Graceville Estate LLC

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1) Review of R's medical record revealed a current written service plan dated March 9, 2025. This service plan indicated R1 received medication administration. 2) Review of R1's medical record revealed a signed medication order dated March 9, 2025. The medication order stated "Alendronate 70 mg(milligrams);1 tab; Q (every) Friday". 3) Review of R1's medical record revealed a May 2025 medication administration record (MAR). This MAR stated "Alendronate; 70mg; Take 1 tab by mouth every Friday". However, the MAR indicated R1 was administered "Alendronate" every day at 7 am. 4) During an observation of R1's medications, Alendronate was observed. 5) In an interview, E1 reported Alendronate was administered per the medication order. E1 acknowledged R1's medication record did not accurately reflect the medication was given per the medication order.

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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy regarding fall prevention and fall recovery, including initial training and continued competency training, had been developed. 2. A review of E3's and E5's personnel record revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged E3 and E5 did not have documentation of fall prevention and fall recovery training. E1 reported E3 and E5 had recently been hired and the required training had not been completed yet.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for one of five employees sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E5 was fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: 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." 2. A review of E5's personnel record revealed no documentation of evidence to indicate a good faith effort to contact previous employers was made to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged E5's personnel record did not include the documentation required in A.R.S. \'a7 36-411(C)(1).

Based on documentation review, record review, and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in R9-814(B)(2), for one of one resident sampled who received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident's representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility." 2. A review of R2's medical record revealed a service plan dated May 13, 2023. Under the heading, "Mobility and Assistive Device,'' the service plan reported R2 was non-ambulatory and confined to a bed. 3. A review of R2's medical record revealed documentation dated July 2022. The documentation indicated R2 was authorized to reside in the assisted living facility. 4. Further review of R2's medical record did not reveal documentation of the facility's compliance with R9-10-814(B)(2)(b) every six months. 5. In an interview, E1 acknowledged R2 was retained as a resident without the facility being in compliance with R9-10-814(B)(2)(b). E1 reported E1 had the documentation. However, E1 was unable to find the documentation the day of the inspection.