The Groves Assisted Living Place Llc-lemon

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 documentation revealed an evacuation drill had been conducted on January 4, 2023. However, an evacuation drill conducted on or before July 4, 2023 was not available for review. 2. In an interview, E1 acknowledged documentation of evacuation drills conducted at least once every six months had not been provided to the Compliance Officer upon request.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the hot water temperature measured at 134.1\'b0 F in a shared bathroom. 2. In an interview, E1 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On May 26, 2023, the Compliance Officer requested the following documents during the on-site inspection: - Documentation of notification of the Department of R1's death; and - A copy of R1's advanced directive. However, this documentation was not provided. 2. In an interview, E1 reported the facility had not notified the Department of R1's death. E1 reported R1's advanced directive was never obtained by the facility prior to R1's death. E1 acknowledged this documentation had not been provided for review.

Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. \'a7 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures, last reviewed August 1, 2021, revealed a policy titled, "Suspicious death." This policy stated, "Arizona Department of Health regulation R9-10-803.K.1. requires that a manager provide written documentation to the Department of a resident's death, if the resident's death is required to be reported according to A.R.S. 11-593 within one working day after the resident's death...Death occurring suddenly when in apparent good health...When death of a resident occurs and the Manager believes the death resulted due to one of the above a written circumstances a written report including all the information regarding the death should be faxed to the Arizona Department of Health Services at 520-628-6991 within one day of the resident's death." 2. A review of R1's medical record revealed an incident report dated February 23, 2023 at 8:00 pm. The incident report stated, "I went to say good night like I will do when I am at the facility and check what the emergency room said to [R1]. I saw [R1] was not moving. I checked [R1] pulse, [R1] didn't have any. [R1] was sitting down watching TV, none response, pallid. I said, '[R1] answer me, don't be playing games,' but [R1] non response. I immediately called 911, they ask me if [R1] didn't have pulse, I said, 'No.' I waited until we get there, 8:23 time went by I did a 2nd call because it was taking to long for them to arrive. I call again at 9:45 pm I said no one is here. They said 2 police are on their way. 10:15 3 officers arrived. The police officers lay the body on the bed, one of the officer pronounced dead at the scene in [R1's] room." 3. A review of Department records revealed notification of R1's death had not been received from the facility within one working day after February 23, 2023. 4. In an interview, E1 acknowledged R1's death was unexpected. E1 reported R1 had been sent to the hospital on February 22, 2023 for neck and back pain. They initially tried to send R1 to the Veteran's Hospital, but R1's vitals were normal and the Veteran's Hospital refused to admit R1. They ended up sending R1 to a Banner Hospital via non-emergency transportation. E1 reported R1 was discharged back to the facility on February 23, 2023 at approximately 4 pm. There was a new order for a blood pressure medication but no other significant findings were communicated to the facility by the hospital. E1 reported R1 ate dinner, went outside to smoke

Based on documentation review, record review, and interview, the manager failed to implement an ongoing quality management program that, at a minimum, included a method to identify, document, and evaluate incidents. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures, last reviewed August 1, 2021, revealed a policy titled "Quality Management." This policy stated "...Incidents involving contacting medical services will be documented on a written incident report form. The incident report form will identify the date, time, and location of the incident involving the resident..." 2. A review of R2's medical record revealed an incident report. The incident report indicated the time was 6:00 pm and the incident occurred in R2's room. However, the incident report did not include the date of the incident. The incident report stated, "[R2] was on the floor and a mess of books and papers was also on the floor. [R2] had a bruise on [R2's] head and also in [R2's] interior right arm." The incident reported stated medical services were contacted, "...Nurse was also called but no response from her..." 3. A review of R2's medical record revealed an incident report. The incident report indicated the location of the incident was, "room." However, the incident report did not include the date or the time of the incident. The incident report stated, "[R2] was really confuse, call nurse and they come and check [R2] did blood work, urine sample, then call back with result order were said to send [R2] to hospital.... Instructions was to send to hospital." 4. In an interview, E1 acknowledged the incident reports for R2 did not include the dates of the incidents as required by the facility's quality management policy.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained a copy of the resident's health care directive, for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures, reviewed August 1, 2021, revealed a policy titled, "Health Care and Advanced Directives." This policy stated, "...2. The resident and/or the representative will be asked to provide the facility with a copy of their Health Care Directives (Living will, Health care power of attorney, or DNR). This documentation will be maintained in the resident's medical record. If the resident does not have this documentation the resident and/or resident's representative will be instructed on the Policy and Procedure for obtaining Health Care Directives....A copy of the resident's Health Care Directives will be maintained in the resident's medical record and followed by the caregivers." 2. A review of R1's medical record revealed a form titled, "The Groves Assisted Living Place LLC, Initial Physician Plan of Care." This form stated, "this person's code status is: DNAR/DNR." 3. A review of R1's medical record revealed a form titled, "Licensed Medical Provider Authorization for DNR." This form stated, "Your Patient has an Advanced Directive and/or a Pre-hospital medical care directive (commonly known as a Do Not Resuscitate, DNR, or orange form). In order for our facility to honor your patient's wishes, we require an order to allow a natural death. Please review and sign the order below so we can continue to provide the appropriate care and services to your patient. [R1] has an advanced directive and/or a pre-hospital medical care directive. Staffs are to provide medical interventions, such as the Heimlich maneuver or other therapies deemed necessary to provide emergency intervention, comfort care, or alleviate pain. I fully expect the staff at this facility to contact myself, or the hospice provider should there be one, for instructions immediately concerning any emergency situation. I also expect that my patient will be transported to a hospital or other appropriate facility for skilled care when necessary, as determined by emergency personnel or my patient's hospice provider, and wanted by my patient or their legal representative." The form was signed and dated by a medical practitioner. 4. A review of R1's medical record revealed an incident report dated February 23, 2023 at 8:00 pm. The incident report stated, "I went to say good night like I will do when I am at the facility and check what the emergency room said to [R1]. I saw [R1] was not moving. I checked [R1] pulse, [R1] didn't have any. [R1] was sitting down watching TV, none response

Based on record review, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering medication, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a Medication Administration Record (MAR) dated February 2023. The MAR included the name of E2 and their initials at the bottom of the MAR and on various days and times to indicate E2 had administered those medications. However, The MAR had five different initials, indicating medication had been administered by four additional caregivers whose names were not included on the MAR. 2. A review of R2's medical record revealed a Medication Administration Record (MAR) dated February 2023. The MAR included the name of E2 and their initials at the bottom of the MAR and on various days and times to indicate E2 had administered those medications. However, The MAR had five different initials, indicating medication had been administered by four additional caregivers whose names were not included on the MAR. 3. In an interview, E1 acknowledged some of the personnel administering medications at the facility had failed to include their name on the MAR.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication, and false and misleading documentation was provided to the Department. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 18, 2022, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed medication order dated November 8, 2022. This medication order included: - "Metformin Tab 500 MG, 500 MG daily PO"; - "Rosuvastatin, 2.5 MG PO QHS"; - "Tamsulosin 0.4 MG PO daily"; - "Carboxymethylcellulose NA 0.5% ophthalmic solution 1 drop PRN QID"; - "Acetaminophen 500 MG PO Q6 HRS PRN"; and - "Losartan 100 mg, 100 mg PO daily." 3. A review of R1's medical record revealed a prescription dated February 23, 2023, which stated, "Hydrochlorthiazide 25 MG Tabs, Take one tablet by mouth every day." 4. A review of R1's medical record revealed an incident report dated February 22, 2023 at 2:42 pm, which stated, "[R1] complain about shortness of breath, when [R1] had a pain from [their] neck all the way to [their] back. Check all vital signs were good / ask when the shortness of breath started, [R1] said this morning. I call at 2:42 pm to the VA hospital, give vital signs to the nurse on the phone, talk to [R1] who explained, told me [not] to send [R1] to the hospital because at that moment all vital signs were good. I call the non-emergency number they told me to get [R1] ready by 6 pm they will pick [R1] up and if something changes to call 911. [R1] went out to smoke. [R1] was good all afternoon, nothing changed, [R1] got ready to be picked up by 6 pm, keep checking [R1's] vital signs every hour. 5. In an interview, E1 reported the VA hospital refused to admit R1 but they were able to get R1 transported to a Banner hospital. E1 reported R1 left the facility around 6 p.m. after dinner and the hospital kept R1 over night and R1 returned to the facility at around 4 p.m. on February 23, 2023. 6. A review of R1's medical record revealed an incident report dated February 23, 2023 at 8:00 pm. The incident report stated, "I went to say good night like I will do when I am at the facility and check what the emergency room said to [R1]. I saw [R1] was not moving. I checked [R1] pulse, [R1] didn't have any. [R1] was sitting down watching TV, none response, pallid. I said, '[R1] answer me, don't be playing games,' but [R1] non response. I immediately called 911, they ask me if [R1] didn't have pulse, I said, 'No.' I waited until we get there, 8:23 time went by I did a 2nd call because it was taking to long for them to arrive. I call again at 9:45 pm I said no one is here. They said 2 police are on their way. 10:15 3 officers arrived. The police officers lay the body on the bed, one

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R2's medical record revealed an undated incident report. The incident report stated, "[R2] was really confuse, call nurse and they come and check [R2] did blood work, urine sample, then call back with result order were said to send [R2] to hospital.... Instructions was to send to hospital." 2. In an interview, E1 reported R2 never returned from the hospital. E1 acknowledged the incident report did not document notification of R2's emergency contact.