Faubush Family Homes

Based on record review and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E3’s personnel record revealed completed training regarding fall prevention completed on June 1, 2025. However, completed training regarding fall recovery was not available for review. 2. In an interview, E1 acknowledged the facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial and continued competency training. This is a repeat deficiency from the compliance and complaint investigation conducted on July 17, 2023.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness 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 the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. While on-site for the compliance and complaint inspection, the Compliance Officer observed E3 at the facility, providing services to residents. 4. A review of E3's personnel record revealed a negative TB blood test that was less than 12 months old; however, no documentation of E3's risks of prior exposure to infectious tuberculosis and if E3 had signs or symptoms of tuberculosis was available. Based on E3’s date of hire, this documentation was required. 5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113. This is a repeat deficiency from the compliance and complaint investigation conducted on July 17, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that, when initially developed, was signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R2's medical record revealed a completed service plan dated May 20, 2025. However, the service plan was not signed and dated by the approving nurse, resident or resident's representative, and the manager. 2. In an interview, E1 acknowledged R2's service plan was not signed and dated by the resident or the resident's representative, the manager, and the nurse who reviewed the service plan. 3. This is a repeat deficiency from the compliance and complaint inspection conducted on July 17, 2023.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan that indicated R1 would receive the following services: Maximum assistance with nutrition; Maximum assistance with hygiene; Two showers provided per week; Maximum assistance with hair washing and nail care, weekly; Maximum assistance with oral hygiene, twice a day (bid); Maximum assistance with dressing; Maximum assistance with walking and transferring; Maximum assistance with toileting; and Maximum assistance with skin care. 2. A review of R1's activities of daily living (ADL) documentation revealed missing documentation of all aforementioned services on the following dates: June 1-3, 2025, on the 6:00 AM - 2:00 PM shift; June 10, 2025, on the 2:00 PM - 10:00 PM shift; June 16- 17, 2025, on the 2:00 PM - 10:00 PM shift; June 16, 2025, on the 10:00 PM - 6:00 AM shift; June 19, 2025, on the 6:00 AM - 2:00 PM shift; June 23, 2025, on the 6:00 AM - 2:00 PM and 10:00 PM - 6:00 AM shifts; June 25 - 26, 2025, on the 2:00 PM - 10:00 PM shift; June 26, 2025 - present, on the 6:00 AM - 2:00 PM shift; and June 29, 2025 - present, on the 10:00 PM - 6:00 AM shift. 3. A review of R2's medical record revealed a service plan that indicated R2 would receive the following services: Maximum assistance with nutrition; Maximum assistance with hygiene; Two showers provided per week; Maximum assistance with hair washing and nail care, weekly; Minimum assistance with oral hygiene, bid; Moderate assistance with dressing; Minimum assistance with walking and transferring; Maximum assistance with toileting; and Minimum assistance with skin care. 4. A review of R2's ADL documentation revealed missing documentation of all aforementioned services on the following dates: June 1-3, 2025, on the 6:00 AM - 2:00 PM shift; June 10, 2025, on the 2:00 PM - 10:00 PM shift; June 16- 17, 2025, on the 2:00 PM - 10:00 PM shift; June 16, 2025, on the 10:00 PM - 6:00 AM shift; June 19, 2025, on the 6:00 AM - 2:00 PM shift; June 23, 2025, on the 6:00 AM - 2:00 PM and 10:00 PM - 6:00 AM shifts; June 25 - 26, 2025, on the 2:00 PM - 10:00 PM shift; June 26, 2025 - present, on the 6:00 AM - 2:00 PM shift; and June 29, 2025 - present, on the 10:00 PM - 6:00 AM shift. 5. In an interview, E1 reported R1 and R2 received all services per R1’s and R2's service plan. E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical record.

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 an environmental tour of the facility, the Compliance Officer observed the back door from the facility equipped with an alarm to alert employees of egress; however, the alarms were not functioning at the time of inspection. 3. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review, observation, and interview, the manager failed to ensure that 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 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 R2's medical record revealed medication orders for the following medications: Metoprolol Succinate 50 milligrams (mg), 1 tablet by mouth (po) once a day (qd); Carbidopa-Levodopa 25-100 mg, 1 tablet po four times a day; Levothyroxine 125 micrograms (mcg), 1 tablet po qd; Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po twice a day (bid); and Flecainide Acetate 50 mg, 1 tablet po bid. 2. A review of R2's Medication Administration Record (MAR) for June 2025 revealed R2 was administered the following medications: Metoprolol Succinate 100 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; Carbidopa-Levodopa 25-100 mg, 1 tablet at 8:00 AM, 8:00 AM [sic], and 12:00 PM, and indicated 1 tablet was administered June 1, 2025 - present; Levothyroxine 150 mcg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present; and Flecainide Acetate 50 mg, 1 tablet po qd, and indicated 1 tablet was administered June 1, 2025 - present. 3. While on-site for the compliance and complaint inspection, the Compliance Officer observed the following medications available for administration to R2: Metoprolol Succinate 100 mg; Carbidopa-Levodopa 25-100 mg; Levothyroxine 150 mcg; Hydrocodone-Acetaminophen 10-325 mg; and Flecainide Acetate 50 mg. 4. The Compliance Officer also observed a medication organizer prefilled for R2, which indicated R2 received the following medications: Metoprolol Succinate 100 mg, 1/2 tablet po qd; Carbidopa-Levodopa 25-100 mg, 1 tablet po at 8:00 AM, 12:00 PM, and 4:00 PM; Levothyroxine 150 mcg, 1 tablet po qd; Hydrocodone-Acetaminophen 10-325 mg, 1 tablet po qd; and Flecainide Acetate 50 mg, 1 tablet po qd. 5. In an interview, E1 reported documentation on R2's MAR was not accurate, and would be adjusted for July 2025. E1 acknowledged medication was not administered to R2 in compliance with the aforementioned medication orders and documented in R2's medical record.

Based on observation, record review, and interview, the manager failed to ensure that medication stored by the 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 were unable to self-administer medications. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officer observed a closet used for medication storage equipped with a locking mechanism. However, the medication closet was not locked at the time of inspection. 2. In an interview, E1 acknowledged medication stored by the facility 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 that oxygen containers were secured in an upright position. The deficient practice posted a potential explosion or leak of compressed gas. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed an oxygen container stored upright in the entryway of the home. However, the container was not secured in any way. 2. In an interview, E1 reported that the containers should have been stored in a designated container for oxygen storage. E1 acknowledged that the oxygen container stored by the facility was not secured in an upright position.

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of the facility's policies and procedures revealed a fall prevention and fall recovery training program to include initial and continued competency training was not available for review. 2. A review of E2's E3's E4's, E5's E6's, E7's, and E9's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. A review of documentation provided by E1 for E8 revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 4. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the on-site compliance inspection conducted on March 30, 2022.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(A)(C), for six of eight current employees sampled. The deficient practice posed a risk if E3, E4, E6, and E7 were a danger to a vulnerable population. Findings include: 1. A review of E3's (hired in 2022) personnel record revealed documentation of a fingerprint clearance card was not available for review. 2. A review of the Arizona Department of Public Safety fingerprint verification website revealed a fingerprint clearance card had not been issued to E3. 3. A review of E4's (hired in 2023) personnel record revealed documentation of a fingerprint clearance card was not available for review. 4. A review of the Arizona Department of Public Safety fingerprint verification website revealed a fingerprint clearance card had not been issued to E4. 6. A review of E6's (hired in 2022) personnel record revealed documentation of a fingerprint clearance card was not available for review. 7. A review of the Arizona Department of Public Safety fingerprint verification website revealed E6's fingerprint clearance card was denied in October 2022. 8. In an interview, E1 reported E6 applied for a good cause exemption and the documentation should've been in E6's personnel record. 9. A review of E7's (hired in 2022) personnel record revealed documentation of a fingerprint clearance card was not available for review. 10. A review of the Arizona Department of Public Safety fingerprint verification website revealed a fingerprint clearance card had not been issued to E7. 11. A review of documentation provided by E1 for E8 revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 12. A review of E9's (hired in 2021) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 15. In an interview, E1 acknowledged E3, E4, E6, and E7 did not have valid fingerprint clearance cards.

Based on documentation review, record review, observation, and interview, 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 five caregivers and three of three assistant caregivers sampled. The deficient practice posed a risk if E3, E4, E5, E6, and E8 was unable to meet a residents needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "APPLICANT AND EMPLOYEE REQUIREMENT" (dated October 1, 2021). The policy stated "Upon being hired by the facility the applicant must...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for..." 2. A review of E3's (hired in 2022) personnel record revealed E3 was hired as an assistant caregiver. A review of E3's personnel record revealed documentation of the verification of E3's skills and knowledge. However the document was not dated to indicate E3's skills and knowledge were verified and documented before E3 provided physical health services. 3. A review of E4's (hired in 2023) personnel record revealed E4 was hired as an assistant caregiver. A review of E4's personnel record revealed documentation of the verification of E4's skills and knowledge. However the document was not dated to indicate E4's skills and knowledge were verified and documented before E4 provided physical health services. 4. A review of E5's (hired in 2022) personnel record revealed E5 was hired as a caregiver. A review of E5's personnel record revealed documentation of the verification of E5's skills and knowledge. However the document was not signed to indicate E5's skills and knowledge were verified and documented before E5 provided physical health services. 5. A review of E6's (hired in 2022) personnel record revealed E6 was hired as a caregiver. However, documentation of the verification of E6's skills and knowledge was not available for review. 6. The Compliance Officer observed E8 on the premises and working upon arrival at approximately 10:45 AM. 7. An review of documentation provided by E1, for E8 revealed documentation of the verification of E8's skills and knowledge was not available for review. 8. In an interview, E1 acknowledged E3's and E4's skills and knowledge were not dated to indicate verification, E5's skills and knowledge was not signed to indicate verification, and E6's and E8's skills and knowledge were not verified and documented prior to E6 and E8 providing physical health services and according to the facility's policies and procedures.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if shifts and tasks were covered. Findings include: 1. A review of electronic documentation provided by E1 revealed documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for July 9, 2023 through July 22, 2023. However, documentation 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 was not available for review. 2. In an interview, E1 acknowledged documentation maintained for at least 12 months of caregivers and assistant caregivers working each day, including the hours worked by each, was not available for review.

Based on record review and interview, the manager failed to ensure an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three assistant caregivers sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of documentation provided from E1, for E8 revealed documentation of freedom from infectious TB was not available for review. 2. In an interview, E1 acknowledged E8's personnel record did not include evidence of freedom from infectious TB.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of three assistant caregivers sampled and two of five caregivers sampled. The deficient practice posed a risk to the health and safety of residents if caregivers were not orientated to the specific duties to be performed. Findings include: R9-10-101.155."Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of the facility's policies and procedures revealed a policy titled "EMPLOYEE ORIENTATION AND ONGOING TRAINING POLICY AND PROCEDURE" (dated October 1, 2021). The policy stated "...The manager/owner of the facility shall ensure that a new employee completes orientation before the starting date of employment..." 2. A review of E4's (hired in March 2023) personnel record revealed a document titled "Orientation Checklist" (dated in Februaury 2023). However, the following areas to indicate the orientation was completed were left blank: -"Witnessed By...Date"; and -"Manager's Signature...Date." 3. A review of E6's (hired in September 2022) personnel record revealed documentation E6 received orientation specific to the duties to be performed was not available for review. 4. A review of E7's (hired in September 2022) personnel record revealed documentation E7 received orientation specific to the duties to be performed. However, the documentation was dated in October 2022, and not before E7 provided assisted living services. 5. In an interview, E1 acknowledged E4, E6 and E7 did not receive orientation specific to the duties to be performed before providing assisted living services to the residents.

Based on observation, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-806(C)(1)(c)(i)(iii)(vi)(ix), for one of three assistant caregiver sampled. The deficient practice posed a risk as the Department was unable to verify the required information. Findings include: R9-10-101.165 "Personnel member" means, except as defined in specific Articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient. 1. The Compliance Officer observed E8 on the premises and working when the Compliance Officer arrived at approximately 10:45 AM. 2. A review of documentation provided by E1 revealed the following documentation for E8: -Name -Phone number, and -Education and experience. However, documentation of the requirements in R9-10-806(C)(1)(c)(i)(iii)(vi)(ix) was not available for review. 3. In an interview, E1 acknowledged the documentation provided did not include the required documentation.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB), before or within calendar days after the resident's date of occupancy, for three of five residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed evidence of freedom from infectious TB. However, it was completed 108 calendar days after R1's date of admission. 2. A review of R2's (admitted in 2022) medical record revealed evidence of freedom from infectious TB. However, it was completed 265 calendar days after R1's date of admission. 3. A review of R4's (admitted in 2023) medical record revealed evidence of freedom from infectious TB. However, it was completed 44 calendar days after R1's date of admission. 4. In an interview, E1 acknowledged R1's, R2's, and R4's evidence of freedom from infectious TB was not completed before or within calendar days after the resident's date of occupancy.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for three of five residents sampled. The deficient practice posed a risk if the residents required a higher level of care. Findings include: 1. A review of R1's (accepted in 2022) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. A review of R2's (accepted in 2022) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 3. A review of R3's (accepted in 2023) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 4. In an interview, E1 acknowledged documentation to include whether R1, R2, and R3 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

Based on documentation review, record review and interview, the manager failed to ensure a documented residency agreement with the assisted living facility included the facility's policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan, for four of five residents sampled. Findings include: 1. A review of the facility's polices and procedures revealed a policy titled "TERMINATION OF RESIDENCY" (dated October 1, 2021). The policy stated "...The resident or resident representative may terminate the residency after providing 14 day written notice to the facility for documentation of the facility's failure to comply with the resident's service plan or the residency agreement..." 2. A review of R1's (accepted in 2022) medical record revealed a residency agreement. The residency agreement stated "...If you wish to leave the facility, you are required to give 30 days prior notice of the date you wish to terminate this agreement. a. However, if you are leaving because of a health emergency, 30 days advance notice is not required." However, the residency agreement did not include the policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan. 3. A review of R2's (accepted in 2022) medical record revealed a residency agreement. The residency agreement stated "...If you wish to leave the facility, you are required to give 30 days prior notice of the date you wish to terminate this agreement. a. However, if you are leaving because of a health emergency, 30 days advance notice is not required." However, the residency agreement did not include the policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan. 4. A review of R4's (accepted in 2023) medical record revealed a residency agreement. The residency agreement stated "...If you wish to leave the facility, you are required to give 30 days prior notice of the date you wish to terminate this agreement. a. However, if you are leaving because of a health emergency, 30 days advance notice is not required." However, the residency agreement did not include the policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan. 5. A review of R5's (accepted in 2023) medical record revealed a residency agreement. The residency agreement stated "...If you wish to leave the facility, you are required to give 30 days prior notice of the date you wish to terminate this agreement. a. However, if you are leaving because of a health emergency, 30 days advance notice is not required." However, the residency agreement did not include the po

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by a nurse or medical practitioner, for two of five residents sampled who received medication administration. The deficient practice posed a risk if the service plans were not developed to articulate decisions and agreements. Findings include: 1. A review of R4's medical record revealed a service plan, for personal care services (dated in February 2023). The service plan revealed R4 received medication administration. However, R4's service plan was not signed and dated by a nurse or medical practitioner. 2. A review of R5's medical record revealed a service plan, for personal care services (dated in February 2023). The service plan revealed R5 received medication administration. However, R5's service plan was not signed and dated by a nurse or medical practitioner. 3. In an interview, E1 acknowledged R4's and R5's service plans were not signed and dated by a nurse or medical practitioner.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement and any amendments, for one of five residents sampled. Findings include: 1. A review of R3's medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review. 2. In an interview, E1 reported R3's residency agreements was completed and was unble to find the residency agreement. E1 acknowledged R3's medical record did not contain a signed residency agreement during the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented for medication services to include responding to a medication error. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: R9-10-101(136) "Medication error" means: a. The failure to administer an ordered medication; b. The administration of a medication not ordered; or c. The administration of a medication: i. In an incorrect dosage, ii. More than 60 minutes before or after the ordered time of administration unless ordered to do so, or iii. By an incorrect route of administration. 1. A review of the facility's policies and procedures revealed a policy titled "MEDICATION & TREATMENT" (dated October 1, 2021). The policy stated "All medication prescriptions will be checked against the doctors' orders prior to administration; the MARS will also be checked to ensure that it matches both the order and the prescription. If a medication error has occurred the person finding the order will document the error on an incident report form and in the resident's progress notes. The manager of the facility shall be notified immediately upon the discovery of a medication error. The resident's physician and the representative will be notified of the error and the caregiver or manager shall take instructions for care from the resident's physician..." 2. A review of R4's medical record revealed a medication administration record (MAR) for March 2023. A review of the MAR revealed a hand written note on the back side of the MAR. The note stated "Gave [R4] meds that were in [R4's] med set. [R4] was missing some, so have yet to sign off. Took photos though of the meds I gave [R4]. I gave [R4] 3 meds out of six meds, assumed [E1] or [E5] knew which meds [R4] was out of. Already had gave them to [R4] w/o cross referencing them. My bad won't let that happen again." However, an incident report and a progress note documenting the medication error was not available for review. Additionally, documentation of the manager, R4's physician and R4's representative were notified was not available for review. 3. In an interview, E1 acknowledged policies and procedures were not implemented for responding to a medication error.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for three of five residents sampled who received 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 R1's medical record revealed a service plan (dated in March 2023) for personal care services. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed medication orders for the following medications: -Metoprolol 25mg; -Xarelto 20mg; -Levetiracetam 750mg; and -Levofloxacin 500mg. 3. A review of R1's medical record revealed a medication administration record (MAR) for July 2023. However, the following medications were not documented as administered on the following dates and the following times: -Metoprolol 25mg: July 2, 2023 8:00pm; -Xarelto 20mg: July 2, 2023 8:00pm; -Levetiracetam 750mg: July 2, 2023 8:00pm; and -Levofloxacin 500mg: July 2, 2023 8:00pm. 4. A review of R3's medical record revealed a service plan (dated in March 2023) for personal care services. The service plan revealed R3 received medication administration. 5. A review of R3's medical record revealed medication orders for the following medications: -Levetiraceta Sol 12.5ml; -Midorine hcl 5mg; and -Wixela inhub 500-50mcg. 6. A review of R3's medical record revealed a MAR for July 2023. However, the following medications were not documented as administered on the following dates and the following times: -Levetiraceta Sol 12.5ml: July 2, 2023 8:00pm; -Midorine hcl 5mg: July 2, 2023 8:00pm; and -Wixela inhub 500-50mcg: July 2, 2023 8:00pm. 7. A review of R5's medical record revealed a service plan (dated in February 2023) for personal care services. The service plan revealed R5 received medication administration. 8. A review of R5's medical record revealed medication orders for the following medications: -Atorvastain 20mg; -Duloxetine hci 30mg; -Metoprlol 12.5mg; -Famotidine 20mg 9. A review of R5's medical record revealed a MAR for July 2023. However, the following medications were not documented as administered on the following dates and the following times: -Atorvastain 20mg: July 2, 2023 8:00pm. -Duloxetine hci 30mg: July 2, 2023 8:00pm; -Metoprlol 12.5mg: July 2, 2023 8:00pm; and -Famotidine 20mg: July 2, 2023 8:00pm. 10. In an interview, E1 acknowledged medications administered to R1, R3, and R5 were not documented in R1's, R3's and R5's medical records.

Based on observation and interview, the manager failed to ensure a disposable fire extinguisher was replaced when the indicator reached the red zone. Findings include: 1. The Compliance Officer observed a disposable fire extinguisher mounted on the wall in the kitchen area of the facility. The Compliance Officer observed the fire extinguisher's indicator had reached the red zone. 2. In an interview, E1 acknowledged the fire extinguisher was in the red zone.