Greenway Home Care, LLC

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's disaster plan revealed a review conducted on December 31, 2024. However, documentation of additional reviews was not available. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, 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 sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medications.” The policy stated the following: “1. No medication or treatment to be administered to the resident without a physician or medical practitioner order or instructions.” “12. 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. Time and date will be recorded as wll as the initials of the person that administered the medication or assisted in the self-administration of medication. [...].” 2. A review of R1’s medical record revealed the following: A signed medication list, dated December 1, 2025. A current service plan dated October 14, 2025, which indicated R1 received medication administration and “manager/caregiver sets up mediset.” A letter from R1’s family member stated, “I am [R1’s] Medical POA in addition to being an Internal Medicine physician licensed in the state of Arizona. [O1] have been overseeing [R1’s] prescription medication, obtaining it from the pharmacy and placing it into medication administration boxes for it to be dispensed to [R1] by the caregivers in [R1’s] group home.” 3. A review of R1’s medication administration record (MAR) for December 2025 revealed the following: 13 medications were administered and signed in the morning Two medications were administered and signed in the evening No bedtime medication was indicated as administered 4. A review of R1’s medication organizer revealed the following: Several medications were in the morning slot. Two medications were in the noon slot Seven medications were in the bedtime slot. 5. In an interview, E3 acknowledged that the medication organizer did not match the MAR or medication order. E3 reported that O1 set up the medication organizers. 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure documentation of medication administration included the date and time of administration, the strength, dosage, and signature of the individual administering medication. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident, and the Department was provided false or misleading information. Findings include: 1. In observation, R2's medications were observed on site. 2. In record review, R2's medical record (received directed care, and medication administration services) included a medication order dated August 20, 2024, as follows: - "increase Lantus 14 (hard to read) units in the morning. Do not skip. [Further documentation illegible]." - "increase Novolog 6 units with breakfast and 5 units with lunch and dinner. [illegible] Add 1 unit for every 10 units above [illegible]. Do not give meal insulin if less than 100." - "PER PROVIDER ... LANTUS IS 14 UNITS QAM. DISCONTINUE ANY OTHER DOSING. NOVOLOG IS 6 UNITS WITH BREAKFAST, 5 UNIT WITH LUNCH AND DINNER AND UPDATE SLIDING SCALE TO TID AC..." 3. In record review, R2's medication administration record (MAR), dated September 2024, indicated the following medication administration for R2: - "Lantus SOLOSTAR 100UN/ML INSULIN INJECT 12 UN SQ QD AM," was administered daily at 3am September 1 - 30, 2024. -"Novolog w/Admelo G Sol 100unit/ml inject per sliding scale sub before meals" was administered daily at 8am September 1 - 30, 2024. - "INS Glargine/Lantus 100un/ml. Give 14 AM and 7 UNITS PM (CK SUGAR 1st)" was documented as administered at 8am and 8pm daily September 1 - 30, 2024. The September MAR did not indicate the Insulin medication was administered as ordered. 4. During an interview, E1 reported the caregivers administered the Insulin medication to R2, as ordered, and in accordance with the sliding scale; however, acknowledged the medication administration was not documented accordingly on R2's MARs. 5. In record review, R2's MAR dated September 2024 and October 2024, indicated medications were administered by E1, E2, and E5; however, the MAR's did not include the name and signature of E5, and the signatures of E1 and E2. Additionally, E2's initials were documented on the MAR on several days in October, for medication administration; however, the initials were observed to be of different handwriting on some days. 6. During an interview, E1 and E2 acknowledged E2's initials on the MAR on October 4, 18, 21, 22, and 24, did not match E2's initials documented on the other days in October 2024; and acknowledged the initials on the MAR should be documented by the caregiver who administered the medication to the resident.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below, which posed a health risk to the residents. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed a food storage pantry had items with labels which indicated "Refrigerate after opening." The items which required refrigeration included; opened bottles of Kroger sugar free syrup, Kikkoman Soy Sauce, Great Value Caramel syrup and Great Value Chocolate Syrup. 2. During an interview, E1 acknowledged the foods were not refrigerated after opening.

Based on observation and interview, the manager failed to ensure facility equipment and food contact surfaces were clean. The deficient practice posed a health and safety risk to residents if food services were not maintained in a clean manner. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed the facility's oven was heavily soiled with black and brown substances, on the inside bottom and door. 2. During an interview, E1 reported the caregivers cleaned the oven; however, the oven inside had black and brown stains observed, during the inspection.