The Forum at Tucson

Based on record review and interview, for two of two sampled residents who required behavioral care, the manager failed to ensure a service plan included the psychosocial interactions or behaviors for which the resident required assistance, the psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. Findings include: A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Trintillex 20 mg tablet, take 1 tablet by mouth daily for depression." A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Buspirone HCL 30 MG tablet, take 1 tablet by mouth twice daily for depression." A review of R1's medical record revealed a doctor's note, dated February 3, 2026, which stated, "[R1] is treated in our office by [R1's medical practitioner] and it is medically necessary for [R1] to take the Clonazepam 1 mg QHD (nightly) for anxiety and sleep." A review of R1's medical record revealed a service plan, dated June 13, 2025. The service plan included a list of medical diagnoses, including "Paranoid Delusion," "Suicidal Ideation," and "Depression." However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, the psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. A review of R2's medical record revealed a document titled "Physician Health Statement and Admission Orders." The form was not signed or dated, but indicated the following: "Behavioral/Mental Health Conditions: Suicide Ideations, Depression -> Controlled by Rx Cymbalta." A review of R2's medical record revealed a document titled "Doctor's Progress Note," dated September 29, 2025. The note was signed and stated, "[R2's] SI Dx has been cleared. Depression Dx is controlled by Cymbalta Rx." A review of R2's medical record revealed a service plan, dated October 30, 2025, for personal care services. The service plan included a list of medical diagnoses, including "Major Depressive Disorder, single episode, severe without psychotic features," and "Major depressive disorder, recurrent." However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, the psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's service plan was updated at least once every six months, for two of nine sampled residents receiving personal care services. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: A review of R1's medical record revealed a service plan dated June 13, 2025, for personal care services. Based on the date of R1's service plan, an update was required by December 31, 2025. A review of R3's medical record revealed a service plan dated February 5, 2025, for personal care services. Based on the date of R3's service plan, an update was required by August 31, 2025. . In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on January 15, 2025.

Based on record review and interview, the manager failed to ensure a service plan, when initially developed and when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse, medical practitioner, or behavioral health professional who reviewed the service plan, for two of nine sampled residents. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include. A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Trintillex 20 mg tablet, take 1 tablet by mouth daily for depression." A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Buspirone HCL 30 MG tablet, take 1 tablet by mouth twice daily for depression." A review of R1's medical record revealed a doctor's note, dated February 3, 2026, which stated, "[R1] is treated in our office by [R1's medical practitioner] and it is medically necessary for [R1] to take the Clonazepam 1 mg QHD (nightly) for anxiety and sleep." A review of R1's medical record revealed a service plan, dated June 13, 2025. The service plan included a list of medical diagnoses, including "Paranoid Delusion," "Suicidal Ideation," and "Depression." However, the service plan had not been reviewed and signed by a medical practitioner or behavioral health professional. A review of R2's medical record revealed a document titled "Physician Health Statement and Admission Orders." The form was not signed or dated, but indicated the following: "Behavioral/Mental Health Conditions: Suicide Ideations, Depression -> Controlled by Rx Cymbalta." A review of R2's medical record revealed a document titled "Doctor's Progress Note," dated September 29, 2025. The note was signed and stated, "[R2's] SI Dx has been cleared. Depression Dx is controlled by Cymbalta Rx." A review of R2's medical record revealed a service plan, dated October 30, 2025, for personal care services. The service plan included a list of medical diagnoses, including "Major Depressive Disorder, single episode, severe without psychotic features," and "Major depressive disorder, recurrent." However, the service plan did not include any signatures. In an exit interview with E1, and E2, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site Compliance Inspection conducted on November 30, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in a resident's medical record, for one of nine sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: A review of R2's medical record revealed a service plan, dated October 30, 2025, for personal care services. A review of R2's medical record revealed a form titled "Task Administration Record" (ADL) dated February 2026. This form documented the services provided to R2 on each day in February 2026. This form documented the following: For the service, "Fall Intervention: Safety reminders on each shift": The service had been initialed as provided between February 1 and February 9, 2026. On February 10, 2026, at 5:00 AM, the service had been marked "refused." On February 10, 2026, at 1:30 PM, the service had been marked "out of facility." On February 10, 2026, at 9:00 PM, the service had been initialed as provided On February 11, 2026, at 5:00 AM, the service had been marked "refused." On February 11, 2026, at 1:30 PM, the service had been marked "out of facility." On February 11, 2026, at 9:00 PM, the service was marked "refused." On February 12, 2026, at 5:00 AM, the service had been marked "out of facility." On February 12, 2026, at 1:30 PM, the service had been marked "refused." On February 12, 2026, at 9:00 PM, the service had been marked "out of facility." On February 13, 2026, at 5:00 AM, the service had been initialed as provided. On February 13, 2026, at 1:30 PM through the end of the month, the form was marked "HOS," to indicate the resident was at the hospital. For the service, "Fall Intervention: Safety Checks and reminders each shift," the service included identical entries to the previous service, except this service had been initialed as provided on February 11, 2026, at 9:00 PM. A review of facility incident reports revealed an incident report for R2, dated February 10, 2026, at 1:57 PM. The incident report stated, "Resident was found on the floor by the housekeeper as I was walking down the hallway [the housekeeper] called me to come help the resident...resident stated [R2's] legs gave in and [R2] fell...I put a washcloth on [R2's] right side forehead to stop [R2's] bleeding...Resident was sent to [an area hospital]." The incident report indicated R2's physician was notified at 7:56 PM on February 11, 2026, and R2's representative was notified on February 10, 2026, at 1:30 PM. In an interview, E2 reported R2 had not returned from the hospital since February 10, 2026, and the ADL documentation indicating services had been provided or refused after February 10, 2026, was not accurate. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site complaint inspection conducted on February 28, 2024.

Based on record review 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 five sampled residents receiving medication administration. Findings include: A review of R1's, R5's, and R8's medical records revealed each resident had a service plan which included medication administration. A review of R1's, R5's, and R8's medical records revealed each resident had a medication administration record (MAR) dated February 2026, which detailed the medications administered to each resident. A review of R1's, R5's, and R8's medical records revealed signed orders from a medical practitioner for each medication administered to R1, R5, and R8 had not been provided for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager retained two of two sampled residents who required behavioral care without meeting the requirements, to include documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. Findings include: A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Trintillex 20 mg tablet, take 1 tablet by mouth daily for depression." A review of R1's medical record revealed a prescription, dated November 5, 2025, for "Buspirone HCL 30 MG tablet, take 1 tablet by mouth twice daily for depression." A review of R1's medical record revealed a doctor's note, dated February 3, 2026, which stated, "[R1] is treated in our office by [R1's medical practitioner] and it is medically necessary for [R1] to take the Clonazepam 1 mg QHD (nightly) for anxiety and sleep." A review of R1's medical record revealed a service plan, dated June 13, 2025. The service plan included a list of medical diagnoses, including "Paranoid Delusion," "Suicidal Ideation," and "Depression." A review of R1's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident prior to admission and at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility, was not available for review. A review of R2's medical record revealed a document titled "Physician Health Statement and Admission Orders." The form was not signed or dated, but indicated the following: "Behavioral/Mental Health Conditions: Suicide Ideations, Depression -> Controlled by Rx Cymbalta." A review of R2's medical record revealed a document titled "Doctor's Progress Note," dated September 29, 2025. The note was signed and stated, "[R2's] SI Dx has been cleared. Depression Dx is controlled by Cymbalta Rx." A review of R2's medical record revealed a service plan, dated October 30, 2025, for personal care services. The service plan included a list of medical diagnoses, including "Major Depressive Disorder, single episode, severe without psychotic features," and "Major depressive disorder, recurrent." A review of R1's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident prior to admission and at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility, was not available for review. In an exit interview with E1 and E2, the f

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for three of five sampled residents receiving medication administration. Findings include: A review of R1's medical record revealed a medication order, dated December 17, 2025, which included, "...Hydroxyzine pamoate 25 mg, twice a day." A review of R1's medical record revealed a prescription, dated November 10, 2025, for "Hydroxyzine pamoate 25 mg oral capsule, take 1 oral capsule 2 times a day." A review of R1's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR documented administration of the following medication: "Hydroxyzine Pamoate, 25 mg oral capsule. Give 1 tablet by mouth every 12 hours as needed for anxiety," had not been administered on any day in February 2026. A review of R1's medical record revealed an order for Hydroxyzine, dated after December 17, 2025, to change the medication to "as needed," was not available for review. A review of R8's medical record revealed unsigned discharge orders from a skilled nursing facility, dated January 30, 2026, as signed orders were not available for review. This order list included: "Carvedilol Oral Tablet, 3.125 MG, Directions, Give 1 tablet by mouth two times a day for HTN Hold for BP <100/70 Pulse <70." A review of R8's medical record revealed a MAR dated February 2026. The MAR documented the administration of "Carvedilol Oral Tablet, 3.125 MG, Directions, Give 1 tablet by mouth two times a day for hypertension. Hold for BP less than 100/70 and Pulse rate less than 70." The MAR indicated the medication had been held in the morning on February 2, 3, 6, 10, 20, 21, and 22, 2026, and had been held in the evening on February 3, 2026, and February 5, 2026. A review of R8's medical record revealed blood pressure readings for R8 dated February 2026. These readings included the following issues: On February 9, 2026, at 10:51 AM, R8's pulse was 69; however, Carvedilol had not been marked as held; On February 11, 2026, at 10:15 AM, R8's diastolic blood pressure was 68; however, Carvedilol had not been marked as held; On February 12, 2026, at 7:20 AM, R8's diastolic blood pressure was 61 and R8's pulse was 63; however, Carvedilol had not been marked as held; On February 12, 2026, at 6:18 PM, R8's diastolic blood pressure was 68; however, Carvedilol had not been marked as held; On February 13, 2026, at 10:29 AM, R8's diastolic blood pressure was 68, and R8's pulse was 63; however, Carvedilol had not been marked as held; On February 14, 2026, at 09:17 AM, R8's diastolic blood pressure was 63; however, Carvedilol had not been marked as held; On February 16, 2026, at 09:58 AM, R8's pulse was 63; however, Carvedilol had not been marked as held; On February 17, 2026, at 09;10 AM, R8's diastolic blood pressure was 60, and R8's pulse was 62; however, Carvedilol had not been marked as held; On February 18, 20

Based on observation and interview, the manager failed to ensure food was stored free from spoilage and safe for human consumption. Findings include: During an environmental tour of the facility, the Compliance Officer observed an office in the secured memory care unit. The office door was closed and locked; however, the doorknob was loose and the Compliance Officer was able to open the door without the key. Inside the office, the Compliance Officer observed a refrigerator. The refrigerator contained a metal tray with several open packages of lunchmeats, each of which were moldy and spoiled. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, when a resident had an accident resulting in the resident needing medical services, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider. Findings include: A review of facility incident reports revealed an incident report for R2, dated February 10, 2026 at 1:57 PM. The incident report stated, "Resident was found on the floor by the housekeeper as I was walking down the hallway [the housekeeper] called me to come help the resident...resident stated [R2's] legs gave in and [R2] fell...I put a washcloth on [R2's] right side forehead to stop [R2's] bleeding...Resident was sent to [an area hospital]." The incident report indicated R2's physician was notified at 7:56 PM on February 11, 2026, and R2's representative was notified on February 10, 2026, at 1:30 PM. The time of the incident was not clear from the report; however, the physician had not been notified immediately after the other notifications had been made. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of five sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated December 14, 2025, for personal care services. The service plan required caregivers to provide the following services: "Daily Safety Check. Non Scheduled Item. Resident's needs/preferences: Staff will regularly monitor resident for attendance and safety."; "Housekeeping: weekly cleaning. non scheduled item. Resident's needs/preferences: Weekly - Vacuuming, dusting, emptying trash, and sanitizing bathroom"; and "Laundry: Weekly service (Housekeeping Staff) Daily @ As Needed, Resident's needs/preferences: Laundry will be washed, dried, folded/hung up and put away in resident's room weekly. This includes linens and personal items. Service performed by housekeepers." 2. A review of R2's medical record revealed a document titled "Task Administration Record" (ADL) dated December 2025. The task record documented the services provided to R2 during the month and included the following entries: The ADL did not include documentation of safety checks; The ADL included a task titled "Daily Trash Removal," which had been provided on December 1 through December 13, and had not been provided December 14, through December 31. Additionally, this task and schedule did not match the service plan task; and The ADL included three similar tasks titled "Laundry: Weekly Service (CARE STAFF), Friday, Overnight Shift, scheduled at "2:00 PM," "PM" and "11:45 PM." However, each ADL had been provided one time during the month of December. The 2:00 PM laundry task was completed on December 24, the PM task was completed on December 26, and the 11:45 PM task was completed on December 24, 2025. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the complaint inspection conducted February 28, 2024.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of ten residents sampled. The deficient practice posed a risk as there was no timely service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan dated July 10, 2024. However, July 10, 2024 was more than 14 calendar days after R2's date of acceptance and a previous service plan was not available for review. 2. In an interview, E1 acknowledged a completed service plan, dated no later than 14 days after R2's date of acceptance, had not been provided for review.

Based on record review, and interview, the manager failed to ensure a resident had a written service plan which accurately included the level of service the resident was expected to receive, for two of ten residents sampled. Findings include: A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R1's medical record revealed a service plan, dated March 31, 2024, for personal care services. However, the service plan did not include any personal care services and had not been updated at least every once every six months. 2. In an interview, E8 reported R1 was receiving Supervisory care and the service plan was incorrect. 3. A review of R6's medical record revealed a service plan, dated October 9, 2024. However, the service plan did not include the level of care R6's was expected to receive. 4. In an interview, E1 acknowledged the service plan provided for R1 had not correctly identified the level of care R1 was expected to receive and R6's service plan did not include the level of care R6 was expected to receive.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medications, for two of ten residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 10, 2024, for directed care services. The service plan stated, "Bathing.. I will maintain current level of function in bathing...I need physical assist with bathing, but i can participate in part of the bathing activity.. My Caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to the nurse and coordinator." However, the service plan did not include the amount, type, and frequency of the bathing service to be provided to R2. 2. A review of R3's medical record revealed a service plan, dated December 17, 2024, for personal care services. The service plan stated, "Bathing.. I will maintain current level of function in bathing-assist...I require staff standby supervision, set up, verbal cues and/or reminders to complete tasks...my caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to the nurse and coordinator...My caregivers will observe the skin for any redness, open areas, scratches, cuts, tears, bruises/discolorations and report any changes to the nurse." However, the service plan did not include the frequency of the bathing service to be provided to R3. 3. In an interview, E1 acknowledged R2's and R3's service plans did not include the type, amount, and frequency of the bathing service.

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 ten residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 10, 2024, for directed care services. The service plan did not include hospice services. 2. A review of R2's medical record revealed R2 enrolled with hospice services on September 25, 2024. 3. A review of R2's medical record revealed an updated service plan, dated on or before October 9, 2024, was not available for review. 4. In an interview, E1 acknowledged R2's service plan had not been updated within 14 calendar days after R2 had a significant change in condition requiring hospice services.

Based on record review, and interview, for one of seven residents sampled, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R5's medical record revealed a service plan, dated May 11, 2024, for personal care services. However, an updated service plan, dated on or before November 11, 2024, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R5.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of three residents sampled receiving directed care services. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated July 10, 2024. However, a required service plan update, dated on or before October 10, 2024, was not available for review. 2. In an interview, E1 acknowledged R2's updated service plan had not been provided for review.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of ten residents sampled. Findings include: 1. A review of R6's medical record revealed a service plan dated October 9, 2024. The service plan documented R6 required the following assisted living service: "I have altered cardiovascular status, I will be free from any s/sx of cardiovascular distress related to hypertension...My caregivers will monitor for any signs and symptoms of Hypertension with daily BPs." 2. A review of R6's medical record revealed R6's blood pressure had been documented on October 9, 2024 and on December 10, 2024. 3. In an interview, E1 acknowledged that a caregiver did not provide a resident with the assisted living services in the resident's service plan.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of ten residents sampled who received medication administration. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R3's medical record revealed a service plan, dated December 17, 2024, for personal care services including medication administration. 2. A review of R3's medical record revealed an order, dated August 30, 2024, which included the following: - "Clobetasol 0.05% scalp solution, few drops once a day at bedtime to the open wound on the right parietal scalp for two weeks, take 1 week off, then restart the treatment for two weeks"; and - "Hydrocortisone 2.5% topical cream, Apply to the rash in groins once a day in the morning for up to one month as needed." 3. A review of R3's medical record revealed an electronic Medication Administration Record (eMAR) dated January 2025. The MAR documented the following: - "Clobetasol Propionate External Liquid 0.05%," was scheduled for administration at bedtime and had been administered on each day in January 2025; and - "Hydrocortisone External Kit 2.5%," was scheduled for administration in the morning and had been administered on each day in January 2025. 4. A review of R3's January 2025 eMAR revealed R3 had been administered, "Triamcinolone Acetonide External Cream 0.1% Apply to arms, shoulders topically two times a day for itching," on each day at 09:00 and at 20:00. 5. A review of R3's medical record revealed an order for Triamcinolone was not available for review. 6. In an interview, E1 acknowledged R3's medical record did not document medication had been administered to R3 as ordered. This is a repeat deficiency from the on-site compliance inspection conducted November 30, 2023.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility evacuation drills revealed an evacuation drill conducted on May 6, 2024. However a second evacuation drill conducted on or before November 6, 2024 was not provided for review. 2. A review of facility evacuation drills revealed a drill conducted on September 30, 2024. However, the evacuation drill did not include the time taken to evacuate, and did not include a list of residents needing assistance to evacuate or a list of residents who did not evacuate. 3. In an interview, E8 reported the facility did one full evacuation drill and one partial evacuation drill which did not involve residents. 4. In an interview, E1 acknowledged the facility's documentation of evacuation drills for employees and residents, conducted at least once every six months, had not been provided for review.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents included all individuals on the premises. Findings include: 1. A review of facility evacuation drills revealed a drill conducted on September 30, 2024. However, the evacuation drill did not include the time taken to evacuate, and did not include a list of residents needing assistance to evacuate or a list of residents who did not evacuate. 3. In an interview, E8 reported the facility conducted one full evacuation drill in May 2024 and one partial evacuation drill in September 2024 which did not involve residents. 4. In an interview, E1 acknowledged the facility's evacuation drill conducted on September 30, 2024 had not included all individuals on the site.

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer an opioid in treating a patient documented in the resident's medical record the effect of the opioid administered, for one of one resident sampled who received medication administration of an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Opioid Administration and Assistance in the Self Administration of Prescribed Opioids." The policy stated "Following administration or taking an opioid medication by the resident, the licensed nurse or medication technician will record the effectiveness of the medication at relieving the pain..." 2. A review of R6's medical record revealed a service plan dated October 9, 2024, for personal care services including medication administration. 3. A review of R6's medical record revealed an electronic medication administration record (eMAR) dated January 2025. The eMAR documented "Hydrocodone-Acetaminophen Oral Tablet 7.5-325MG" had been administered at, "AM," "MD," "PM1," and "HS1," on each day between January 1, 2025, and the day of the on-site inspection. The eMAR documented an assessment of R6's need for the medication, however, documentation of the effectiveness of the medication was not available for review. 4. In an interview, E1 acknowledged the effect of the Hydrocodone administered to R6 during January 2025, had not been documented in R6's medical record.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for six of eight residents sampled. Findings include: 1. A review of R1's, R3's, R4's, R5's, R6's, and R8's medical records revealed each resident had a current service plan which included the service, "I require safety checks by my caregivers every shift." 2. A review of R1's, R3's, R4's, R5's, R6's and R8's medical record revealed documentation of services provided to each resident on each shift. However, documentation of safety checks on each shift was inconsistent or unavailable. 3. In an interview, E1 acknowledged the services provided to each resident were not accurately documented in each resident's medical record.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan, and if a review was required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan, when initially developed and when updated, for four of nine residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated August 25, 2023. However, the service plan signature page was not provided for review. 2. A review of R3's medical record revealed a service plan dated November 25, 2023. However, the service plan signature page was not provided for review. 3. A review of R6's medical record revealed a service plan dated November 28, 2023. However, the service plan signature page was not provided for review. 4. A review of R7's medical record revealed a service plan dated August 30, 2023. However, the service plan signature page was not provided for review. 5. In an interview, E1, E2, and E3 acknowledged the service plan signature pages had not been provided for provided for R1, R3, R6, and R7.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for three of nine residents sampled. Findings include: 1. A review of R4's medical record revealed a service plan, updated September 20, 2023, which included medication administration. 2. A review of R4's medical record revealed an order,signed November 3, 2023, which stated, "Acetaminophen (Tylenol) 325 MG Tablet, Take 2 tablets by mouth three times a day. May also take 1 tablet every six hours as needed for pain. OK to CRUSH. Start Date 09/29/2023." 3. A review of R4's medical record revealed a medication administration record (MAR) dated November 2023. The MAR documented the medications administered to R4 during the month of November 2023. However, the MAR indicated the following: - "Acetaminophen ER Oral Tablet 650 MG, Give 1 tablet by mouth three times a day," had been administered three times per day on November 1, 2023 and November 2, 2023; - No Acetaminophen had been administered on November 3, 2023 through November 10, 2023; and - "Acetaminophen 325 MG, Give 2 tablets by mouth three times a day for pain," had started administration on November 11, 2023. 4. A review of R6's medical record revealed a service plan, updated November 28, 2023, which included medication administration. 5. A review of R6's medical record revealed current medication orders were not available for review. 6. A review of R6's medical record revealed a MAR dated November 2023. The MAR documented R6 had received administration of multiple medications during the month. 7. A review of R7's medical record revealed a service plan, updated August 30, 2023, which included medication administration 8. A review of R7's medical record revealed an order,signed October 15, 2023, which stated, "Amlodipine Besylate Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for Hypertension. Hold if SBP is less than 100, is DBP less than 50, if heart rate is less than 60." 9. A review of R7's medical record revealed a MAR dated November 2023. The MAR documented the medications administered to R7 during the month of November 2023. The MAR indicated R7 had been administered, "Amlodipine Besylate Oral Tablet 5 MG," on each day in November 2023. However, the MAR did not include documentation of R7's blood pressure or heart rate before each dose of the medication as required. 10. In an interview, E1, E2, and E3 acknowledged the provided orders and MARs for R4, R6, and R7 had included omissions or discrepancies and did not document all medications had been administered in compliance with a medication order for each resident.

Based on record review and interview, the manager failed to ensure a resident was provided a diet to meet the resident's nutritional needs as specified in the resident's service plan, for two of nine residents sampled. Findings include: 1. A review of R1's medical record revealed a current service plan dated June 16, 2023. However, R1's diet was not specified in the service plan as required. 2. A review of R4's medical record revealed a current service plan dated September 20, 2023. However, R4's diet was not specified in the service plan as required. 3. In an interview, E1, E2, and E3 acknowledged the service plans provided for R1 and R4 did not specify each resident's nutritional needs. Technical Assistance for this rule was provided during the on-site compliance inspection conducted on January 17, 2023.

Based on observation and interview, the manager failed to ensure the premises were free from a situation that may cause a resident to suffer physical injury. Findings include: 1. During an environmental tour, the Compliance Officer inspected a resident's bedroom in the secured memory care unit. In an unlocked medicine cabinet in the resident's private bathroom, the Compliance Officer observed a bottle of nail polish remover, a poisonous material. Due to the acuity of the residents in the unit, unsecured poisons represented a hazard which could cause a resident to suffer physical injury. 2. In an interview, E1, E2, and E3 acknowledged the premises were not free from a situation that may cause a resident to suffer physical injury.