Serva Assisted Living of Scottsdale

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility's quality management program. The deficient practice posed a risk if the quality management program procedures were not implemented to effectively manage services provided. Findings include: 1. In documention review, the facility's policy titled "Quality Management," page 158 and 159, documented, "... The manager or Designee shall document monthly: Number/type of incidents, Number of residents experiencing falls; Number of residents experiencing weight loss; Number of residents with decubitus ulcers; Number of residents with possible Health Care Associated Infections; Number of residents reporting the loss of personal property/clothing; Number of errors in the documentation of medications (MARs), treatments, ADL's etc. provided to residents... Maintain a line graph for each of the above to identify trends from month month, Monthly meetings between the licensee or representative, the manager, any designees, service plan nurse, caregivers, and others as needed, to discuss each months findings and any identified trends... The monthly report shall be completed and maintained on a quarterly basis... An Assurance checklist will be performed by manager/caregiver/designee on a regular basis for at least once a month... A quarterly report will be compiled for residents having falls, medication errors,..." 2. In documentation review, the facility did not have documentation of monthly or quarterly quality management reports. 3. During an interview, E1 and E2 acknowledged the Quality Management program had not been implemented per the facility's policy and procedures, and reports had not been documented, as required. 4. This is a repeat deficiency from the compliance inspection conducted on July 5, 2022.

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure medications were administered in compliance with a medication order. Findings include: 1. The medical record for R2 was reviewed by the compliance officer during later morning hours on June 20, 2023. The medications for R2 were observed to be available on site during the inspection. 2. In record review, R2's medical record included a medication order for Metoprolol Tartrate 25 MG, take 1/2 tablet enterally twice daily... hold for SBP less than 100 or heart rate less than 60. 3. R2's Medication administration record (MAR), dated June 2023, did not include documentation R2's blood pressure and heart rate were measured at 5:00pm on June 19, 2023, and at 8:00am on June 20, 2023, and did not include documentation of whether or not R2 received the Metoprolol medication. 4. During an interview with E2, the compliance officer was unable to determine whether the Metoprolol medication was administered to R2, or not administered. E2 reported R2's blood pressure and heart rate were measured; however, [E2] was not able to locate documentation of the results. E1 and E2 acknowledged the medication administration and R2's blood pressure and heart rate were not documented as required. 5. This is a repeat deficiency from the prior compliance inspection conducted on July 5, 2022.

Based on observation, record review, and interview, for two of three residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a medication administered to a resident was not documented as administered. Findings include: 1. The medical records for R2 and R3 were reviewed by the compliance officer during later morning hours on June 20, 2023. The medications for R2 and R3 were observed to be available on site during the inspection. 2. In record review, R2's medical record included a medication order for Metoprolol Tartrate 25 MG, take 1/2 tablet enterally twice daily... hold for SBP less than 100 or heart rate less than 60. 3. R2's Medication administration record (MAR), dated June 2023, did not include documentation R2's blood pressure and heart rate were measured at 5:00pm on June 19, 2023, and at 8:00am on June 20, 2023, and did not include documentation of whether or not R2 received the Metoprolol medication. 4. During an interview with E2, the compliance officer was unable to determine whether the Metoprolol medication was administered to R2, or not administered. E2 reported R2's blood pressure and heart rate were measured; however, [E2] was not able to locate documentation of the results. 5. In record review, R3's medical record included medication orders for Anora Ellipta 62.5-25mcg/inh AEPB one puff inhale orally once daily, Aspirin 81mg, one tablet by mouth daily, Calcium 600+D3 600-800 mg, one tablet by mouth daily, Citalopram Hydrobromide 10 mg, one tablet by mouth once daily, cranberry 600 mg, one capsule by mouth every day, Keppra 250 mg, one tablet by mouth three times a day, Lovastatin 20 mg, one tablet by mouth at bedtime, Macular Health Formula, one capsule by mouth one daily, Lanoprost 0.0005 % solution, one drop in both eyes at bedtime, Timolol Maleate 0.5% Solution, one drop in the morning, Acetaminophen 325 mg tabs. 6. R3's MAR, dated June 2023, did not include documentation R3 received any medications on June 19, 2023, and the morning medications on June 20, 2023. 7. During an interview, E1 and E2 reported the medications were administered to R3 as ordered; however, the medication administration was not documented on the MAR at the time of administration, as required.

Based on documentation review and interview, the manager failed to ensure documentation of an evacuation drill included the time taken to evacuate the facility, and the names of all residents needing assistance during an evacuation. Findings include: 1. In documentation review, the facility's documentation of an evacuation drill conducted on January 2, 2023, did not include the time taken to evacuate the facility, and the names of all residents who needed assistance with evacuation. The documentation included only the names of two residents who needed assistance during the evacuation. 2. During an interview, the findings were reviewed E1 and E2, who acknowledged the time taken to evacuate the facility was not documented, and all residents, besides the two documented, were evacuated during the drill, and needed some type of assistance with evacuation; however, their names were not included in the documentation of the drill.