Tucson Mountain Assisted Living Home

Based on record review, and interview, for one of one 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 R1's medical record revealed a service plan, updated November 13, 2023, for personal care services. However, an updated service plan, dated on or before May 13, 2024, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R1.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of one sampled residents who received medication administration. Findings include: 1. A review of R1's medical record revealed a service plan, updated November 13, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated September 16, 2024, which included and order for sliding scale insulin. 3. A review of R1's medical record revealed an Medication Administration Record (MAR) dated September 2024. The MAR documented the medications administered to R1 during the month of September, 2024, and documented R1's blood sugar reading prior to each scheduled time of insulin administration. However, the MAR included multiple empty sections, where documentation of R1's blood sugar and documentation of medication administration had not been completed. 4. In an interview, E1 acknowledged the MAR provided for R1 did not accurately document the medications administered to R1.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of a posted work schedule, dated January 2024, revealed the following: - The schedule stated, "All care given by E1 24/7 unless noted"; - The schedule indicated E2 worked at, "7:00 AM [E2] 7pm-7am" on each Monday and Tuesday; - The schedule indicated E3 worked at ,"7pm-7am," on each Tuesday; - The schedule indicated E4 worked at, "7:00 AM [E4] 7 pm," on each Wednesday and Thursday; - The schedule indicated E2 worked at, "7am-7am," on each Friday; and - The schedule indicated E3 worked at, "7am-7am," on each Saturday and Sunday. 2. In a telephonic interview, E1 described the shift pattern as a mixture of 24 hour and 12 hour shifts. 3. A review of facility disaster drills and evacuation drills conducted during the previous twelve months revealed documentation of the following drills: - January 10, 2024, no time noted, a staff only drill (Disaster Drill); - October 1, 2023, no time noted, a staff and resident drill (Evacuation Drill); - July 1, 2023, no time noted, a staff only drill (Disaster Drill); - April 7, 2023, 10:30 AM, a staff and resident drill (Evacuation Drill); and - January 5, 2023 at 1 PM, a staff only drill (Disaster Drill). 4. In a telephonic interview, E1 acknowledged the provided documentation of disaster drills did not include documentation of disaster drills conducted on each shift at least once every three months. Technical assistance for this rule was provided during the on-site compliance inspection conducted on February 22, 2023.

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", dated May 18, 2018, which stated, "...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 Medical Record.....please see attached Numeric Pain Rating Scale." 2. A review of R1's medical record revealed a service plan, updated November 13, 2023, for personal care services including medication administration. 3. A review of R1's medical record revealed a signed list of medication orders dated April 21, 2023. The list included the order, "Tramadol 50 MG, 1 tab PO Q6hrs PRN." 4. During the on-site inspection, the facility received a fax from R1's doctor with an order for, "Tramadol, 50 MG, Take 1 tab at bedtime as needed." 5. A review of R1's medical record revealed a Medication Administration Record (MAR) dated January 2024. The MAR indicated R1 had been administered 50 milligrams of Tramadol at 8 PM on each day in January, 2024 except January 27, 28, and January 31, 2024. 6. A review of R1's medical record revealed a pain scale record, or other documentation of assessment and monitoring of R1 related to the administration of the opioid medication, was not available for review. 7. In a telephonic interview, E1 acknowledged the caregivers administering opioids to R1 had not documented the identification of the R1 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.