Gardens of Scottsdale, the

Based on documentation review, interview, and record review, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for three of five sampled staff. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed A.R.S. § 36-420.01(A) went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled “Employee Orientation and In-Service Education.” The P&P stated: “1. Orientation a. All new employees and volunteers’ complete orientation before performing duties independently. b. Orientation includes, at a minimum and as applicable to the role: v. Fall prevention and fall recovery. 2. In-Service Education b. In-service topics include, as applicable to the employees job duties: v. Fall prevention and fall recovery.” 3. In an interview, E1 acknowledged the P&P did not include the timeframe for the continued competency training/in-service training for fall prevention and fall recovery. E1 reported staff were required to be training in fall prevention and fall recovery upon hire and on a yearly basis thereafter. 4. A review of E1’s personnel record revealed E1 was hired as the manager on November 17, 2025, after this statute went into effect. The review revealed documentation of training regarding fall prevention and fall recovery completed on December 9, 2025. However, the review revealed no such training upon hire. 5. In an interview, when the Compliance Officer asked if E1 had documentation of having received training regarding fall prevention and fall recovery upon hire, E1 reported E1 did not. E1 reported E1 received such training at E1’s prior assisted living facility, but not at this assisted living facility until December 9, 2025. 6. A review of E5’s personnel record revealed E5 was hired as a caregiver on April 20, 2020, before this statute went into effect. The review revealed documentation of training regarding fall prevention and fall recovery completed on July 24, 2024, and December 9, 2025. However, the review revealed no training regarding fall prevention and fall recovery before July 24, 2024, within one year after July 24, 2024, or within one year before December 9, 2025. 7. In an interview, E1 reported the facility switched management companies in September 2025 and the current management company did not have access to training records dated before September 18, 2025, other than those already in the physical personnel records provided to the Compliance Officer. 8. A review of E6’s personnel record revealed E6 was hired as a caregiver on November 9, 2020, before this statute went into effect. The review revealed documentation of training regarding fall prevention and fall recovery completed on July 24, 2024, and December 14, 2025. However, the review revealed

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for one of five sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel.” 3. A review of E5’s personnel record revealed E5 was hired as a caregiver on April 20, 2020, before this rule went into effect. The review revealed documentation of training and education related to recognizing the signs and symptoms of TB dated July 24, 2024, and October 4, 2025. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB within one year after July 24, 2024, or within one year before October 4, 2025. 4. In an interview, E1 reported the facility switched management companies in September 2025 and the current management company did not have access to training records dated before September 18, 2025, other than those already in the physical personnel records provided to the Compliance Officer. Regarding the missing training documentation, E1 stated, “If it didn't transfer over, it probably wasn’t done.” 5. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on February 18-19, 2025.

Based on documentation review, interview, and record review, the governing authority failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of four caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Employee Job Descriptions, Duties, and Qualifications.” The P&P stated: “2. Position Requirements b. Direct care staff must meet all state-required caregiver qualifications, including: i. Completion of an approved caregiver training program.” 2. A review of facility personnel schedules indicated E6 worked as a caregiver on a weekly basis between January 4, 2025, and the dates of the inspection. 3. In an interview, E1 reported E6 was hired as a caregiver. 4. A review of E6's personnel record revealed E6 was hired as a caregiver on November 9, 2020. The review revealed a photocopy of a caregiver certificate reportedly given by AZ Assisted Living Caregiver and Manager Training Programs, LLC on January 28, 2013. 5. A review of Department documentation revealed ALTP 0150 AZ Assisted Living Caregivers and Manager Training Program was not an active caregiver training program on January 28, 2013, when the certificate was issued. 6. A review of the NCIA Board website revealed ALTP 0150 AZ Assisted Living Caregivers and Manager Training Program was active between May 11, 2009, and July 31, 2012, and was not an active caregiver training program on January 28, 2013, when the certificate was issued. 7. In an interview, E6 reported E6 had been in the United States of America for more than 20 years and took the caregiver training course around 2012. 8. In an interview, E1 reported E6 was hired long before E1 took over as the manager. E1 reported not knowing ALTP 0150 AZ Assisted Living Caregivers and Manager Training Program was not an active caregiver training program on January 28, 2013, when E6’s certificate was issued. 9. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of five sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. R9-10-113(A)(2)(a)(i) 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…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." 3. A review of facility documentation revealed a series of personnel schedules that indicated E8 worked on a weekly basis between March 10, 2025, and the dates of the inspection. 4. A review of E8’s personnel record revealed E8 was hired as a caregiver on February 16, 2023, after the rule went into effect. However, the review revealed no documentation assessing risks of prior exposure to infectious TB. 5. In an interview, E1 reported the facility switched management companies in September 2025. E1 reported that any TB documentation the prior management company had for E8 was in the physical personnel record provided to the Compliance Officer. 6. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on February 18-19, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for four of four sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis." 3. A review of R1’s, R2’s, R3’s, and R4’s medical records revealed the four residents were admitted to the facility after this rule went into effect and more than seven days before the dates of the inspection. However, the review revealed no documentation of assessing risks of prior exposure to infectious TB or determining if R1, R2, R3, and R4 had signs or symptoms of tuberculosis. 4. In an interview, when the Compliance Officer asked if any of the residents at the facility had the aforementioned documentation, E2 stated, “I don’t think so.” 5. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on February 18-19, 2025.

Based on record review 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 three of four sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2’s medical record revealed a service plan dated January 12, 2026. The service plan indicated R2 was to receive assistance with bathing each Wednesday and Saturday. The review further revealed documentation of assisted living services (ADLs) provided to R2 dated January 2026. The ADLs revealed the following: - R2 refused assistance with bathing on January 14, 17, and 28, 2026; - R2 received assistance bathing on January 21, 2026; and - No documentation demonstrating R2 received or refused assistance with bathing between January 22 and 27, 2026, including on Saturday, January 24, 2026. 2. In an interview, E9 reported E9 bathed R2 but did not document it. 3. A review of R3’s medical record revealed a service plan dated November 9, 2025. The service plan indicated R3 was to receive multiple services daily in the afternoon and evening hours, including the following: - Toileting at 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, and 9:00 PM; - Reminders for meals at 4:30 PM; - Dressing at 7:00 PM; - Oral care at 7:00 PM; - Personal grooming at 8:00 PM; - Trash removal at 8:00 PM; and - Secured unit checks every two hours, sound the clock. The review further revealed ADLs dated January 2026. However, the ADLs revealed documentation demonstrating facility personnel provided no services to R4 on the following dates between the following hours: - January 1, 2026, between 3:37 PM and 8:22 PM; - January 2, 2026, between 3:05 PM and 8:44 PM; - January 3, 2026, between 1:19 PM and 5:25 PM; - January 4, 2026, between 1:27 PM and 7:54 PM; - January 5, 2026, between 1:23 PM and 5:29 PM; - January 6, 2026, between 12:29 PM and 9:01 PM; - January 8, 2026, between 1:20 PM and 6:42 PM; - January 9, 2026, between 3:22 PM and 8:33 PM; - January 10, 2026, between 1:10 PM and 5:26 PM; - January 11, 2026, between 1:58 PM and 8:17 PM; - January 12, 2026, between 1:10 PM and 8:05 PM; - January 13, 2026, between 1:12 PM and 8:22 PM; - January 14, 2026, between 1:08 PM and 7:06 PM; - January 15, 2026, between 1:11 PM and 5:17 PM, and 5:21 PM and 8:51 PM; - January 16, 2026, between 1:18 PM and 8:28 PM; - January 17, 2026, between 5:29 PM and 8:18 PM; - January 18, 2026, between 1:54 PM and 8:13 PM; - January 19, 2026, between 1:23 PM and 8:45 PM; - January 20, 2026, between 1:29 PM and 8:16 PM; - January 21, 2026, between 5:12 PM and 8:24 PM; - January 22, 2026, between 1:23 PM and 9:03 PM; - January 23, 2026, between 1:08 PM and 6:20 PM; - January 24, 2026, between 1:25 PM and 5:39 PM; - January 25, 2026, between 1:06 PM and 8:23 PM; - January 26, 2026, between 3:25 PM and 7:56 PM; - January 27, 2026, between 1:31 PM and 8:08 PM;

Based on record review and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered, for one of four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to the administration of a non-ordered medication. Findings include: 1. A review of R2’s medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed facility personnel administered Entacapone 200 mg between one and four times a day on January 21-28, 2026. However, the review revealed no medication order for the Entacapone. 2. In an interview, E2 reported not having a signed medication order for the Entacapone. 3. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on September 26, 2023.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of four sampled residents. 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 a service plan dated January 12, 2026. The service plan indicated R2 received medication administration. The review revealed a medication order for “Carbidopa-Levodopa 25-100 mg tablet…Take 1 tablet by mouth at 0600, 1000, [and] 1400” dated December 8, 2025. The review revealed a medication administration record (MAR) dated January 2026. However, the MAR revealed facility personnel administered R1’s Carbidopa Levodopa 25-100 mg two times a day at 5:45 AM and 1:45 PM instead of three times a day at the aforementioned hours as ordered. 2. In an interview, E2 reported R2’s Carbidopa-Levodopa changed from three times a day to two times a day but R2’s doctor would not write a new medication order for the medication. 3. A review of R3’s medical record revealed a service plan dated November 9, 2025. The service plan indicated R3 received medication administration. The review revealed a medication order for “CIPRO 250 MG TABLET Take 1 tablet PO BID 5 days PRESCRIBED QUANTITY: 10 (TEN) TABLETS 1 PACKAGE(S)” dated January 1, 2026. The review revealed a MAR dated January 2026. The MAR revealed facility personnel administered Ciprofloxacin 250 mg to R3 at 8:00 AM on January 4-6, 2026, and at 8:00 PM on January 3-5, 2026, for a total of six tablets. The MAR revealed facility personnel did not administer the Ciprofloxacin at 8:00 PM on January 6, 2026, and 8:00 AM on January 7, 2026, due to the “med [being] completed.” 4. In a series of interviews, when the Compliance Officer requested to observe the medication and container the medication was held in, E2 reported the facility did not have it. E11 reported E11 administered R3’s morning medications on January 7, 2026. E11 confirmed E11 did not administer the Ciprofloxacin at 8:00 AM on January 7, 2026. When the Compliance Officer pointed out the medication was only administered six out of the ordered ten times and asked where the four remaining tablets were, E2 reported E2 did not know. 5. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. This is a repeat citation from the complaint and compliance inspections conducted on February 18-19, 2025, and September 26, 2023.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order and documented in the resident’s medical record, for one of four sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication and medication could not be verified as administered against a medication order. Findings include: 1. A review of R2’s medical record revealed a service plan dated January 12, 2026. The service plan indicated R2 received medication administration. The review revealed a medication administration record (MAR) dated January 2026. The MAR revealed facility personnel administered Entacapone 200 mg between one and four times a day on January 21-28, 2026. The MAR further revealed documentation demonstrating facility personnel did not administer Entacapone 200 mg to R2 at 1:45 PM on January 22, 2026. 2. In an interview, E10 reported E10 administered Entacapone 200 mg to R2 at 1:45 PM on January 22, 2026, but did not document the administration. 3. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. This is a repeat citation from the complaint and compliance inspections conducted on February 18-19, 2025, and September 26, 2023.

Based on interview and documentation review, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. In an interview, E1 reported the facility utilized three shifts. 2. A review of facility documentation revealed a series of personnel schedules. The schedules revealed three shifts: 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM. The review further revealed a series of disaster drills for employees for the second shift dated January 30, 2025; May 28, 2025; August 25, 2025; and November 29, 2025. However, the review revealed more than three months between the drills conducted on January 30, 2025, and May 28, 2025. 3. In an interview, referring to the time between January 30, 2025, and May 28, 2025, E1 stated, “They missed this one.” 4. In the exit interview, the Compliance Officer reviewed the findings and E1 and E2 and E1 and E2 offered no further comment. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on February 18-19, 2025.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C)(2), for one of four sampled personnel members. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(2) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of Department documentation revealed E1 was hired as the manager. 3. A review of E1's personnel record revealed documentation in compliance with A.R.S. § 36-411(C)(2) dated November 14, 2024. However, based on E1’s hire date, this documentation was late. 4. In an interview, E1 acknowledged a representative of the residential care institution verified the status of E1's fingerprint clearance card late. This is a repeat citation from the complaint inspection conducted on January 17, 2024.

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. The Compliance Officer observed multiple bedrooms used for residents receiving directed care services. In the bedrooms, the Compliance Officer observed bells, intercoms, or other mechanical means to alert employees to a resident's needs or emergencies were not available. 2. In an interview, E1 reported residents receiving personal care services had call bells but residents receiving directed care services in the memory care unit did not. E1 reported facility personnel visibly checked on the directed care residents instead of having call bells. However, this method did not alert caregivers to an emergencies.

Based on documentation review, record review, and interview, the manager failed to ensure medication was administered in compliance with a medication order and documented in the resident’s medical record, for one of five sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Medication Management Guidelines” dated August 9, 2023. The P&P stated, “Medication Administration is documented on the MAR at the time the medication is provided or taken.” 2. A review of R3's medical record revealed a service plan which indicated R3 was to receive medication administration. The review revealed medication orders for “Carbidopa/Levodopa 25/100 2 tab PO 4xa day” dated February 5, 2024, and "KETOCONAZOLE 2 % CREAMAPPLY TOPICALLY TO AFFECTED AREAS TWICE DAILY” dated November 15, 2024. The review further revealed a medication administration record (MAR) dated February 2025. However, the MAR revealed no documentation of facility personnel having administered R3’s second dose of carbidopa/levodopa on February 15, 2025. The MAR further revealed facility personnel did not administer R3’s ketoconazole on February 1-19, 2025. 3. In an interview, E1 reported facility personnel administered R3’s carbidopa/levodopa on February 15, 2025. E1 stated the error on the MAR was “missed documentation.” E1 confirmed facility personnel did not administer R3’s ketoconazole because the facility did not have it. E1 reported the family delivered the medication to the facility during the inspection. This is a repeat citation from the complaint and compliance inspection conducted on September 26, 2023.

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)(2), for one of five personnel members sampled. The deficient practice posed a risk if the personnel member was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C)(2) states: "C. Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E4's personnel record revealed a photocopy of E4's fingerprint clearance card. However, the review revealed no documentation demonstrating compliance with A.R.S. \'a7 36-411(C)(2). 3. A review of the Department of Public Safety website revealed E4's fingerprint clearance card was valid. 4. In an interview, E1 reported E4 was hired as a caregiver. E1 acknowledged the governing authority did not verify the status of E4's fingerprint clearance card. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on September 26, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's education and experience applicable to the individual's job duties, for four of five caregiver records sampled. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Medication Aid, Review Process Summary Form" which stated, "Education and/or Experience: High school diploma or general education degree (GED), or one to three months related experience and/or training or equivalent combination of education and experience preferred." 2. A review of E6's personnel record revealed E6 was hired as a "Medication Aid." E6's personnel record also contained a caregiver certificate. However, no documentation of education or experience applicable to E6's job duties was available for review. 3. A review of E7's personnel record revealed E7 was hired as a "Medication Aid." E7's personnel record also contained a caregiver certificate. However, no documentation of education or experience applicable to E7's job duties was available for review. 4. Further review of facility policies and procedures revealed a policy titled "Resident Assistant, Review Process Summary Form" which stated, "Education and/or Experience: High school diploma or general education degree (GED), or three-six months related experience and/or training or equivalent combination of education and experience desired." 5. A review of E3's personnel record revealed E3 was hired as a "Resident Assistant." E3's personnel record also contained a caregiver certificate. However, no documentation of education or experience applicable to E3's job duties was available for review. 6. A review of E8's personnel record revealed E8 was hired as a "Resident Assistant." E8's personnel record also contained a caregiver certificate. However, no documentation of education or experience applicable to E8's job duties was available for review. 7. In an interview, E10 reported the facility verified all employee's education and experience during the hiring process. However, E10 acknowledged documentation of education and experience applicable to E3's, E6's, E7's, and E8's job duties was not available for review. Technical assistance was provided on this rule during the previous compliance inspection conducted on September 21, 2022.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for three of eight residents sampled. Findings include: 1. A review of R4's medical record revealed a service plan for personal care services dated September 26, 2023. The service plan stated, "ADL Needs: Bathing...I need physical assist with bathing for my back, buttocks and feet but I can participate in part of the bathing activity for the rest; I am dependent on staff for my entire bathing activity; I require 1 staff to assist with my bathing; My caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to nurse and coordinator; ADL: Bathing/Showering." However, R4's service plan did not include the amount and frequency provided for this service. R4's service plan also stated, "ADL Needs: Grooming...I need physical assistance for grooming. I will be able to participate in part of the grooming activity. ADL: Grooming." However, R4's service plan did not specify the amount, type, and frequency provided for this service. 2. A review of R5's medical record revealed a service plan for personal care services dated September 26, 2023. R5's service plan stated, "ADL Needs: Bathing...I require staff standby supervision, set up, verbal cues and/or reminders to complete tasks; My caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to nurse and coordinator; ADL: Bathing/Showering." However, R5's service plan did not include the amount and frequency provided for this service. 3. A review of R6's medical record revealed a service plan for directed care services dated June 24, 2023. R6's service plan stated, "ADL Needs: Bathing...I require staff standby supervision, set up, verbal cues and/or reminders to complete tasks; My caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to nurse and coordinator; ADL: Bathing/Showering." However, R6's service plan did not include the amount and frequency provided for this service.R6's service plan also stated, "ADL Needs: Grooming...I need stand-by supervision; setup, verbal cues and/or reminders to complete tasks." However, R4's service plan did not specify the type and frequency provided for this service. 4. In an interview, E2 acknowledged the aforementioned services in R4's, R5's, and R6's service plans did not include the amount, type, and frequency of the assisted living services being provided to the resident.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of eight residents sampled; and failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of eight residents sampled. Findings include: 1. A review of R5's medical record revealed a medication order, dated January 23, 2023, for "Lantus SoloStar Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously in the morning..." 2. Further review of R5's medical record revealed a medication administration record (MAR) dated September 2023. R5's September 2023 MAR indicated R5 was administered "Lantus" injections as ordered on September 1-16, 18, 20-22, and 25, 2023. An "O" was documented in the boxes on the MAR for September 17, 19, and 23-25, 2023. At the bottom of the MAR was a section titled "Chart Codes" which stated, "O=Other/See Progress Notes." R5's medical record contained a section titled "Prog Notes" which contained notes for R5 dated September 23, 24, and 25, 2023. The notes stated, ""Lantus SoloStar Solution Pen-Injector...No Battery." However, no further information was provided in these notes, and no progress notes were available for September 17 and 19, 2023. 3. In an interview, E11 reported E11 was not sure why R5 did not receive administration of medication on September 17, 19, 23-25, and reported med techs were supposed to document the reasons why medication was not administered. E11 acknowledged the "O"s documented on R5's MAR indicated R5 did not receive the aforementioned medication as ordered on those days. 4. A review of R2's medical record revealed a medication order for "Levothyroxine 100 mcg (micrograms) tablet by mouth daily." 5. Further review of R2's medical record revealed a MAR dated September 2023 which indicated R2 received administration of "Levothyroxine" on September 1-11 and 13-26, 2023. However, "Levothyroxine" was not documented as administered on September 12, 2023. 6. A review of R4's medical record revealed medication orders for the following medications: -"Lisinopril Oral Tablet 10 MG (milligrams), Give 1 tablet by mouth one time a day..."; -"Magnesium Oxide Oral Tablet 400 MG. Give 1 tablet by mouth one time a day for Supplement"; and -"metFormin HCl Oral Tablet 500 MG, Give 1 tablet by mouth two times a day..." 7. Further review of R4's medical record revealed a MAR dated September 2023 which indicated R4 received the above medications as ordered on September 1-11 and 13-26, 2023. However, R4's MAR was blank and did not document the aforementioned medications were administered as ordered on September 12, 2023. 8. In an interview, E2 reported since the boxes on the MAR for the aforementioned dates were blank, facility staff likely forgot to document the administration of the aforementioned medications on those dates. E2 acknowledged facility staff failed to ensure