Marshall Home for Men

Based on documentation review and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of two personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E2’s personnel record did not include documentation of completed initial competency training on fall prevention and fall recovery. Given E2's date of hire, this documentation was required. 2. In an interview, the findings were reviewed with E1. E1 stated E2 received fall prevention and fall recovery training; however, there was no documentation that indicated that specific training was completed. 3. In an exit interview, the findings were reviewed with E1 and no further documentation was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual’s completed orientation and in-service education required by policies and procedures for one of two personnel sampled. Findings Include: 1. A review of the facilities Policy and Procedures revealed a policy titled “Caregiver Orientation and Continuing Education," which stated, “At the time of hire of a new employee the Manager will ensure that the employee receives the appropriate training and orientation needed prior to providing services in this facility… This documentation will be maintained in the employee’s personnel record." 2. A review of E2’s personnel record revealed documentation of E2’s completed orientation was not available for review. Based on E2's date of hire, this documentation was required. 3. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on document review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises or while the resident is receiving services from the assisted living facility, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454, and failed to initiate an investigation and document findings within five working days. The deficient practice posed a risk of a resident's rights violation if a resident was subjected to exploitation. Findings include: 1. A review of R1's medical record revealed an incident report, internal investigation, or other documentation of suspected exploitation was not available for review. 2. A review of R1’s medical record revealed a printed list of charges from a credit card. The statement listed $499.86 of charges dated August 18 and August 19, 2024, to two websites, “Dice Dreams,” and “TikTok.” An attached self-adhesive note stated, “Visa History. May to Nov. This is the only history there is, Thank you.” However, no accompanying documentation of an internal investigation as required accompanied the list of charges. 3. During a telephone call with O1, O1 reported there was an issue with R1’s rent at the facility being charged twice in one month. O1 reported when O1 checked R1’s checking account to see what had happened, they also noticed there was an attached credit card with online charges. O1 reported R1 would have no ability to use their phone to make these kinds of purchases. O1 reported O1 closed the credit account and visited the facility. O1 reported they spoke with the facility staff about the unusual charges and asked the facility keep R1’s debit card secure. O1 said O1 did not pursue the matter further. 4. In an interview, E2 reported they had investigated the allegation of exploitation. 5. In an interview, E1 reported there was nothing to investigate. E1 reported E1 had asked R1 for a bank statement and R1 provided a three year old ripped paper which did not show anything. E1 reported another person, O2 had also mentioned this incident and asked for it to be investigated. 6. In an interview, E1 acknowledged the facility was aware of the allegation of exploitation, however, a report to law enforcement or Adult Protective Services had not been documented, and an investigation of the allegation, completed within five working days of the initial report, had not been provided for review.

Based on record review, and interview, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for one of one resident reviewed who required behavioral care. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. Findings include: 1. A review of R3's medical record revealed a document titled, "Determination for Admission," signed by a medical practitioner or registered nurse on April 24, 2015. This document stated, "Does this person require behavior care…” and was marked, “Yes.” 2. A review of R1’s medical record revealed a progress note from R1’s primary care provider which included a full diagnosis list. The list included, “Bipolar affective disorder; currently manic, mild.” 3. A review of R1’s medical record revealed a letter from R1’s behavioral health provider providing contact information for use if R1 needed assistance with, “changes in symptoms, urgent needs, questions about medication responses, and medication side effects.” 4. A review of R1's medical record a medication administration record dated January 2025 which included the following entry, “Risperidone 50 mg injection given @ VA every 2 weeks.” 5. A review of R1's medical record revealed a, “Mental Health Medication Mgt Note,” from R1’s, “MH Injection Clinic.” The note stated, “Veteran states he is doing well and he is well groomed and appears happy, He likes the Marshall House and said that they feed him well and he gets enough sleep. He denied any side effects.” 6. A review of R1's medical record revealed a service plan, dated January 20, 2025, for personal care services. However, the service plan did not include the following: - The psychosocial interactions or behaviors for which the resident requires assistance; - psychotropic medications ordered for the resident; - planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and

Based on record review and interview, the manager failed to ensure a service plan, for a resident who required behavioral care, was reviewed by a medical practitioner or behavioral health professional, for one of one resident sampled who required behavioral care. R9-10-101(29) states, "Behavioral care a. Means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services." Findings include: 1. A review of R1's medical record revealed a document titled, "Determination for Admission," signed by a medical practitioner or RN on April 24, 2015. This document stated, "Does this person require behavior care…” and was marked, “Yes.” 2. A review of R1’s medical record revealed a progress note from R1’s primary care provider which included a full diagnosis list. The list included, “Bipolar affective disorder; currently manic, mild.” 3. A review of R1’s medical record revealed a letter from R1’s behavioral health provider providing contact information for use if R1 needed assistance with, “changes in symptoms, urgent needs, questions about medication responses, and medication side effects.” 4. A review of R1's medical record a medication administration record dated January 2025 with included the following entry, “Risperidone 50 mg injection given @ VA every 2 weeks.” 5. A review of R1's medical record revealed a, “Mental Health Medication Mgt Note,” from R1’s, “MH Injection Clinic.” The note stated, “Veteran states he is doing well and he is well groomed and appears happy, He likes the Marshall House and said that they feed him well and he gets enough sleep. He denied any side effects.” 6. A review of R1's medical record revealed a service plan, dated January 20, 2025, for personal care services. However, the service plan did not include the requirements in R9-10-808.A.3.e.i and was not reviewed by a medical practitioner or behavioral health professional. 7. In an interview, E1 acknowledged R1's service plan had not been reviewed by a medical practitioner or behavioral health practitioner.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of one resident sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 20, 2025, for personal care services. The service plan did not include hospice services, or a requirement for R1 to wear a cervical collar. 2. A review of R1's medical record revealed a hospice certification of terminal illness with a benefit period starting February 14, 2025. 3. A review of R1’s medical record revealed an incident report dated February 12, 2025 at 9:45 AM. The type of incident was marked, “Fall”. The incident report stated, “Resident was trying to to go the restroom from his bed…I found two employees helping resident in hallway. Resident was using his walker with just socks on, making floor slippery. I was finishing med pass. Housekeepers starting to clean rooms in north dorm. 15 mins prior I had checked on resident, he was starting to wake up. He said he was OK, didn’t need any help. Tried to assist resident back to bed. AS soon as he got up he tensed up and started to fall again. I placed him on the ground against the wall and we called 911. 4. A review of R1’s medical record revealed a hospital discharge dated February 13, 2025. The discharge provided new diagnoses to include: “Cervical Spine Fracture,” “Fall,” “Fall,” “Fracture of cervical vertebra, C2,” and ,“Fracture of L2 vertebra.” The discharge orders included: “You must wear a cervical collar at all times. A Philadelphia collar will be provided for comfort.” 5. A review of R1's medical record revealed an updated service plan, dated on or before February 28, 2025, was not available for review. 6. In an interview, E1 acknowledged R1's service plan had not been updated within 14 calendar days after R1 had a significant change in condition.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the immediate notification of a resident's emergency contact and primary care provider when a resident had an accident, emergency or injury and needed medical services. Findings include: 1. A review of R1’s medication administration record indicated R1 had not been provided medication starting on January 16, 2025 at 10:10 PM through the end of January 2025. A comment on the MAR stated, “Resident sent out to VA hospital, not on property.” 2. A review of R1’s medical record revealed an incident report dated January 16, 2025 was not available for review. 3. In an interview, E1 acknowledged documentation of the immediate notification of R1's emergency contact and primary care provider during the incident when R1 was sent to the hospital on January 16, 2025 was not provided for review.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency or injury and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of R1’s medication administration record indicated R1 had not been provided medication starting on January 16, 2025 at 10:10 PM through the end of January 2025. A comment on the MAR stated, “Resident sent out to VA hospital, not on property.” 2. A review of R1’s medical record revealed an incident report dated January 16, 2025 was not available for review. 3. In an interview, E1 acknowledged documentation of the incident during which R1 was sent to the hospital on January 16, 2025 was not provided for review.

Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for one of one resident sampled for whom an emergency responder had been contacted. Findings include: 1. A review of R1’s medical record revealed incident reports dated January 15, 2025 and February 12, 2025. During both incidents, the facility contacted EMS on R1’s behalf. 2. A request was made to view the documentation provided to the emergency responders as required by ARS 36-420.04. However, the documentation was unavailable for review. 3. In an interview, E1 reported required documentation was provided to emergency responders, but copies of the documentation provided were not made for each individual incident. E1 acknowledged a copy of the documentation given to the emergency responder for each resident was not available for review as required by ARS 36-420.04.

Based on documentation review, record review, and interview, the manager failed to implement a policy and procedure to protect the health and safety of a resident covering assistance in the self-administration of medication and medication administration. Findings include: 1. A review of the facility's policies and procedures, reviewed and approved August 1, 2023, revealed a policy titled, "Medication Policy and Procedures." The policy stated, ""J. If a resident will be off the premises during a time when a scheduled medication should be provided to the resident, the medication will be: 1. Provided up to one hour early or later, if possible; 2. Given to the resident, resident's representative, or family member with written instructions for assistance in the self administration of the medication or medication administration; or 3. An order obtained from the medical practitioner to hold a particular medication." The policy further stated, "Medication Instruction while resident is absent form the facility. A. When a resident requires to be gone from the facility during a medication pass, the following procedure will be followed: 1. Medications can be pre-packed into a medication organizer and given to the resident or resident's representative prior to resident leaving the facility. 2. Instructions including the name of the medication, description, when and how to take the medication, purpose of the medication will be reviewed with responsible party. The caregiver will clarify any questions or concerns the resident may have. 3. The Medication Instruction Sheet While Absent from Facility form is signed by the caregiver preparing the medications and given to the responsible party. 4. Upon the resident's return to the facility the form is obtained by the caregiver and reviewed. Any medications that were not given will be collected at that time. The caregiver will sign the form and this documentation will be placed in the resident's medical record." The medication policy had been approved by a nurse practitioner on September 1, 2023. 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated September 2024. The MAR documented the following: - For the medication, "Dicyclomine 10MG Cap, Take 1 capsule by mouth three times a day," the MAR indicated R1 had not received this medication at 1 PM on September 5,9,10,11,12,17,24,and September 28, 2024, for the reason, "Out of Facility"; - For the medication, "Gabapentin 100 MG CAPS, Take 1 capsule by mouth every 8 hours," the MAR indicated R1 had not received this medication at 2 PM on September 5,7,10,16,17,24, and September 28, 2024, for the reason, "Out of Facility"; and - For the medication, "Sevelamer 800MG TAB, Take 2 tablets by mouth three time a day...", the MAR indicated R1 had not received this medication at 12 PM on September 5,10,11,12,17, and September 28, 2024, for the reason, "Out of Facility." 3. In an interview, E1 reported R1 goes out of the facility for Dialysis t

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed a physician's determination for admission for R2 was not available for review. 2. In an interview, E1, E2 and E3 acknowledged R2's initial admission determination had not been provided for review.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for three of three residents sampled. Findings include: 1. A review of R1's medical record revealed a current service plan listing the services required by R1, including: - "Encourage/assist [R1] to change position every 2-3 hours to help with circulation and skin breakdown prevention"; - "Encourage daily range of motion exercised within [R1's] limitations to help with circulation and lower skin breakdown risk"; - "Check fingernails on shower days to make sure they are short, clean and smooth"; - "Encourage [R1] to drink water or other beverage he/she likes every 1-2 hours throughout the day"; - "Encourage daily exercise and movement within [R1's] abilities"; - "Check feet on shower days for cuts or redness, if seen, report to doctor"; - "Take Blood Pressure: daily"; and - "Check Blood sugars: daily." 2. A review of R1's medical record revealed documentation of services provided to R1 were not available for review. R1's medical record did include documentation of R1's blood pressure, however, R1's blood pressure had not been documented on the days R1 went to dialysis. 3. A review of R2's medical record revealed a current service plan listing the services required by R2, including: - "Shower, 2x Week, Complete, Care Staff give showers as documented on shower schedule,"; - "Dressing, Complete, done morning and bedtime"; - "Grooming, Complete, Frequency: Morning"; - "Oral Care, Complete, Done Morning & Bedtime"; - "Toileting, Monitor, [R2] wheels himself to the bathroom and is able to transfer himself to the toilet"; - "Encourage/assist [R2] to change position every 2-3 hours to help with circulation and skin breakdown prevention"; - "Encourage daily range of motion exercised within [R2's] limitations to help with circulation and lower skin breakdown risk"; - "Check fingernails on shower days to make sure they are short, clean and smooth"; - "Encourage [R2] to drink water or other beverage he/she likes every 1-2 hours throughout the day"; - "Encourage daily exercise and movement within [R2's] abilities"; and - "Check feet on shower days for cuts or redness, if seen, report to doctor." 4. A review of R2's medical record revealed documentation of services provided to R2 were not available for review. 5. A review of R3's medical record revealed a current service plan listing the services required by R3, including: - "Encourage/assist [R3] to change position every 2-3 hours to help with circulation and skin breakdown prevention"; - "Encourage daily range of motion exercised within [R3's] limitations to help with circulation and lower skin breakdown risk"; - "Check fingernails on shower days to make sure they are short, clean and smooth"; - "Encourage [R3] to drink water or other beverage he/she likes every 1-2 hours throughout the day"; - "Encourage daily exercise and movement within [R3's] abilities"; - "Chec

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for three of three residents sampled. Findings include: 1. A review of R1's medical record revealed a signed list of medication orders dated June 6, 2024, which included: - "Sevlamer 800MG Tab, take 1 tablet by mouth three times a day with breakfast, lunch and evening meal"; - "Oxycodone 5 mg tab, take 1 tablet by mouth every six hours as needed for pain." However, this order had been marked, "D/C Start every 8 hrs." 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated September 2024. The MAR documented the medications administered to R1. The MAR documented the following: - "Sevlamer 800MG Tab, take 2 tablets by mouth three times a day," had been administered on each day in September; and - " Oxycodone 5 mg Tab, take 1 tablet by mouth every six hours as needed," had been administered more frequently than every 8 hours on some days in September, 2024. 3. The Compliance Officer observed a cabinet containing R1's medications included a multi dose package of 800 milligram Sevlamer tablets with a label stating, "Take 2 tablets by mouth three times a day," and which included an order date of June 14, 2024. 4. A review of R2's medical record revealed a signed list of medication orders dated July 23, 2024, which included: - "Spironolact 25MG Tab, take 1/2 tablet by mouth daily." 5. A review of R2's medical record revealed a MAR dated September 2024. The MAR documented the medications administered to R2. The MAR documented the following: - "Spironolact 25MG tab, take 1 tablet by mouth daily," had been administered to R2 on each day in September. 6. The Compliance Officer observed a cabinet containing R2's medications included a multi dose package of 25 milligram Spironolcactone tablets with a label stating, "Take 1 tablet by mouth daily," and which included an order date of July 24, 2024. 7. A review of R3's medical record revealed an unsigned list of medication orders dated September 14, 2024, which included: - "Ezetimibe 10 mg tablet, take one tablet by mouth every day." 8. A review of R3's medical record revealed a MAR dated September 2024. The MAR documented the medications administered to R2. The MAR documented the following: - "Ezetimibe 5 MG, take 1/2 tab by mouth every day," had been administered to R3 on each day in September. 9. The Compliance Officer observed a cabinet containing R3's medications included a multi dose package of 10 milligram Ezetimibe tablets with a label stating, "Take 1 tablet by mouth every day." 10. In an interview, E1, E2, and E3 acknowledged medications had not been administered to each resident according to an available medication order.

Based on observation, record review, documentation review, and interview, the manager failed to ensure medication stored in a resident's room was stored according to the resident's service plan, for one of three residents sampled who received personal care. Findings include: 1. During an environmental tour the Compliance Officer observed a container of Simethicone in a bedside shelving unit in R3's shared bedroom. The medications were not secured. 2. A review of R3's medical record revealed a service plan, dated July 22, 2024, which indicated R3 received personal care services. 3. A review of R3's medical record revealed a service plan, dated May 15, 2023, which indicated R3 received personal care services. The service plan indicated R3's medications were to be stored, "...in accordance with their policies and procedures." The service plan did not authorize R3 to store medications in R3's bedroom. 4. A review of the facility's, "Medication Policy and Procedures" revealed a storage policy which stated, "B. If the residents of this facility have been certified by their medical practitioner to be mentally and physically capable of managing their own medications may be allowed to do so (Supervisory Care Resident Only!!); 1. Medication will be kept in a locked container, drawer, or cabinet or a resident locks the entrance to the room when the resident is not in the room; and 2. An employee has a key and access to the resident's room and medication storage container, drawer, or cabinet; or a. as stated in the resident's service plan; 3. A "Medication Self-Administration Assessment" (please see form) will be completed at least one time on an annual basis in order to assess a resident's ability to self-administer medications. The resident must be able to perform each step indicated on the assessment form in order to store medications in their room and self-administer medications. This assessment is maintained in the residents medical record." 5. In an interview, E1, E2, and E3 acknowledged R3's service plan did not authorize R3 to store medications in R3's bedroom, and the medication stored in R3's bedroom was not stored according to the facility's policies and procedures.

Based on observation and interview, the manager failed to ensure that frozen foods were stored at a temperature of 0\'b0 F or below. Findings include: 1. During a facility tour, the Compliance Officer observed the facility's walk-in freezer had an external thermometer which registered at 28\'b0 F, and a second thermometer on a rack inside the walk-in which registered at 20\'b0 F. 2. In an interview, E8 reported the walk-in had been left open for an extended period of time and should quickly recover. 3. Approximately one hour later, the Compliance Officer observed the temperatures were unchanged. 4. In an interview, E1, E2, and E3 acknowledged frozen foods had not been stored at or below 0\'b0 F.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Opioid Prescribing and Treatment," which stated, "Pain Management Scales....2. A numeric system, often using the numbers one through ten, can be used to measure pain. The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses shall be documented in the Resident's medical record." 2. A review of R1's medical record revealed an order, dated June 6, 2024, for, Oxycodone 5 milligram tablets, to be given every 8 hours as needed. 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated September 2024. The MAR indicated R1 had been administered Hydrocodone on September 1 though September 23, September 25, and September 27 through September 30. The PRN comment section of the MAR included the following information: The date and time of administration, the reason given, "Pain," the initials of the person who administered the opioid and monitored the resident, and the results, "Effective." 4. A review of R1's medical record revealed documentation of R1's numeric rating of R1's level of pain prior to administration and R1's numeric rating of the effect of the opioid were not available for review. 5. In an interview, E1, E2, and E3 acknowledged the caregivers administering opioids to R1 had not documented the identification of R1's need for the opioid before every administered dose and had not documented monitoring of the effectiveness of the opioid in the manner prescribed by the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for two of four residents sampled. Findings include: 1. A review of R3's medical record revealed a documented residency agreement. However, the residency agreement had not been signed or dated by the manager. 2. A review of R4's medical record revealed a documented residency agreement, signed by the resident. However, the residency agreement had not been signed or dated by the manager. 3. In an interview, E1 and E2 acknowledged the manager had not signed and dated the residency agreements provided for R3 and R4.

Based on record review, and interview, the manager failed to obtain on the documented agreement, required in subsection (D), the signature of the resident before or within five working days after a resident's acceptance by the assisted living facility, for two of four residents sampled. Findings include: 1. A review of R3's medical record revealed a documented residency agreement. However, the signature of the resident had not been obtained. Based on R3's acceptance date, the documentation was required. 2. A review of R4's medical record revealed a documented residency agreement. The agreement had been signed by R4. However, R4's signature was dated fifty-eight days after R4's acceptance date. 3. In an interview, E1 and E2 acknowledged the residency agreements for R3 and R4 had not been signed by the resident within five working days after the resident's acceptance by the assisted living facility.

Based on record review and interview the manager failed to ensure a resident had a written service plan signed by a nurse or medical practitioner who reviewed the service plan when initially developed and when updated, for three of four residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 6, 2023, for personal care services including medication administration. However, the service plan had not been signed by a nurse or medical practitioner. 2. A review of R2's medical record revealed service plans, dated May 16, 2023 and October 30, 2022, for personal care services including medication administration. However, the service plans had not been signed by a nurse or medical practitioner. 3. A review of R4's medical record revealed a service plans, dated May 15, 2023 and November 8, 2022, for personal care services including medication administration. However, the service plans had not been signed by a nurse or medical practitioner. 4. In an interview, E1 and E2 acknowledged R1's, R2's and R4's service plans had not been signed by a nurse or medical practioner.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for three of four residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, updated May 16, 2023, for personal care services including medication administration. 2. A review of R2's medical record revealed a medication administration record (MAR) dated July 2023. The MAR indicated R2 had been administered, "Banophen 25MG TAB," and "Gavilyte-G Sol," during the month of July 2023. 3. A review of R2's medical record revealed a list of medication orders dated October 27, 2022. However, the list did not include Banophen or Gavilyte. 4. A review of R2's medical record revealed a medication order from a medical practitioner for each of the medications administered to R2 was not available for review. 5. A review of R3's medical record revealed a service plan, updated May 16, 2023, for personal care services including medication administration. 6. A review of R3's medical record revealed a medication administration record (MAR) dated July 2023. The MAR indicated R3 had been administered, "Cephalexin 500mg cap," "Eliquis 5MG tab," "Fluoxetine 20MG cap," "Fluoxetine 40MG cap," "Gabapentin 300MG cap," "Glipizide 5MG tab," "Lisinopril 30MG tab," "Methadone HCL Intensol," "Pioglitazone 15 MG tab," "Rosuvastatin 10MG tab," "Tamsulosin 0.4MG Cap," "Trulicity 0.75/0.5 INJ," and "Cyclobenzapr 5 MG tab," during the month of July 2023. 7. A review of R3's medical record revealed a list of medication orders was not available for review. 8. A review of R3's medical record revealed a medication order from a medical practitioner for the medications administered to R3 was not available for review. 9. A review of R4's medical record revealed a service plan, updated May 15, 2023, for personal care services including medication administration. 10. A review of R4's medical record revealed a medication administration record (MAR) dated July 2023. The MAR indicated R4 had been administered, "Flovent HFA 110MCG," "Mirtazapine 30MG tab," and "Spiriva Handihlr Cap," during the month of July 2023. 11. A review of R4's medical record revealed a list of medication orders dated October 27, 2022. However, the list did not include Flovent, Mirtazapine, or Spiriva. 12. A review of R4's medical record revealed a medication order from a medical practitioner for each of the medications administered to R4 was not available for review. 13. In an interview, E1 and E2 acknowledged R2's, R3's and R4's medical records did not contain a medication order from a medical practitioner for each medication administered to each resident.

Based on record review and interview, the manager failed to ensure for a resident who requested or received behavioral care from the assisted living facility, a behavioral health professional or medical practitioner evaluated the resident at least once every six months throughout the duration of the resident's need for behavioral care, for one of three residents sampled who requested behavioral care. Findings include: 1. A review of R1's medical record revealed a document titled, "Determination for Admission" dated April 26, 2022, and signed by a medical practitioner. The document stated, "Does this person require behavioral care under the direction of a Licensed Behavioral Health Provider? This care may be provided by a trained Caregiver including administering prescribed psychotropic medications and redirection to manage behaviors. Yes." 2. Further review of R1's medical record revealed a document titled "Determination for residency to continue in the facility." The document stated, "Arizona state regulation R9-10-812 requires the Resident's Primary Care Provider (PCP) or Behavioral Health Professional (BHP) to review the facility's scope of services and agreed that the Resident's needs can be met by the Assisted Living Facility's Scope of Services. The PCP or BHP is required to examine the Resident at the onset of the condition or within 30 calendar days before acceptance and at least once every (6) six months throughout the duration of the Resident's condition(s)." However, the form had been left blank and was not signed by R1's PCP or BHP. 3. A review of R1's medical record revealed a psychiatric progress note dated February 7, 2023 from an outpatient behavioral health provider. The progress note stated, "Member continues to have poor insight and judgement regarding the need for mental health treatment. Member only attends appointments for injection due to staff bringing him to appointment. He continues to want off COT as he voiced he does not want to take medications. He does not feel he needs mental health treatment, thus without supervision he would likely not continue services. Due to this poor insight and judgement regarding the need for mental health treatment, it is recommended he continue with COT at this time." The progress note established R1 was receiving behavioral care as defined in R9-10-101.29.a.ii, which defines behavioral care to include, "behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and." 5. In an interview, E1 and E2 acknowledged documentation to demonstrate a behavioral health professional or medical practitioner evaluated R1 at least once every six months throughout the duration of R1's need for behavioral care was not available for review.