Bethesda Gardens.

“Based on documentation review, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident is not placed at risk of harm. The deficient practice posed a risk as R2 eloped from the facility.   Findings include:    1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2.  A review of facility policy and procedures revealed a policy titled “Elopement policy” which reported that once the staff determines that a resident is an “Elopement Risk,” the staff should create an individualized plan based on the resident’s wandering behavior. The care plan should identify the needs that may prompt that person to wander or elope, and develop interventions such as behavior logs, periodic checks, and strategies to engage and redirect people to safe wandering. The facility should identify residents with a history of wandering or confusion so that the staff can be alert to their needs.   3.  A review of facility documentation revealed an incident report dated February 14, 2026, which stated “around 4:30 pm, E1 was notified that R2 was not able to be located on the property. R2 was found by the Phoenix police when R2 was about to board a city bus at 8:19 pm on February 14, 2026.” 4. A review of R2’s medical record revealed a service plan dated December 3, 2025 which showed that R2 suffered from hallucinations, anxiety, exit seeking, high thyroid, dementia, and memory loss.   5. In an interview, E1 reported that during the facility investigation, E1 believed R2 left the facility when family members were helping a resident move in left and R2 possibly followed them. E1 also noted R2 was not determined to be an elopement risk.   6. In an interview, findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered, for one of ten residents sampled. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility. Findings include: 1. A review of facility documentation revealed an incident and investigative report dated February 14, 2026 for the elopement of R2 from the facility. 2. A review of facility documentation revealed that E1 provided written notification of R2's elopement to Adult Protective Services immediately after the incident occurred; however, E1 did not provide notification to the Department within 24 hours of the elopement being discovered, as required. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide the emergency responders with a written document that included all information required in A.R.S. § 36-420.04, for one of four residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings Include: 1. A review of R2's medical record revealed an incident that occurred on August 4, 2025. The incident report stated, “During morning medication pass at 5 am, staff went into the R2 room to let R2 know that R2's morning medication wasn’t available. When the staff walked in, they found R2 lying motionless in bed. Staff checked R2, and R2 was pale, cold, and R2's feet were turning purple. The staff checked vital signs, and there wasn’t any reading. The nurse and 911 were called.” 2. A review of Department documentation revealed an intake report dated August 3, 2025, which included sworn testimony that stated, “Staff/facility insufficient to meet patient need for safety and wellbeing as patient left unattended for extended period of time. Staff failed to provide a patient care report (DNR) per ARS 36-420.04, A9. Inappropriate utilization of the 911 system (deceased patient with known DNR). Bethesda Gardens-Phoenix's assisted living staff explains to the fire department that they have a DNR. When asked for it, the assisted living staff left to retrieve it and were notified that it must be present and would be an orange form. The fire department waited approximately 15 minutes until the staff admitted they were unable to find it. The fire department cleared the scene and returned to service.” 3. In an interview, E3 acknowledged that the documentation the fire department requested wasn’t given to the fire department.  4. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on the documentation review and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.   1.     A review of facility documentation revealed an incident report dated March 24, 2025. The incident report revealed that R1 suffered burns from a bathroom circulation fan that caught on fire.   2.     A review of facility documentation revealed no documentation showing how often the premises and equipment used at the assisted living facility were maintained.   3.     In an interview, E1 acknowledged that the premises were not free from conditions or situations that may cause a resident or other individual to suffer physical injury.”

“Based on the documentation review and interview, the manager failed to ensure that the equipment used at the assisted living facility was maintained in working order.   1.      A review of facility policies and procedures revealed a policy titled “Deep cleaning of residents' apartments.” The policy stated that cleaning the bathroom would include cleaning the vents. However, no documentation showed how often the vents were cleaned in the residents' apartments.   2.     A review of facility documentation revealed an incident report dated March 24, 2025. The incident report revealed that a bathroom vent caught fire and burned R1.   3.      In an interview, E1 reported that the facility does not check bathroom vents to ensure they are in working order.    This is a repeat deficiency from a compliance and complaint inspection conducted on February 15, 2024.”

“Based on documentation review, video review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.   Findings include:   1.      A review of department documentation revealed a complaint intake dated February 12, 2025, which reported that resident was not treated well. “The staff who assisted the resident back into bed after a fall pulled the covers over resident and completely covered resident head.”   2.      A review of video evidence revealed E5 helping R10 back into the bed and throwing a blanket over R10’s head.   3.      In an interview, E1 reported that E5's action was not acceptable behavior, and acknowledged that R10 was not treated with dignity, respect, and consideration. This is a repeat deficiency from a complaint inspection conducted on February 18, 2025.”

“Based documentation review, and interview the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.   Findings include:   1. Review of department documentation revealed a complaint intake dated February 18, 2025, which reported that a staff member came into R1's room in the presence of other staff, lifted R1's shirt, and rubbed R1's belly while making degrading comments about R1's appearance.   2.     A documentation review of E1 interviewing E3 regarding the allegations reported that E3 was speaking to another employee who was assisting R1 and the topic was about breast appearance. In the document E3 reported that “E3 was talking about E3 own appearance and what society wanted” it was not towards R1.   3.     In an interview, E1 reported that E1 spoke to E3 and reminded E3 about workplace conduct and how it is not okay to have conversations like that in front of residents.   4. In an interview, E1 reported that E3's conversation was not acceptable behavior, and acknowledged that R1 was not treated with dignity, respect, and consideration.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident covering how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "At Risk Behaviors" which detailed how caregivers should follow up after a resident exhibits intense or out of control behavior, however, the policy did not cover how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. 2. In an interview, E1 acknowledged a policy and procedure was not available covering how a caregiver would respond in the moment to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual.”

“Based on interview and observation, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. In an interview, R4 stated "the staff look at me like I am dirt." 2. In an interview, E2 stated "Maybe [R4] wasn't the best person to have you speak to, we all hate [R4]." 3. The Compliance Officer observed that R4 was only a few steps away, and within earshot, when the interview with E2 took place. 4. In an interview, E1 reported that E2's statement was not acceptable behavior, and acknowledged that R4 was not treated with dignity, respect, and consideration.”

“Based on record review, documentation review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to meet the needs of residents. Findings include: 1. A review of E2's, E3's, and E4's personnel records revealed documentation of skills and knowledge verification was not available for review at time of the inspection. 2. A review of facility documentation revealed a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection. 3. In an interview, E1 reported currently working on corrections for these items. E1 acknowledged E1 failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for three of three sampled personnel members. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of E2's, E3's, and E4's personnel records revealed documentation of skills and knowledge verification was not available for review at time of the inspection. 2. In an interview, E1 reported currently working on corrections for these items. E1 acknowledged E2's, E3's, and E4's personnel records did not include documentation of E2's, E3's, and E4's skills and knowledge applicable to the individual's job duties at the time of the inspection.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three sampled personnel members. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of E3's personnel record revealed documentation of completed orientation was not available for review at time of inspection. 2. In an interview, E1 acknowledged E3's personnel record did not include documentation of E3's completed orientation required by policies and procedures.”

“Based on record review, documentation review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to meet the needs of residents. Findings include: 1. A review of E2's, E3's, and E4's personnel records revealed documentation of skills and knowledge verification was not available for review at time of the inspection. 2. A review of facility documentation revealed a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection. 3. In an interview, E1 reported currently working on corrections for these items. E1 acknowledged E1 failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers.”

“Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for three of three sampled personnel members. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of E2's, E3's, and E4's personnel records revealed documentation of skills and knowledge verification was not available for review at time of the inspection. 2. In an interview, E1 reported currently working on corrections for these items. E1 acknowledged E2's, E3's, and E4's personnel records did not include documentation of E2's, E3's, and E4's skills and knowledge applicable to the individual's job duties at the time of the inspection.”

“Based on record review and interview, the manager failed to ensure a service plan included offering skin maintenance and incontinence care to ensure a resident maintained the highest practicable level of independence when toileting, for two of two sampled residents receiving personal care services. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of R2's and R3's medical records revealed service plans indicating R2 and R3 required personal care services. However, the service plans did not include skin maintenance and incontinence care to ensure a resident maintained the highest practicable level of independence when toileting. 2. In an interview, E1 acknowledged R2's and R3's service plans did not include skin maintenance and incontinence care to ensure a resident maintained the highest practicable level of independence when toileting.”

“Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "FIRST AID: GUIDELINES" dated October 17, 2019. The policy and procedure stated "Falls: When a resident falls, let him/her lie on the floor and check resident carefully. Determine if emergency action is needed...If no injury is found, and no emergency action needed, get assistance from another staff member to help Resident in getting up." 2. In an interview, R10 reported having a fall in October 2023, calling for help, no one coming, and then being helped back up by someone from the fire department. 3. In a separate interview, E2 reported the facility used only one medication technician per wing of about 15-20 residents and had a few floating caregivers per shift. When asked what personnel did when more than one call button went off at once, E2 reported the medication technician would go to each room to triage the situation and then assist the person who needed help the most. When asked what would happen if one resident fell and another needed help on the toilet, E2 reported the medication technician would assist the resident who fell and the resident on the toilet would have to wait. 4. A review of facility documentation revealed a series of "Observations" documents dated April 2023, October 2023, and November 2023. The documents revealed the following: -The April 2023 document revealed an incident involving R1 at 2:10 AM on April 21, 2023. The document stated: "Resident had a fall at approximately 2:10 AM. 911 was called in to get [R1] off the floor and into [R1's] bed." -The April 2023 document revealed an incident involving R1 at 11:24 AM on April 21, 2023. The document stated: "Incident Summary: Call received from the Med Tech on duty stating that the resident had been lowered to the ground to prevent a fall during transfer to [R1's] bed. Resident unable to get off the floor non-emergent called for lift assist. No injuries noted." -The October 2023 document revealed an incident involving R10 at 6:00 PM on October 30, 2023. The document stated: "Resident called for assistance had a fall. Vitals taken resident checked out for any visible injuries, skintares [sic], lumps or bumps to head or body. Paramedics called to check out resident was not taken to Hospital resident Refused." -The November 2023 document revealed an incident involving R3 at 4:29 PM on November 15, 2023. The document stated: "Resident had a fall in [R3's] bedroom [R3] was laying [sic] next to [R3's] bed at 12:30am staff assisted resident un successful [sic] on getting resident up off of floor EMT/ Fire Department contacted, Department came out [and] assisted resident up and helped [R3] back into [R3's] bed." 5. In an interview, E2 stated, "We don't have the man-power." E2 reported the facility called 911 or the fire department when a resident was too heavy or too large for the caregivers to lift.”

“Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a "Course Completion History" document. The document revealed the facility had two courses for falls: "Identifying Fall Risk in Assisted Living" and "About Falls." A review of the course curricula revealed the "Identifying Fall Risk in Assisted Living" course covered fall prevention but did not cover fall recovery and the "About Falls" course covered both. The document revealed E1 and E9 did not take either course. 2. A review of E1's and E9's personnel records revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E1 there was no documentation available for review to reflect E1 and E9 completed fall prevention and fall recovery training. This is a repeat citation from the compliance and complaint inspection conducted on March 28, 2023 and the compliance inspection conducted on April 21, 2022.”

“Based on record review and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for four of eight personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "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, nursing care institution or home health agency." 2. A review of E4's personnel record revealed the following: -E4 was hired as a caregiver/medication technician; -An application for employment which included E4's previous employment; and -Three "APPLICANTS TELEPHONE REFERENCE CHECKS" forms for E4, each form revealing the governing authority contacted E4's co-workers and not E4's previous employers as required by A.R.S. \'a7 36-411(C)(1). 3. A review of the personnel records of E5, E7, and E8 revealed E5, E7, and E8 were hired as caregivers/medication technicians. The review revealed applications for E5, E7, and E8 which included previous employment for each. The review further revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E5, E7, and E8. 4. In an interview, E1 acknowledged there was no documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E4, E5, E7, and E8 available for review at the time of the inspection.”

“Based on documentation review, interview, and record review, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services and according to policies and procedures, for two of eight caregivers and assistant caregivers sampled. The deficient practice posed a risk if a caregiver or an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed no policy and procedure covering how the facility would verify and document a caregiver's or assistant caregiver's skills and knowledge. 2. In an interview, E1 acknowledged the facility did not have a policy and procedure covering how the facility would verify and document a caregiver's or assistant caregiver's skills and knowledge. E1 reported the facility usually used the "orientation form" to verify skills and knowledge. 3. A review of E3's personnel record revealed E3 was hired as a caregiver/medication technician. The review revealed an "Orientation Checklist for Care Staff" which included E3's skills and knowledge. However, the verification was not documented as completed until approximately eighteen months after E3's hire date. 4. A review of E9's personnel record revealed E9 was hired as an assistant caregiver. The review revealed an "Orientation Checklist for Care Staff" which included E9's skills and knowledge. However, the verification was not documented as completed until approximately one month after E9's hire date. 5. A review of facility documentation revealed a series of personnel schedules dated between January 2023 and February 2024. The schedules revealed the following: -E3 provided physical health services as a caregiver/medication technician on a regular basis between January 2023 and May 22, 2023, prior to E3's skills and knowledge being verified; and -E9 provided physical health services as an assistant caregiver on a regular basis between January 2024 and February 13, 2024, prior to E9's skills and knowledge being verified. 6. In an interview, E1 confirmed E3's and E9's skills and knowledge were not verified and documented until after E3 and E9 provided physical health services.”

“Based on interview, observation, and documentation review, the manager failed to ensure an assisted living facility had caregivers and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk as the employees were unable to ensure the health and safety of residents. Findings include: 1. In an interview, R10 reported having a fall in October 2023, calling for help, no one coming, and then being helped up by someone from the fire department. 2. In a separate interview, E2 reported the facility used only one medication technician per wing of about 15-20 residents and had a few "floating" caregivers per shift. When asked what personnel did when more than one call button went off at once, E2 reported the medication technician would go to each room to triage the situation and then assist the person who needed help the most. When asked what would happen if one resident fell and another needed help on the toilet, E2 reported the medication technician would assist the resident who fell and the resident on the toilet would have to wait. 3. During the environmental inspection of the facility, the Compliance Officer heard a resident calling out for help. The Compliance Officer observed a medication technician at a medication cart and signaled for assistance. The Compliance Officer observed the medication technician assist the resident, say the medication technician needed to go to another floor for a medication, and leave the wing without another caregiver/medication technician coming to assist. The Compliance Officer observed the medication technician return after approximately five minutes. 4. A review of facility documentation revealed a series of "Observations" documents dated April 2023, November 2023, December 2023, and February 2024. The documents revealed the following: -The April 2023 document revealed an incident involving R1 at 2:10 AM on April 21, 2023. The document stated: "Resident had a fall at approximately 2:10 AM. 911 was called in to get [R1] off the floor and into [R1's] bed." -The April 2023 document revealed an incident involving R1 at 11:24 AM on April 21, 2023. The document stated: "Incident Summary: Call received from the Med Tech on duty stating that the resident had been lowered to the ground to prevent a fall during transfer to [R1's] bed. Resident unable to get off the floor non-emergent called for lift assist. No injuries noted." -The November 2023 document revealed an incident involving R2 at 10:30 AM on November 8, 2023. The document stated: "Med tech notified HSD resident was given the medication of another resident...PCP notified and recommended resident be sent out to ER for evaluation." -The November 2023 document revealed an incident involving R6 at 8:41 AM on November 9, 2023. The document stated: "Please be reminded to ensure that when the resident is taking the medication in [R6's] mouth that there is none fell of the floor from [R6's] hand. Family seen an Aspirin tablet in [R6's] room on the carpet floor and showed it to me. Last night the family found a Tylenol sitting on [R6's] table." -The November 2023 document revealed an incident involving R3 at 4:29 PM on November 15, 2023. The document stated: "Resident had a fall in [R3's] bedroom [R3] was laying [sic] next to [R3's] bed at 12:30am staff assisted resident un successful [sic] on getting resident up off of floor EMT/ Fire Department contacted, Department came out [and] assisted resident up and helped [R3] back into [R3's] bed." -The December 2023 document revealed an incident involving a resident at 10:14 AM on December 27, 2023. The document stated: "Staff found resident's evening medication on [the resident's] counter in [the resident's] room." -The December 2023 document revealed an incident involving a resident at 10:48 AM on December 27, 2023. The document stated: "Staff found resident's evening medication on [the resident's] table." -The December 2023 document revealed an incident involving R11 at 1:37 PM on December 31, 2023. The document stated: "I [E10] gave [R11's] medication of 5 pm. [R11] requests be cause [R11] is going out with [R11's family member] and [R11] will return later." -The February 2024 document revealed an incident involving R9 at 10:27 PM on February 8, 2024. The document stated: "Hair stylist reported that resident talked to [hair stylist] about Med Techs leaving meds with resident and resident soaks [R9's] meds in water and dumps [R9's] meds out into the sink. Resident stated [R9] doesn't take [R9's] meds. So this evening I watched resident take [R9's] meds in front of me." 5. In an interview, E2 stated, "We don't have the man-power." E2 reported the facility called 911 or the fire department when a resident was too heavy or too large for the caregivers to lift.”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training certification specific to adults before providing assisted living services to a resident, for one of eight personnel members (with records) sampled. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E5's personnel records revealed E5 was hired as a caregiver/medication technician in late 2022. The review revealed a printout of E5's cardiopulmonary resuscitation (CPR) training certification. However, the review revealed no documentation of E5's first aid training certification specific to adults. 2. A review of facility documentation revealed E5 worked as a caregiver/medication technician on a regular basis between February 2023 and February 2024. 3. In an interview, E1 acknowledged E5's personnel record did not contain documentation of first aid training certification.”

“Based on documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee or volunteer, for 15 of 23 employees or volunteers sampled. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between February 2023 and February 2024. The schedules revealed E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, and E24 were from "Agency" and worked at least one shift providing physical health services. 2. A review of facility personnel records revealed no personnel records for E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, and E24. 3. In an interview, E1, "I'm almost 100 percent sure we don't have records [for Agency caregivers]." E1 later reported not having personnel records for E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, and E24.”

“Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for four of eleven residents sampled. 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 facility policies and procedures revealed a policy and procedure titled "MEDICATION SYSTEM" dated January 28, 2020. The policy and procedure stated: "IV. Medication Handling and Dispensing [Administering] Procedure...B. Have Resident in view; MAR for Resident to be served. Chart all medications as they are administered...F. Without touching the medication, remove from cassette/card and place in med cup. Watch the Resident swallow the medication and record in the designated area on the MAR by the following means: 1. Initials=given." 2. A review of facility documentation revealed an "Unusual Occurrence Report" for R2 dated November 8, 2023. The report stated, "[R2] was given the medication of another resident." The review further revealed an "Observations" document which included a report of the aforementioned incident. The document stated: "Med tech notified HSD resident was given the medication of another resident...PCP notified and recommended resident be sent out to ER for evaluation." 3. A review of R2's medical record revealed a medication administration record (MAR) dated November 2023. The MAR revealed R2 did not receive R2's 10:00 AM medication on November 8, 2023. 4. In an interview, E1 confirmed R2 received the medication of another resident on November 8, 2023. 5. A review of R2's medical record revealed a current service plan which indicated R2 required medication administration services. The review revealed medication orders for "TYLENOL [acetaminophen] EXTRA STRENGTH 500 MG (milligrams)", "Midodrine HCI 5 MG", and "Trelegy Ellipta 100 mcg (micrograms)-62.5 mcg-25 mcg" dated before February 2024. The review further revealed a MAR dated February 2024. The MAR indicated the following: -R2 did not receive "ACETAMINOPHEN 500 MG" as ordered at 2:00 PM on February 13, 2024, with the reason noted as "Medication not available;" -R2 did not receive "MIDODRINE HCL 5 MG" as ordered at 5:00 PM on February 13, 2024, with the reason noted as "Medication not available;" and -R2 did not receive "TRELEGY ELLIPTA 100-62.5-25" as ordered at 10:00 AM on February 12, 2024, with the reason noted as the "Medication not available." 6. A review of R5's medical record revealed a current service plan which indicated R5 required medication administration services. The review revealed medication orders for "DEMECLOCYCLINE 300 MG"and "LINZESS 290 MCG" dated before February 2024. The review further revealed a MAR dated February 2024. The MAR indicated R5 did not receive "DEMECLOCYCLINE 300 MG" as ordered at 8:00 AM on February 14-15, 2024, with the reason noted as "Medication not available" and R5 did not receive "LINZESS 290 MCG" as ordered at 8:00 AM on February 4-7, 2024, with the reason noted as "Medication not available." 7. A review of R6's medical record revealed a current service plan which indicated R6 required medication administration services. The review revealed a medication order for "RANOLAZINE ER 500 MG" dated before November 2023. The review further revealed a MAR dated November 2023. The MAR indicated R6 did not receive "RANOLAZINE ER 500 MG" as ordered at 8:00 AM on November 20, 2023, with the reason noted as "Medication not available." 8. A review of R10's medical record revealed a current service plan which indicated R10 required medication administration services. The review revealed a medication order for "FUROSEMIDE 20 MG" dated February 11, 2023. The review further revealed a MAR dated February 2024. The MAR indicated R10 did not receive "FUROSEMIDE 20 MG" as ordered at 8:00 AM on February 13, 2024, with the reason noted as "Medication not available." 9. A review of facility documentation revealed a series of "Observations" documents dated November 2023, December 2023, and February 2024. The documents revealed the following: -The November 2023 document revealed an incident involving R6 at 8:41 AM on November 9, 2023. The document stated: "Please be reminded to ensure that when the resident is taking the medication in [R6's] mouth that there is none fell of the floor from [R6's] hand. Family seen an Aspirin tablet in [R6's] room on the carpet floor and showed it to me. Last night the family found a Tylenol sitting on [R6's] table." -The December 2023 document revealed an incident involving a resident at 10:14 AM on December 27, 2023. The document stated: "Staff found resident's evening medication on [the resident's] counter in [the resident's] room." -The December 2023 document revealed an incident involving a resident at 10:48 AM on December 27, 2023. The document stated: "Staff found resident's evening medication on [the resident's] table." -The December 2023 document revealed an incident involving R11 at 1:37 PM on December 31, 2023. The document stated: "I [E10] gave [R11's] medication of 5 pm. [R11] requests be cause [R11] is going out with [R11's family member] and [R11] will return later." -The February 2024 document revealed an incident involving R9 at 10:27 PM on February 8, 2024. The document stated: "Hair stylist reported that resident talked to [hair stylist] about Med Techs leaving meds with resident and resident soaks [R9's] meds in water and dumps [R9's] meds out into the sink. Resident stated [R9] doesn't take [R9's] meds. So this evening I watched resident take [R9's] meds in front of me." 10. In an interview, E1 confirmed the aforementioned medications were not administered as ordered.”

“Based on documentation review, observation, interview, and record review, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of eleven residents sampled. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "MEDICATION SYSTEM" dated January 28, 2020. The policy and procedure stated: "IV. Medication Handling and Dispensing [Administering] Procedure...B. Have Resident in view; MAR for Resident to be served. Chart all medications as they are administered...F. Without touching the medication, remove from cassette/card and place in med cup. Watch the Resident swallow the medication and record in the designated area on the MAR by the following means: 1. Initials=given." 2. During the environmental inspection of the facility conducted on February 15, 2024, at 10:30 AM, the Compliance Officer observed R10 was alone in R10's unit before the Compliance Officer and E2 entered. Upon entering the unit, the Compliance Officer observed R10 sitting at a dining table with a small cup of medication on the table. 3. In an interview, R10 reported the caregiver on duty had left the medication on the table for R10 to take after R10 finished breakfast. R10 reported this was a common occurrence. R10 stated one of the medications was "Gabapentin." 4. A review of drugs.com revealed the medication in the cup included "Aspirin 81 mg (milligrams)," "Cetirizine Hydrochloride 10 mg," "Gabapentin 300 mg," "Lansoprazole 30 mg," and "Lisinopril 10 mg" along with on unidentified tablet. 5. A review of R10's medical record revealed a medication administration record (MAR) dated February 2024. The MAR indicated R10 received "ASPIRIN EC 81 MG," "CETIRIZINE HCL 10 MG," "FUROSEMIDE 20 MG," GABAPENTIN 300 MG," "LANSOPRAZOLE DR 30 MG," "LISINOPRIL 10 MG, " and "VITAMIN D3 1000U" at 8:00 AM on February 15, 2024, even though the Compliance Officer observed R10's morning medication at 10:30 AM. 6. In an interview, E1 reported medication technicians were not supposed to leave residents with medication and the MAR was not supposed to be signed until the medication technician(s) saw the residents take the medication.”

“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. The deficient practice posed a risk if employees were unable to implement a disaster plan and evacuate the residents during an emergency. Findings include: 1. A review of facility documentation revealed the most recent evacuation drill was conducted on August 25, 2022. The review revealed no documentation of evacuation drills for employees and residents conducted after August 25, 2022. 2. In an interview, E1 acknowledged the evacuation drill dated August 25, 2022, was conducted more than six months before the date of the inspection.”

“Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the names of individuals who observed the accident, emergency, or injury, for one of eleven residents sampled. Findings include: 1. A review of facility documentation revealed an "Unusual Occurrence Report" for R2 dated November 8, 2023. The report stated, "[R2] was given the medication of another resident." The report stated R2 was "Taken to [the] Hospital." The review further revealed an "Observations" document which included a report of the aforementioned incident. The document stated: "Med tech notified HSD resident was given the medication of another resident...PCP notified and recommended resident be sent out to ER for evaluation." However, neither document included the names of individuals who observed the accident, emergency, or injury. 2. In an interview, E1 reported E3 was the individual who observed the medication error. E1 acknowledged the incident reports did not include E3's name as the witness.”

“Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed garbage in uncovered containers lined with plastic bags in the kitchen, a dining room storage area, and in a hallway. 2. In an interview, E2 acknowledged the garbage containers were not covered. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on March 28, 2023.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area separate from food preparation and storage, and were inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked food storage room near an elevator. In the room, the Compliance Officer observed food on shelves. On separate shelves, on the floor, and in an unlocked closet within the room, the Compliance Officer observed poisonous or toxic materials including bleach, degreaser, dish detergent, disinfectant, multi-quat sanitizer, multi-surface cleaner, and stainless steel polish. The Compliance Officer also observed an unlocked laundry room. Under the sink in the laundry room, the Compliance Officer observed a bottle of "Hillyard Creme Clean." 2. In an interview, E2 reported the food storage room door was usually locked and should have been locked, and the cleaner should not have been left under the sink in the laundry room. This is a repeat citation from the compliance and complaint inspection conducted on March 28, 2023.”

“Based on interview and observation, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. In an interview, an unnamed resident reported the elevator connecting the first, second, and third floors of the facility had been broken for two months. E2 reported the other elevator only connected the second and third floor of the facility as the facility was on a hill. E2 reported meals were brought to the residents on the first floor because the residents could not get to the second and third floors. E2 reported residents had to go outside and go up the hill if the resident wanted to go to the second or third floors. 2. The Compliance Officer observed both elevators were working during the inspection. 3. In an interview, E1 confirmed the elevator connecting the first, second, and third floors of the facility had previously been broken. E1 first stated it was "fixed late October" then reported it was broken as of August 1, 2023, and fixed on September 28, 2023.”