Park Senior Villas at Houghton - Villa Hh.

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed R1 was being administered “traZODone 50 MG, TAKE 1 TABLET BY MOUTH EVERY EVENING." Further review revealed a signed medication order dated November 2, 2024, ordering, “Hold Trazadone 50mg on the evening of 11/2/2024 once”. 3. A review of R1's medication administration record (MAR) dated November 2024 revealed Trazadone 50mg was not administered (as directed) on November 2, 2024. However, further review of R1’s MAR revealed Trazadone 50mg was also held in the evening from November 4-18, 2024. 4. A review of R2's medical record revealed R2 received medication administration. 5. A review of R2's medical record revealed signed medication orders dated January 24, 2025, which included “Acetaminophen (Tylenol 8 Hour Arthritis Pain) 650 MG Oral Tablet Extended Release, Give 2 tablets by mouth every 8 hours” and “Metoprolol Tartrate 25 MG Oral Tablet, Give 1 Tablet by mouth 2 times per day with food.” 6. A review of R2's MAR dated February 2025 revealed Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 MG was scheduled to be administered twice per day; however, it was held on February 6, 19, 24, 26, and 27, 2025. The reasons for holding the medication was documented as “Adverse reaction, med not available, and 5200 mg of Acetaminophen has been passed, exceeding the 24 hr limit of 3000 mg.” 7. In an interview, E4 reported E4 discovered the system was incorrectly calculating each dose as 2600 mg, which prevented caregivers from administering the correct dosage of Tylenol.   8. Further review of R2’s MAR revealed R2 was administered “Metoprolol Tartrate 100 MG, TAKE 1 TABLET BY MOUTH TWICE DAILY…," rather than Metoprolol Tartrate 25 MG as ordered. 9. In an interview, E1 acknowledged the medications administered to R1 and R2 were not administered in compliance with medication orders.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit.  Findings include: 1. During a tour of the facility, the Compliance Officer found unlocked medication in a resident room. The Compliance Officer observed a bottle of “Equate Non-Drowsy Allergy Relief Nasal Spray Fluticasone Propionate," and a bottle of “Equate Original Nasal Spray Oxymetazoline HCI 0.05% Nasal Decongestant." Both were found unsecured, on a side table in a resident room.   2. In an interview, E1 acknowledged the medications were found unlocked in a resident room and not stored in a separate locked room, closet, cabinet, or self-contained unit”

“Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk if a report was not made as required to adequately protect residents involved. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.110 stated "Immediate" means without delay. 3. A review of facility documents revealed two documents, titled "Accident/Incident Report", dated June 28, 2024. These documents detailed an incident of possible sexual abuse between two residents on June 28, 2024. Based on the documented reports, the incident required a report for possible sexual abuse. 4. In an interview, E1 reported the incident was not reported to adult protective services (APS) until Monday, July 1, 2024. E1 acknowledged the suspected abuse was not reported according to A.R.S. \'a7 46-454. E1 reported the delay was due to a misunderstanding of the reporting timeframe and R2 was moved to another facility on July 5, 2024.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order for "Fluticasone-Salmeterol (Advair Diskus) 250-50 MCG/ACT", "Inhale 1 puff BID", dated May 3, 2023. 3. A review of R1's medication administration record (MAR) dated February 2024. The MAR revealed on February 15, 2024, the medication was unavailable and waiting for a refill. Between February 15, 2024 and February 28, 2024, the medication was documented as not available and waiting for a refill, however on some occasions it was documented as administered. 4. A review of R1's medication revealed the medication was not available. 5. In an interview E1 acknowledged the medication administered to a resident was not accurately documented.”