Golden Times Assisted Living Home

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of three sampled residents. The deficient practice posed a risk if the resident did not recieve adequate follow-up care. Findings include: 1. A review of R1's medical record revealed a document titled "Progress Note" March 12, 2024 which reflected "Refusing to get to go to the table to eat. Ate breakfast. No Lunch. Sent to ER can't control pain, around 12pm." There was no documentation to reflect the primary care provider was notified. 2. In an interview, E1 acknowledged R2 went to the hospital via emergency medical services, there was no documentation to reflect the primary care provider was notified.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. Findings include: 1. A review of facility documentation revealed documentation of a fall prevention and fall recovery training program. 2. A review of E3's personnel record revealed no documentation of initial training in fall prevention and fall recovery. 3. In a joint interview, E1 and E4 acknowledged the facility did not administer a training program including initial training in fall prevention and fall recovery for E3.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R3's medical record revealed no documentation to indicate R3 was notified of the availability of vaccination for influenza and pneumonia. Based on R3's date of admission, this documentation was required. 2. In a joint interview, E1 and E4 acknowledged R3's medical record did not contain documentation to indicate R3 was notified of the availability of vaccination for influenza and pneumonia.

Based on 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 three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan dated May 9, 2023. The service plan indicated R1 received medication administration services. 2. A review of R1's medical record revealed a medication order dated July 6, 2023 for "Sumatriptan 50 mg (milligrams) 1 tab PO Everyday. No more than 2 tab day Can repeat 1 tab in 2 hours." 3. A review of R1's medical record revealed medication administration records (MARs) dated August and September 2023. The MAR indicated "Sumatriptan 50 mg" was "PRN" (as needed). 4. A review of R2's medical record revealed a service plan dated July 18, 2023. The service plan indicated R2 received medication administration services. 5. A review of R2's medical record revealed a medication order dated August 25, 2023 for "Miralax 3350 NF 17 g (grams) PO in 8oz (ounces) of water daily PRN". 6. A review of R2's medical record revealed a MAR dated September 2023. The MAR indicated "Miralax" was not included as a medication administered to R2. 7. In a joint interview, E1 and E4 acknowledged "Sumatriptan" was not administered to R1 in compliance with a medication order. E1 reported R2 had a new medication order to discontinue "Miralax" but the order was not signed by a medical practitioner.