Harvest at Queen Creek Assisted Living LLC

Based on record review and interview, for one of two residents sampled, the manager failed to ensure a caregiver or assistant caregiver assisted with activities of daily living according to the resident’s service plan, and/or documented services provided in the resident's medical record. Findings include: 1. A review of R2’s medical record revealed an order dated September 16, 2025, which read “Apply abdominal binder if SBP is less or equal to 100.” A review of R2’s service plan, dated October 15, 2025, revealed R2 received directed care services. The service plan, which included many illegible, handwritten notes, did not contain the service “Apply abdominal binder.” Further review of R2’s medical record revealed documentation of R2’s daily blood pressure readings for September and October 2025, which included numerous days where R2’s systolic blood pressure was documented as being at or below 100. R2’s medical record also contained a form for documenting provision of R2’s activities of daily living and medication administration (MAR). However, evidence of documentation of the application of an abdominal belly band to R2, when R2’s systolic blood pressure was at or below 100, was unavailable for review. 2. In an interview, E2 advised when R2’s systolic blood pressure was at or below 100, the belly band was being applied as ordered. E2 advised the application of the belly band was not being documented. 3. In an interview, E1 agreed the service for the application of R2’s bellyband was not identified in R2's service plan. E1 confirmed the application of R2's bellyband as ordered, but agreed the service was not documented. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, for two of two residents sampled, the manager failed to ensure an entry in a resident’s medical record was legible. Findings include: 1. A review of R1’s and R2’s medical records revealed current service plans for each resident. The service plans included numerous handwritten notes, in various sections such as “Medical Diagnosis” or “Maintain Safety,” which were largely illegible. 2. In an interview, E1 advised the service plans were completed by “O1,” a registered nurse contracted by the facility. The Compliance Officer asked E1 for their interpretation or clarification on some of the handwritten notes; however, E1 was unable to read many of the notes. E1 agreed the handwritten notes were largely illegible. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.