Lone Mountain Memory Care.

“Based on record review and interview, the assisted living home failed to maintain a copy of documentation provided to an emergency responder, for one of two residents sampled. The deficient practice posed a risk if the Department was unable to verify the required documentation was provided during a resident emergency.   Findings include:   A.R.S. § 36-420.04.A.1-9 "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 1. A review of R2’s medical record revealed an incident report dated April 19, 2026. The incident report stated, “When [the caregiver] went to check [the caregiver] witnessed another resident push [R2], [R2] fell and hit [R2’s] head.” The report later revealed that 911 was called.  2. A review of R2’s medical record did not reveal a copy of documentation provided to an emergency responder for R2’s transfer to the hospital on April 19, 2026.  3. In an interview, E4 reported the “medtech” did not make a copy of documentation that was provided to an emergency responder for R2. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed a strong urine smell and very sticky floors throughout the facility. The COs observed a strong smell coming from a particular section where R3's room was located. 2. During an environmental inspection of R3's bedroom the COs observed a stronger smell of urine once the door was opened. There were stains covering the walls throughout the entire interior of R3's bedroom unit. 3. During an environmental inspection of R3's bedroom, E1 reported R3 had urinated into the air conditioning unit and often splattered food onto the walls. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure the facility had caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a health and safety risk to a resident who was administered a medication after the medication was stopped by a medical practitioner. Findings include: 1. In record review, R1's medical record (received directed care services) included documentation R1 had a fall on June 18, and June 19, 2024; both falls required medical services, and R1 was transported to the hospital. R1's record included a hospital "After Visit Summary," for the June 18, 2024, hospital visit, which documented, "Fall, initial encounter, Traumatic cephalohematoma..." R1's record did not include an After Visit Summary for the June 19, 2024, hospital visit. 2. In documentation review, O1 submitted a report to the Compliance Officer, titled, "After Visit Summary," from the medical practitioner, dated "6/19/2024 - 6/22/2024." The summary documented, "... fall from ground level... frailty syndrome in geriatric patient, Blunt head injury, initial encounter, Chronic anticoagulation, Scalp laceration, initial encounter... no resolved problems... Your medications have changed, START taking: lacosamide (VIMPAT), STOP taking: apixaban 5 mg Tabs tablet (ELIQUIS)..." 3. In record review, R1's medical record included "Progress Notes," which documented: - "6/20/2024... called honor health deer valley to speak to nurse, R1 was admitted due to ... fall... left side of face is very swollen and bruised also resident has a minor brain bleed and UTI... is being treated with IV antibiotics for UTI and they are monitoring .... for ... minor brain bleed. - "7/11/2024," Resident had blood and blood clots when toileting. Hospice nurse came for visit/assessment. Stated no active bleeding and will prescribe medication for f/u..." - "7/26/2024 5:30pm Resident threw up it was black... called hospice and left a message..." - "7/26/2024 10:27pm Hospice nurse came to see resident in response to resident vomiting. .. took resident out along with a transportation for hospice respite care ... signed off on resident's medication. Hospice nurse was given all of resident's medication." 4. In record review, R1's medication administration record dated "June 1, 2024 - June 30, 2024," and "July 1, 2024 - July 31, 2024," included documentation a caregiver administered the Eliquis medication to R1 at 5:00pm on June 22, 2024, and at 8:00am and 5:00pm, daily June 23 - July 23, 2024, at which time the MAR indicated the Eliquis medication was discontinued. R1's medication administration record included documentation the Lacosamide medication was administered at 6:00pm on June 22, and at 6:00am and 6:00pm on June 23 - 26, and at 6:00am on June 27, 2024, and then discontinued. 5. During an interview, O2 reported being aware the hospital discontinued the Eliquis, following R1's hospital visit on June 19, 2024, and O2 reviewed with a facility caregiver within 48 hours of R1's discharge. O2 reported the resident had changes in services; from Home Health (with O2) to Hospice services, and then to a different Hospice agency (again with O2), and the first Hospice service agency may have continued the order for the Eliquis (no order in the record). However, on July 7, 2024, O2 found the Eliquis medication for R1 was on site, and O2 discontinued the order, and reviewed this change with E1, who worked as a medication tech that day. The order was sent to E1's telephone, as the facility's printer was not working. On July 26, 2024, O2 found R1 had an Eliquis medication blister pack "card: 2/2" on site, dated on July 11, 2024, as 56 tablets dispensed, and 22 tablets remained. 6. During an interview, the findings were reviewed with E1, who acknowledged the facility did not meet the resident's needs when a resident continued to receive a medication that was discontinued by the medical practitioner.”

“Based on documentation review, record review, and interview, for three of four caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. In record review, the personnel records for E2 (hired on January 10, 2024, as a caregiver), and E3 (hired March 30, 2024, as an assistant caregiver), did not include documentation of a screening and risk assessment to assess the risks of prior exposure to infectious TB, and determine if the individual had signs and symptoms of TB. 3. In record review, E5's personnel record (hired as a caregiver on July 16, 2024), included documentation of a negative skin test that was more than 13 months old. The record did not include documentation the caregiver provided current evidence of freedom from infectious TB, and a screening and risk assessment to assess the risks of prior exposure to infectious TB, and determine if the individual had signs and symptoms of TB. 4. During an interview, the findings were reviewed with E1, who reported E5 transferred from a sister facility, and had a recent TB skin test. The documentation showed a TB skin test, that was less than 12 months old; however, the test was not read. E1 acknowledged the personnel records did not include the documentation of freedom from TB, as required by R9-10-113.”

“Based on record review, documentation review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid (FA) training. The deficient practice posed a health and safety risk to residents if caregivers did not have FA training. Findings include: 1. In record review, E5's personnel record (hired July 16, 2024, as a caregiver) included documentation of FA training completed on February 22, 2022, and "expires on Feb 22, 2024." The record did not include documentation E5 had current FA training, as required. 2. In documentation review, the staffing schedule indicated E5 worked shifts at the facility, from 2:00pm - 10:00pm on July 16 - 20, 23-27, and 30-31, 2024. 3. During an interview, E1 acknowledged E5 did not provide documentation of current FA training, as required.”

“Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to residents, if the service plan did not include documentation of the resident's condition, and services to be provided for the resident. Findings include: 1. In record review, R1's medical record (received personal care services), included documentation R1 had a fall on June 18, and June 19, 2024; both falls required medical services, and R1 was transported to the hospital. The record included the following progress notes: - "6/18/2024, resident slipped and fell while trying to ambulate, hit back of ... head, paramedics called ... will be going to ... hospital." - "6/19/2024, resident was found in ... apartment laying on ... bed, staff noticed ... had swelling and bruising with a laceration to the left side of ... face... notice in ... bathroom ... was blood on the floor by the sink and realized... slipped on ... carpets in the bathroom." - "6/20/2024, called honor health ... to speak to nurse ... was admitted due to ... fall... which left side of face is very swollen and bruised.... has a minor brain bleed and UTI... is being treated with IV antibiotics for UTI and they are monitoring [R1] for ... minor brain bleed." 2. In documentation review, O1 submitted a report to the Compliance Officer, titled, "After Visit Summary," dated "6/19/2024 - 6/22/2024." The summary documented, "... fall from ground level... frailty syndrome in geriatric patient, Blunt head injury, initial encounter, Chronic anticoagulation, Scalp laceration, initial encounter... no resolved problems... Your medications have changed, START taking: lacosamide (VIMPAT), STOP taking: apixaban 5 mg Tabs tablet (ELIQUIS)..." 3. In record review, R1's medical record included a service plan, (received directed care services) dated June 29, 2024. The service plan included documentation R1 had a medication order for "Eliquis 5 mg tab, give 5 mg by mouth two times per day..." The service plan documented, "6/21/2024 Remind resident to use walker when ambulating." The service plan did not include documentation of R1's falls, head injury, medication change, UTI, and swelling, bruising and laceration to the face. The service plan was not signed and dated by the manager or the resident's representative. 4. During an interview, E1 acknowledged R1's service plan was not updated with the resident's change of condition and a description of the resident's medical and health problems.”

“Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner who reviewed the service plan. The deficient practice posed a health and safety risk if the resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. R9-10-808.A(3)(d) states "For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner." 2. In record review, R1's medical record (received directed care and Hospice services) included a service plan, dated June 29, 2024. The service plan was signed by the nurse on June 29, 2024; however, was not signed and dated by the resident's representative and the manager. 3. In record review, R2's medical record did not include documentation of a service plan. 4. During an interview with E1, the Compliance Officer requested to review R2's service plans. E1 provided three service plans for R2; dated March 16, 2024, May 13, 2024, and July 8, 2024. The service plans were all signed and dated by the manager and the resident's representative on August 2, 2024 (the date of the inspection). E1 reported R2's representative was at the facility on August 2, 2024, and signed the service plans. E1 acknowledged the services plans for R2 were signed and dated by the representative and the manager on August 2, 2024, and not reviewed and signed and dated when the service plans were completed. 5. During an interview, E1 acknowledged the residents' service plans were not signed and dated, as required. This is a repeat deficiency from the compliance and complaint inspection conducted November 16, 2023.”

“Based on documentation review, record review, and interview, for one two residents reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to a resident who had medication administered after the medical practitioner ordered the medication be discontinued. Findings include: 1. In record review, R1's medical record (received directed care services) included documentation R1 had a fall on June 18, and June 19, 2024; both falls required medical services, and R1 was transported to the hospital. R1's record included a hospital "After Visit Summary," for the June 18, 2024, hospital visit, which documented, "Fall, initial encounter, Traumatic cephalohematoma..." R1's record did not include an After Visit Summary for the June 19, 2024, hospital visit. 2. In documentation review, O1 submitted a report to the Compliance Officer, titled, "After Visit Summary," dated "6/19/2024 - 6/22/2024," signed by the medical practitioner. The summary documented, "... fall from ground level... frailty syndrome in geriatric patient, Blunt head injury, initial encounter, Chronic anticoagulation, Scalp laceration, initial encounter... no resolved problems... Your medications have changed, START taking: lacosamide (VIMPAT), STOP taking: apixaban 5 mg Tabs tablet (ELIQUIS)..." 3. In record review, R1's medical record included "Progress Notes," which documented: - "6/20/2024... called honor health deer valley to speak to nurse, R1 was admitted due to ... fall... left side of face is very swollen and bruised also resident has a minor brain bleed and UTI... is being treated with IV antibiotics for UTI and they are monitoring .... for ... minor brain bleed. - "7/11/2024," Resident had blood and blood clots when toileting. Hospice nurse came for visit/assessment. Stated no active bleeding and will prescribe medication for f/u..." - "7/26/2024 5:30pm Resident threw up it was black... called hospice and left a message..." - "7/26/2024 10:27pm Hospice nurse came to see resident in response to resident vomiting. .. took resident out along with a transportation for hospice respite care ... signed off on resident's medication. Hospice nurse was given all of resident's medication." 4. In documentation review, the medical records from Honor Health Deer Valley Medical Center, dated June 19, 2024, included the following documentation, [R1] who presents to DV MC emergency department after falling out of bed this morning. Patient's medical history is unclear. Patient is confused but records show ... is currently taking Eliquis. The patient is amnesic to the event. ... endorses head strike/loss of consciousness and left periorbital ecchymosis is present on exam. Initial CT head demonstrates a high left frontal lobe tSAH. Neuro critical care was consulted for this finding...""NEURO: Subarachnoid hemorrhage Neurosurgery consult Neuro Critical Care consult Reverse Eliquis kcentra Hold Eliquis Antiepileptics per Neuro Critical Care Blood pressure controls per Neuro Critical Care..." and "CVS: Hypertension , atrial fibrillation Hold Eliquis Cardiology consult BP controls per Neuro Critical Care Home medications P.r.n. antihypertensives..." 5. In record review, R1's medication administration record dated "June 1, 2024 - June 30, 2024," and "July 1, 2024 - July 31, 2024," included documentation a caregiver administered the Eliquis medication to R1 at 5:00pm on June 22, 2024, and at 8:00am and 5:00pm, daily June 23 - July 23, 2024, at which time the MAR indicated the Eliquis medication was discontinued. R1's medication administration record included documentation the Lacosamide medication was administered at 6:00pm on June 22, and at 6:00am and 6:00pm on June 23 - 26, and at 6:00am on June 27, 2024, and then discontinued. 6. During an interview, O2 reported being aware the hospital discontinued the Eliquis, following R1's hospital visit on June 19, 2024, and O2 reviewed with a facility caregiver within 48 hours of R1's discharge. O2 reported the resident had changes in services; from Home Health (with O2) to Hospice services, and then to a different Hospice agency (again with O2), and the first Hospice service agency may have continued the order for the Eliquis (no order in the record). However, on July 7, 2024, O2 found the Eliquis medication for R1 was on site, and O2 discontinued the order, and reviewed this change with E1, who worked as a medication tech that day. The order was sent to E1's telephone, as the facility's printer was not working. On July 26, 2024, O2 found R1 had an Eliquis medication blister pack "card: 2/2" on site, dated on July 11, 2024, as 56 tablets dispensed, and 22 tablets remained. 7. During an interview, E1 reported the facility did not receive the hospital "After Visit Summary" discharge instructions, and medication changes, following R1's hospital visit on June 19, 2022. E1 acknowledged R1 continued to receive the Eliquis medication June 23 through July 23, 2024, after the order was to be discontinued. E1 reported R1 no longer resided at the facility since July 26, 2024, and moved out with a 30 day notice.”

“Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the date and time of the emergency, a description of the accident, emergency or injury, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. The deficient practice posed a risk if the facility did not document an accident, emergency, or injury, as required, to ensure the health and safety of residents. Findings include: 1. In record review, R2's medical record (received directed care services) included documentation of an "Office Visit Note," from the nurse practitioner, dated May 17, 2024. The note documented, "Patient seen to perform an in-depth assessment of current condition... History, Patient sent to hospital for acute confusion and weakness. Family came to pick [R2] up and noticed... could barely walk and confused. Went to hospital ED at Mayo. Testing done including CT head - all was negative. While at Ed patients's condition improved, referred to neurology..." 2. In record review, R2's medical record included a progress note, dated May 12, 2024, which indicated R2's legs felt weak, was confused, family notified and took R2 to the emergency room. 3. In record review, R2's medical record did not include the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, on May 12 or May 17, 2024, for which R2 required medical services. 4. During an interview, E1 acknowledged R1 required medical services, was sent to the hospital, and the caregiver did not document the date and time of the emergency, a description of the accident, emergency or injury, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. This is a repeat deficiency from the complaint inspection conducted June 12, 2024.”

“Based on documentation review, record review and interview, for one of four residents reviewed, the manager failed to ensure a written service plan, when updated, was signed and dated by the resident or resident's representative. The deficient practice posed a health and safety risk if the resident or the resident's representative did not acknowledge the services that were to be provided, and the facility provided false and misleading information to the Department. Findings include: 1. In documentation review, the Department received documentation from O1, dated March 21, 2024, which stated "... yesterday, I received a request from that facility to sign a care plan for [R1] that has an effective date of 3/18/24... care plan Vitals that are dated 11/28/2023! I am going to send an email to the facility stating that I do not plan on signing the document..." 2. In record review, R1's medical record (received directed care services and had a Power of Attorney), included a service plan dated March 18, 2024, which included documentation of vitals dated "11/28/2023." The service plan included a signature from O1, dated March 18, 2024. The signature on the service plan appeared to be a different signature than O1's signature on other documents observed in R1's record, i.e., O1's consent for Influenza and Pneumonia vaccination for R1, and a service plan signed November 16, 2023. 3. In email correspondence on June 14, 2024, O1 reported "I absolutely did not sign a care plan for R1 on March 18, 2024." 4. During an interview, the findings were reviewed with E1 who reported being unaware if the service plan was signed by O1, or someone else for O1. E1 reported different facility personnel had been auditing the service plans to bring them into compliance.”

“Based on documentation review, record review, and interview, for one of four residents reviewed, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency or injury, the names of individuals who observed the incident, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. The deficient practice posed a risk if the facility did not document an accident, emergency, or injury, as required, to ensure the health and safety of residents. Findings include: 1. In documentation review, a policy facility policy titled, "Resident Care Events/Incident Reporting & Investigation," documented, "... Spectrum Retirement Communities, LLC... recognizes the importance of reporting accidents and incidents as an integral part of its risk identification and risk management strategy's as well as quality assurance and process improvement.... is committed to improving the quality of care and safety of residents... through the consistent monitoring and review of incidents that result, or had the potential to result in injury, damage or other loss. The community will investigate any incidents involving residents or visitors to determine the cause of the incident. The Incident Report must be filled out with accurate information after an incident has happened and immediately after the person involved in the incident is safe. The investigation and conclusions shall be completed within 3 days.... The DON or ED must document what was observed and report on the INCIDENT REPORT FORM. a. Complete the INCIDENT REPORT in the Electronic Health Record (HER). The DON or Wellness Nurse will evaluate the resident after the incident has occurred... All incidents involving Residents require an evaluation within 3 business days of the incident... Document any communication with the Resident or resident representative in the EHR. 2. In documentation review, the Department received a report, which documented, "... R2 was seen by ... mobile doctor O2... saw that ... right ear was severely bruised, swollen, cut and infected. Prescribed drops for infection... nobody on staff notified , ... medical (POA)... visit in the afternoon, ... discovered... injury... was concerned about the swelling in the inner area near the ear opening. The bruising went down... neck a few inches too. ... (POA) took ... to urgent care..." 3. During an interview, O3 reported O4 visited the facility on May 31, 2024, and observed R2 had brushing of the head and neck area, and requested O3 come to the facility to see R2. O3 went to the facility and saw R2 had a bruise on ear, that was swollen and cut, and the bruise was down through R2's neck. O3 reported it looked like a trauma injury; however, didn't know what happened. O3 took R2 to urgent care for treatment. O3 spoke with O2, the Nurse Practitioner, who reported having seen R2 on May 28, 2024, and said the "ear looked better." O3 reported being R2's POA, and was not contacted by the facility about R2's injury. 4. In record review, R2's record did not include documentation of an injury, incident report, or investigation related to R2's injury, per the facility's incident reporting policy, nor notification to R2's primary care provider or POA. R2's record, however, included a prescription for Ciprofloxacin-Dexamethasone "4 drops into affected ear 4 times per day for 7 days." 5. In documentation review, E1 provided a text message communication to O2, reporting, "R2 has a weird cut on ... ear... we have no idea what happened it wasn't like that yesterday it seems to be swollen... O2 prescribed antibiotics and said "...has otitis externa." 6. In documentation review, a report from O5 indicated "patient presents with ear problem... swelling of the right external canal... discoloration of the right external ear... significant edema noted... yellow exudate draining from the right external canal... is a hematoma noted over the concha of the right external ear... bruising noted over the right external ear... A report from O6 documented, "... Diagnoses... Hematoma of right external ear... Acute otitis externa of right ear, unspecified type..." 7. During an interview, E1 reported an incident report was not completed because the doctor said R2 had an ear infection. E1 did not provide any further information related to R2's injury, however, reported O2 was notified of a cut on the ear and swelling, and acknowledged an incident report was required per R9-10-818.D.”

“Based on documentation review, and interview, the manager failed to allow the Department access to books, records, accounts and any other information, as requested, during the inspection. The deficient practice posed a risk to residents as the Department was unable to determine compliance with policies and procedures, as required in Article 8. Findings include: A.R.S. \'a7 36-401.A.15. Definitions; adult foster care In this chapter, unless the context otherwise requires: "Department" means the department of health services. 1. During a compliance inspection and investigation of complaints, conducted on November 15, 2023, at or around 3:00pm, the Compliance Officer (CO) requested to review the facility's policies and procedures, along with other documentation to be reviewed during the inspection. On November 16, 2023, the CO had not received the facility's policies and procedures, and again requested to review the facility's policies and procedures, and specified "all policies and procedures as required per Article 8, for assisted living facilities." The facility's policies and procedures were not made available for review. 2. During an interview, E1 reported the facility's policies and procedures were located and accessible to staff on the computer; however, could not be made accessible to the CO. E1 reported the policies would be printed for the CO; however, only the specific policies requested. The CO requested to review all applicable policies and procedures required by Article 8, as defined primarily (but not exclusively) in R9-10-803.C., in whatever form available. The policies and procedures required by Article 8, were not made available for review.”

“Based on documentation review, record review, and interview, for ten of ten staff reviewed, the administrator failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident if staff were not trained in both fall prevention and fall recovery. Findings include: 1. In record review, the personnel records for E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10, included documentation the staff received orientation which included documentation of "Identifying Fall Risk in Assisted Living." The records did not include documentation the staff received training in fall recovery. 2. In documentation review, with O4, a review of the Relias Training on "Identifying Fall Risk in Assisted Living," revealed no indication the training included training on Fall Recovery. 3. During an interview, E1 reported the facility was developing a training program for staff on Fall Prevention and Fall Recovery, and acknowledged the staff were not trained on fall recovery, as required.”

“Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department with two hours after a Department request: Findings include: 1. During an Entrance interview on November 15, 2023, at 2:38pm, the Compliance Officer (CO) requested to review all documentation related to a self reported incident, and facility investigation concerning R4 and E5. The CO was provided a report titled "Incident Form" however, the report did not include the required documentation per R9-10-803.J., to indicate an investigation was conducted as required. 2. During an interview, E1 reported that E1 was not involved in the investigation of the alleged incident related to R4 and E5, and that incidents and related investigations, including interviews, were managed by the corporate office. E1 acknowledged the incident form provided to the CO did not include the required documentation to indicate an investigation was conducted, as required. 3. During an interview, on November 16, 2023, the CO was provided a document (during the exit interview at 3:00pm), titled, "Summary of Investigation," which included documentation related to the alleged incident involving R4. E1 reported the documentation was provided to the CO earlier, and put on the cabinet in the conference room. E1; however, acknowledged the required documentation was not provided with two hours of request.”

“Based on record review and interview, for three of four residents' service plans reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan. This posed a health and safety risk if a resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. In record review, R1's medical record (received directed care and medication administration services) included a service plan dated November 19, 2022. The service plan was not signed by the manager and nurse, and was signed and dated on January 29, 2023, by the resident's power of attorney. 2. During an interview with E1, the Compliance officer reported the record indicated the most recent service plan in R1's record was dated November 19, 2022. E1 provided a service plan dated September 20, 2023. The service plan did not include signatures from the nurse or POA. E1 reported the POA was emailed the service plan; however, did not sign it, and reported the nurse had signed the service plan according to an electronic record, dated September 20, 2023, which indicated, nurse "signed the envelope." E1 acknowledged the service plan, however, did not include the signatures of the nurse and the POA. 3. In record review, R2's service plan (received directed care and medication administration services), included a service plan dated October 12, 2023. The service plan included the required signatures; however, did not include the dates signed. 4. In record review, R3's service plan (received directed care and medication administration services), included a service plan dated October 12, 2023. The service plan included the required signatures; however, did not include the dates signed. 5. During an interview, the findings were reviewed with E1. E1 reported the facility might have a signed service plan for R1 located in the computer; however, no further documentation was provided for review. E1 acknowledged the service plans for R2 and R3 did not include the dated signatures of the resident's representative, the manager and the nurse, as required. 6. This is a repeat deficiency from the complaint investigation conducted on November 8, 2022.”

“Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area, used only for medication storage. The deficient practice posed a risk if medications were not stored separately with medications only. Findings include: 1. During an environmental inspection conducted on November 16, 2023, with E1 and O3, the Compliance Officer observed a locked "medication room" which contained miscellaneous supplies, an unlocked mini refrigerator, several containers of filled sharps containers, and a locked refrigerator/refrigerator and freezer. The mini refrigerator contained a package of Lorazepam medication package (a schedule IV controlled substance) which included 10 syringes, and was labeled as dispensed on November 15, 2023. 2. In R13's unit, one bottle of Salicylic Acid was observed unlocked. 3. During an interview, E1 acknowledged the medication was not stored in a separate locked area, used only for medication storage.”

“Based on record review and interview, for one resident reviewed, who had an injury resulting in the need for medical services, the caregiver failed to immediately notify a resident's emergency contact of a resident injury, and need for medical services. The deficient practice posed a risk if a resident sustained an injury, and the resident's emergency contact was not notified. Findings include: 1. In record review, R7's medical record (received directed care services), and had a Power of Attorney (O5), included documentation R7 had a fall on October 13, 2022, which indicated no injury was observed, and R7's "Family Member," was notified of the incident. The report did not include documentation of the "Notification Method." R7's record included documentation of a report titled, "Rapid Lab/Rapid-Ray... Mobile Imaging," dated October 13, 2022, which documented... "Pain in left shoulder... Findings. There is a suggestion of a non-displaced fracture along the inferior order of the lateral clavicle..." 2. In record review, R7's medical record included documentation of an "Incident Form," dated October 27, 2022, with "discoloration to the residents left eyebrow..." The form documented a description of the fall and injury. The report documented a "Healthcare Provider Agency" was notified; however, the report did not indicate R7's representative was notified. 3. During an interview, O5 reported R7 was observed with a bruise on the hand in July 2022, had a fall in August or September, 2022, had two falls in October, resulting in a shoulder fracture, and a black eye in October 2022. O5 reported [O5] was not notified by the facility of the incidents that occurred with R7, and when discussed with the provider, was informed the provider reported the incidents to an incorrect telephone number for O5. 4. During an interview, E1 reported O5 was notified of the resident's injuries; however, acknowledged the report dated October 27, 2022, did not include documentation O5 was notified. E1 reported being unaware if the facility had an incorrect telephone number for O5.”