical health services [has] the required skills and knowledge before providing any services to the residents." 5. In an interview, E3 reported E6 was hired as an assistant caregiver and E7 was hired as a caregiver. 6. A review of the personnel records of E6 and E7 revealed E6 was hired as an assistant caregiver and E7 was hired as a caregiver. The review revealed E6's skills and knowledge were verified and documented on December 19, 2023. The review revealed no documentation to indicate E7's skills and knowledge were verified. The review further revealed no documentation of E7's completed orientation or compliance with A.R.S. \'a7 36-411(C)(1)-(2). 7. A review of resident medical records revealed E6 provided physical health services on December 2, 4, 6, 11, 15, and 17, 2023, before E6's skills and knowledge were verified, and E7 provided physical health services on December 2-5, 2023. 8. In an interview, E3 reported not being told E7 started working until after the fact. E7 reported knowing all paperwork should have been done before E7 started working, but E7 refused to fill out all required hire paperwork.

Based on documentation review, interview, and record 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. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing and Recordkeeping" dated January 16, 2023. The policy and procedure stated: "A work schedule is developed with all volunteers and staff members who provide assisted living services to residents and is maintained at the facility for at least 12 months from the date of the work schedule. The work schedule must contain facility name, dates, and a key of abbreviation (names of working staff/volunteers, hours scheduled, hours worked, etc.)." 2. In an interview, E5 reported E5 was the only personnel member at the facility with the residents for several hours in the evening/night on December 23-25, 2023, even though others were scheduled to work. E5 reported E8 (the caregiver scheduled for the overnight shift on December 23, 2023), did not stay the entire night. E4 reported E4 left around 12:00 PM on December 25, 2023, even though E4 was scheduled for the entire day. 3. A review of resident medical records revealed the following: -E5 provided physical health services on December 8, 15, and 22, 2023; -E6 provided physical health services on December 4 and 11, 2023; and -E7 provided physical health services on December 2-5, 2023. 4. A review of facility documentation revealed a personnel schedule dated December 2023. The schedule revealed the following: -E1 was scheduled as "On call" all day on December 23-25, 2023; -E4 was scheduled for 24 hours on December 25, 2023; -E5 was not scheduled on December 8, 15, and 22, 2023; -E6 was not scheduled on December 4 and 11, 2023; -E7 was not on the schedule; and -E8 was scheduled for 24 hours on December 23, 2023. 5. In a telephonic interview, E1 reported leaving E5 at the facility alone with the residents. E1 reported being at the facility on December 23, 2023, from 7:00 AM to 10:00 PM; on December 24, 2023, from 6:45 AM to 11:00 PM; and on December 25, 2023, from 7:00 AM to 11:45 PM. E3 stated, "You're supposed to be here" to which E1 responded, "It's true." E3 stated, "You left [E5] assistant caregiver by [E5's]self, right?" and E1 responded, "Right." 6. In an interview, E3 confirmed the personnel schedule was not accurate.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver before providing assisted living services to a resident, for one of two caregivers sampled. The deficient practice posed a risk if the caregiver was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure titled, "Orientation and In-Service Training" dated January 1, 2023. The policy and procedure stated, "It is required that each employee and volunteer receives orientation before providing assisted living services to a resident." 2. A review of resident medical records revealed E7 provided physical health services on December 2-5, 2023. 3. In an interview, E3 reported E7 was hired as a caregiver. 4. A review of E7's personnel record revealed E7 was hired as a caregiver and worked at the facility for less than a week. The review revealed a blank "EMPLOYEE ORIENTATION CHECKLIST" in E7's personnel record. The review revealed no documentation to indicate E7 received orientation specific to the duties to be performed by E7 before providing assisted living services to a resident. 5. In an interview, E3 reported not being told E7 started working until after the fact. E3 reported knowing all paperwork should have been done before E7 started working, but reported E7 refused to fill out all required hire paperwork.

Based on documentation review, record review, and interview, 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 six personnel members sampled. The deficient practice posed a risk if the caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "First Aid and CPR Training" dated January 1, 2023. The policy and procedure stated, "Each employee or volunteer will present proof of training in First Aid and CPR in the form of an unexpired card(s)." 2. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed a photocopy of E4's first aid and CPR training certification from "Heart Savers" dated as expired in October 2022 as well as a current certificate from "National Safety Council" dated effective January 20, 2023. 3. A review of facility documentation revealed E4 worked alone on January 2, 3, 6, 9, 10, 13, 16, 17, and 20, 2023, without current first aid and CPR training. 4. In an interview, E3 and E4 acknowledged E4 did not provide current documentation of first aid training and CPR training certification specific to adults before providing assisted living services to a resident.

Based on record review, observation, and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for nine of nine total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A medical record review revealed documentation of assisted living services provided to all nine residents dated December 2023. The documents revealed the nine residents received services on December 1-22 and 26-28, 2023. However, the documents revealed no documentation demonstrating any of the nine residents received services on December 23-25, 2023. 2. During an environmental inspection of the facility, the Compliance Officer observed E4 filling in the empty spaces for December 23-25, 2023, on the documentation of assisted living services provided to all nine residents. 3. In an interview, E4 acknowledged the services provided on December 23-25, 2023, had not been properly documented for all nine residents. E3 asked if E4 was back-signing for those dates, to which E4 stated, "Yes." 4. In a separate interview, E3 reported E3 had spoken with and corrected E4 in the past about properly documenting services provided to residents.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, and the Department was provided false and misleading information. Findings include: 1. A review of facility policies and procedures revealed a policy and procedure titled "Medications Including Opioids and Narcotics: Par III - Medication Administration, Records and Monitoring" dated January 1, 2023. The policy stated, "Assistance with the self-administration of medication or medication administration provided to a resident is in compliance with an order, and is documented in the resident's medical record." 2. A review of R1's medical record revealed a medication order for "levoFLOXacin 500 mg (milligrams) Tan 1 tablet orally for 7 days" dated December 22, 2023. The review further revealed a medication administration record (MAR) for R1 dated December 2023. There was a place to document R1's "levoFLOXacin," however, it was left blank. 3. In an interview, E4 reported R1 started taking "levoFLOXacin" on December 23, 2023, and only refused it once. 4. The Compliance Officer observed R1's "levoFLOXacin" and R1's medication organizer. In the medication organizer, the Compliance Officer observed three tablets of R1's "levoFLOXacin." Based on the order and R1 having refused the medication only once, R1 should have had two tablets remaining and not three. 5. In an interview, E3 and E4 agreed R1's "levoFLOXacin" count was incorrect. 6. A review of R2's medical record revealed the following medication orders: -"Baclofen 20 mg Tab 1 tablet orally 2 times per day" dated November 2, 2023; -"clonazePAM 2 mg Tab 1 tablet orally every 12 hours" dated November 2, 2023; -"Depakote ER Tablet...250 MG...Give 2 tablet by mouth at bedtime" dated October 11, 2023; -"Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day" dated October 11, 2023; -"Nicotine Patch 24 Hour 21 MG/24HR Apply 1 patch transdermally one time a day...and remove per schedule" dated October 11, 2023; -"Oxycodone 30 mg tablets every 4 hours" dated November 2, 2023; -"Polyethylene Glycol 3350 Powder...Give 17 gram by mouth one time a day" dated October 11, 2023; -"Sennosides Tablet 8.6 MG Give 2 tablet by mouth at bedtime" dated October 11, 2023; and -"Sertraline HCI Tablet 25 MG Give 1 tablet by mouth one time a day" dated October 11, 2023. 7. Further review of R2's medical record revealed a series of medication administration records and narcotic administration records dated December 2023. The records revealed R1 did not receive R1's "Baclofen" 23 times, "clonazePAM" 13 times, "Depakote" 10 times, "Docusate Sodium" 32 times, "Nicotine Patch" 16 times, "Oxycodone" 16 times, "Polyethylene Glycol" 17 times, "Sennosides" 16 times, and "Sertralin

Based on documentation review, observation, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for nine of nine total residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information. Findings include: 1. A review of facility policies and procedures revealed a policy and procedure titled "Medications Including Opioids and Narcotics: Par III - Medication Administration, Records and Monitoring" dated January 1, 2023. The policy stated: "The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken...Medication administration records will be filled by the authorized personnel that are doing medication administration and/or assisting in self-medication administration only after observing the resident taking the medication. The time and date will be recorded as well as the initials of the person that administered the medication." 2. During an environmental inspection of the facility, the Compliance Officer observed E4 writing in the medication administration record binder. 3. A review of resident medical records revealed medication administration records (MARs) for all nine residents, dated December 2023. The documents revealed R5's medications were signed for on all days, R1's medications were signed for on most days apart from a few medications on December 23-25, 2023, and the medications for the rest of the nine residents were signed for apart from December 23-25, 2023. The initials for medications signed for on December 23-25, 2023, were those of E1, but appeared to match the handwriting of E4. 4. In an interview, E4 reported E4 was signing off for medication given by E1 on December 23-25, 2023, for all nine residents. E3 asked if E4 was back-signing the medication administration records for E1, to which E4 stated, "Yes." 5. A review of R2's medical record revealed an incident report dated December 18, 2023. The report stated: "[R2] was given lunch meds to take. [R2] came back about 4:30 PM. [R2] did not take [R2's] pills or eat. CG got [R2] in bed and went to the kitchen to get [R2] something to eat and meds. When returned to the room, [R2] was passed out...911 was called. [R2] was taken to the hospital." The report revealed R2 returned to the facility around 9:00 PM the same day. The review further revealed a narcotic administration record dated December 17-19, 2023. The document revealed E4 signed off on R2 having received R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023, even though R2 was not at the facility during those times. 6. In an interview, E4 confirmed R2 did not receive R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023. E4

Based on documentation review, interview, record review, and observation,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 health and safety of a resident. Findings include: 1. A documentation review revealed a sign out-sign in sheet for residents. The document revealed R2 left the facility for a few hours in the afternoon on December 18, 2023. 2. In an interview, E4 reported R2 left the facility to visit a family member, and E3 reported R2 left the facility to go to a doctor's appointment. 3. A review of R2's medical record revealed an incident report dated December 18, 2023. The report stated: "[R2] went out of the facility today. Left about 12 at noon. [R2] was given lunch meds to take. [R2] came back about 4:30 PM. [R2] did not take [R2's] pills or eat. CG got [R2] in bed and went to the kitchen to get [R2] something to eat and meds. When returned to the room, [R2] was passed out. Breathing but unresponsive. 911 was called. [R2] was taken to the hospital. Where the paramedics told us it is an overdose. We checked [R2's] bag and found a little ziplock bag with some powder. Called police and [the police] took it to dispose of it and no report has been [filed]." The review further revealed a narcotic administration record dated December 17-19, 2023. The document revealed E4 signed off on R2 having received R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023, even though R2 was not at the facility during those times. 4. The Compliance Officer observed a photo of the "little ziplock bag with some powder" E4 discovered in R2's bag. The bag appeared to contain an unknown substance which appeared to be small, clear, crystalline rocks. 5. In an interview, E4 confirmed R2 did not receive R2's "Oxycodone" at 4:00 PM and 8:00 PM on December 18, 2023. E4 reported E4 placed R2's "Oxycodone" in a tin and gave the tin to R2 when R2 left earlier in the day. E4 reported the "Oxycodone" was still in the tin when R2 returned several hours later. E4 reported E4 left the "Oxycodone" in the tin until E4 administered it to R2 when R2 returned from the hospital around 9:30 PM. 6. A review of R2's medical record revealed a medication order for "Narcan 4 mg/0.1 mL nasal spray Single spray in one nostril at onset of opioid overdose symptoms...Repeat Q 2-3 minutes until symptoms resolve of EMS arrives." 7. In an interview, the Compliance Officer asked why R2's "Narcan" was not administered when R2 had overdose symptoms on December 18, 2023. E3 and E4 reported the facility did not have R2's "Narcan" until after the incident. 8. The Compliance Officer observed R2's "Narcan." However, the "Narcan" was dated as dispensed on December 18, 2023.