Vineyard Park of Surprise

Based on documentation review and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outdoor area and controlled or alerted employees to a resident’s egress. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide Directed Care Services. 2. The Compliance Officer observed multiple ambulatory residents. 3.A review of a communication log dated August 22, 2025 stated "During dinner time, the staff was brining all the residents to the dinning room for dinner and noticed that one of the resident's was not in the room...staff checked all the rooms...One of the staff saw him sitting at the courtyard...staff approached and noticed was weak and could not walk by self....resident was warm to touch...gave water to cool down...staff noticed not moving and head down...not responding...breathing was getting slower and blood pressure was low...911 called...was able to assess and able to get stable...was not sent to the hospital." 4. In an interview, E1 reported that the exterior door that R2 exited from, which led into the courtyard area, was not broken. However, the dietary kitchen staff used the door to deliver dinner, and the door did not close. E1 acknowledged that a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. 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 R2’s medical record revealed a service plan which indicated R2 received medication administration. The review revealed a medication order dated October 10, 2023, for “TORSEMIDE 10 MG TABLET TAKE 1 TABLET BY MOUTH ONCE DAILY.” The review further revealed a medication administration record (MAR) dated June 2025 which indicated R2 did not receive torsemide on June 2-3, 2025, as the “Medication [was] Not Available.” 2. A review of R3’s medical record revealed a series of service plans which indicated R3 received medication administration. The review revealed a medication order dated April 22, 2025, for the following medications: - “Atorvastatin Calcium Oral Tablet 40 MG…Take one tablet by mouth daily;” - “Jardiance Oral Tablet 10 MG…Take one tablet by mouth daily;” - “Tamsulosin HCI Oral Capsule 0.4 MG…Take one tablet by mouth every evening;” and - “Xarelto Oral Tablet 15 MG…take 1 tab daily.” The review further revealed a MAR dated June 2025 which indicated the following: - R3 did not receive atorvastatin on May 23-25 and 28-29, 2025, as the “Medication [was] Not Available;” - R3 did not receive Jardiance on May 23-26 and 28-29, 2025, as the “Medication [was] Not Available;” - R3 did not receive tamsulosin on May 2-3 and 6-15, 2025, as the “Medication [was] Not Available;” and - R3 did not Xarelto on May 22-26 and 28-29, 2025, as the “Medication [was] Not Available.” 3. In an interview, E1 acknowledged medications administered to R2 and R3 were not administered in compliance with medication orders. This is a repeat citation from the complaint and compliance inspection completed on October 17, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan July 17, 2024 that indicated R1 received the following services: - Personal hygiene assist - Set up/Stand by/Cueing - Resident requires staff assistance with Set up/Stand by/Cueing for daily hygiene tasks. 2. A review of R1's activities of daily living (ADL) documentation for January 2025, revealed documentation of the following services: - Personal Hygiene Assist - 8:00AM and 8:00PM - Documented as completed on the following dates: - January 2, 2025 at 8:00AM; - January 6, 2025 at 8:00AM; and - January 7, 2025 at 8:00AM. However, no other documentation of Personal Hygiene assistance being provided was available. 3. A review of R2's medical record revealed a June 2024 service plan that indicated R2 was to receive the following services: - Behavior-Exit Seeking - Redirect; - Dressing - Set up/Stand by/Cueing; - Encourage resident to hydrate with fluids and eat snacks; - Laundry Assist - Total; - Housekeeping - Weekly Room Clean; - Housekeeping - Daily Bed Making, Daily Trash Removal; and - Supervision/Monitoring - "Resident requires staff monitoring 3-4x for safety." 4. A review of R1's activities of daily living (ADL) documentation for January 2025, revealed documentation of the following services being provided on the following dates: - Dressing - Set up/Stand by/Cueing: - January 2, 2025 - January 4,2025 and January 8, 2025; - Housekeeping - Daily Bed Making: - January 4, 2025; - Housekeeping - Daily Trash Removal: - January 4, 2025; and - Monitoring/Supervision - "3-4x/shift": - January 4, 2025 - January 5, 2025 - January 7, 2025 - January 9, 2025. However, no other documentation of assisted living services in R2's service plan being provided was available and R2 was documented as being out of the facility from January 4, 2025 through the time of review. 4. In an interview, E4 reported R1's and R2's had received all assisted living services documented in R1's and R2's although they were not documented correctly. In an interview, E3 and E4 acknowledged a caregiver failed to document the services provided in R1's and R2's medical record.