Susan Care Home LLC

Based on documentation review, record review, and interview, the manager failed to ensure that documentation of medication administration showed the name and signature of the individual administering or providing assistance in the self-administration of medication for one of two residents reviewed. Findings include: 1. A review of documentation contained a policy and procedure which stated, "The trained caregiver will sign off the medication for the date and time the medication was given to the resident and the medications taken by initialing the medication administration record." 2. A review of R1's medical record contained a Medication Administration Record for March 2026. The MAR did not contain caregiver initials documenting the medication was administered for the following medications on March 23, 2026 for the 8:00 am administration time: Diltiazem 120 mg take one tablet daily Chlorthalidone 25 mg take one tablet daily 3. In an interview, E1 reported the medication was provided to the residents but "forgot" to document on the record. 4. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated June 21, 2023. This service plan stated "Bed Bound" and "*Bed bound residents repositioned every 2-3 hours". However, documentation was not available indicating R1 was repositioned September 1st - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation R1 was repositioned and reported the service was provided as indicated in the service plan.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R2's medical record revealed written service plans for directed care services dated July 18, 2022, October 17, 2022, January 17, 2023, April 17, 2023, and July 17, 2023. These service plans revealed no documentation of R2's weight and stated "Unable to weigh PCP approval on file". In addition, R2's record revealed no documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. In an interview, E1 acknowledged R2's service plan did not include documentation of R2's weight and documentation was not available in R2's record from a medical practitioner stating weighing R2 was contraindicated.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of three employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution..." 2. Review of E3's personnel record revealed E3 worked as a facility caregiver and had a hire date of July 1, 2023. The personnel record revealed a fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged documentation was not available showing E3's work references were obtained upon hire at the facility.