Manors at Glencroft, the

Based on record review, documentation review and interview, the manager failed to ensure that the medication administered to a resident was documented in the resident's medical record in compliance with the medication order. Findings include: 1. A review of R5's medical record revealed a document titled "Physician's Orders", which included various medications, one of which was MIDODRINE HCL 5 MG TABLET TAKE 1 TABLET BY MOUTH EVERY 8 HOURS FOR SBP 131). 2. A review of R5's medication administration record for January 2026 revealed Midodrine was listed under the exceptions notes as "Med Unavailable - Notify Coordinator" on the following dates: January 21, 2026 - 2:00 pm and 8:00 pm January 22, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 23, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 24, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 25, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 26, 2026 - 8:00 am and 8:00 pm January 27, 2026 - 8:00 am, 2:00 pm, and 8:00 pm January 28, 2026 - 8:00 am and 2:00 pm January 29, 2026 - 8:00 am and 2:00 pm January 30, 2026 - 8:00 am, 2:00 pm, and 8:00 pm 3. Further review revealed Midodrine was administered on the following dates: January 26, 2026 - 2:00 pm January 28, 2026 - 8:00 pm January 29, 2026 - 8:00 pm 5. In an interview, E1 reported that the medication administration record showed the wrong documentation for Midodrine. The medication would not have been available. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454 and document the actions taken by the manager to prevent the suspected abuse from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report regarding an altercation between R1 and R2 dated March 21, 2025. The report stated “this writer was assisting another resident with … ADLs when I heard a resident yelling not twice. went to see what was happening since resident was safe on the seat. this writer saw ... (R2) … and (R1) in the hallway… (R2) … was walking towards the living room area one slightly further away. (R1) grabbed the closes … (R2) elbow saying, “I was talking to (R2)”… (another resident) told (R1) to let go and shook off (R1) hand. this writer was trying to get (R1) attention while walking towards all three. once there this writer had stepped in between the (R2) … and (R1). this writer had the (R2) … walk away. at this time this writer convinces the (R1) to go into … room. once there was able to get (R1) to sit in … recliner with cat and tv on. once (R3) was calm enough this writer stepped out of (R3) room.” However, Adult Protective Services (APS) was only notified on March 24, 2025 at 3:14 PM. In addition, the incident report did not include documentation for any action taken to prevent the incident from occurring in the future. 4. In an interview, E1 reported that there were several incidents with R1 that weekend and acknowledged the altercation between R1 and R2 was not reported to APS immediately and the incident report did not include documentation of any action taken to prevent the incident from occurring in the future.