The Rubin Community for Senior Living.

“Based on documentation review and interview, the assisted living center failed to provide an emergency responder a written document which included 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, for two of two sampled residents. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: During the on-site inspection, the Compliance Officer requested copies of the documentation provided to emergency responders for E1 and E2, at the time emergency responders had been contacted for each resident. However, the provided documentation did not include a copy of each 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. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 24, 2025 and the complaint inspection conducted on December, 11, 2025.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: A review of R1's medical record revealed a service plan, dated September 25, 2025, for personal care services. The service plan required the provision of the following services to R1: "Assistance required transfers in/out; steadying; to wash self; to dry self; shampooing/rinsing/drying hair; applying lotion"; "Check skin with bath/shower and report any reddened/open areas to Nurse. Twice per week with showers." A review of R1's medical record revealed a progress note, dated January 26, 2026, of the type, "Provider notes." This note stated, "Caregiver asked me to see patient for L hip wound. She reports seeing it today for the first time with [R1's] shower. Patient has a deep wound to L hip. [R1] reports tenderness. There is a black eschar covering wound. [R1] does not know it occurred. No drainage, no signs of infection. Discussed with nurse to get wound team involved for treatment orders. Patient will need wound care as [R1] cannot do it [themselves]. Call for signs of infection or worsening of wound." A review of R1's medical record revealed an order, dated January 27, 2026, which stated, "Clean left hip wound and apply medihoney. Daily assessment of wound. OK to ask wound team to evaluate wound as well." A review of R1's medical record revealed documentation of services provided to R1, which included the following: Showering had been documented on January 2, January 3, January 6, January 9, January 13, January 16, January 20, January 23, January 27, January 30, and February 3, 2026; "Skin Observation during showers," had been documented on January 2, January 6, January 9, January 13, January 16, January 20, January 23, January 27, January 30, and February 3, 2026; and Wound care had not been documented to have been provided at any time. A review of facility documentation revealed an incident report, dated January 31, 2026, at 09:23 AM. The incident report stated, "found resident on the floor. [R1] said [R1] lost balance and [R1] fell on [R1's] back. Only got skin tear at right hand and back of [R1's] head. No pain or bruises at the moment. Vitals were taken and doing routine checks on [R1.]" The incident report included a diagram showing skin tears to R1's head and right hand, and no other documented injuries. In a section titled, "First Aid Administered, If Yes, Type of Care," the report stated, "skin tear on right hand and back of head," instead of the first aid provided. A review of facility documentation revealed a form titled "Emergency Responders Information," dated February 3, 2026. The form stated, "Reason(s) Emergency Service Was Called: [R1] had a fall 1/31/26 and a wound development. POA, Manager, and nurse thought be good idea for an further evaluation." A review of hospital imaging reports for R1 revealed the following: "Date of Exam: 02/03/2026, Examination: HIP MIN 2 VIEWS LT, Clinical Indication: decubitus ulcer, bruising, recent fall." A review of R1's medical record revealed an order, dated February 4, 2026, which stated, "Wound Care Left Hip Pressure Ulcer: Cleanse with wound cleanser, pat dry and apply zinc oxide ointment to wound bed and peri wound once daily and as needed. Floor Nurse Tu, Thu, Weekends." In an interview, E1 reported the wound was noted on January 26, 2026, by R1's physician, who ordered wound care. E1 reported wound care was not initiated by the assisted living facility. E1 reported the wound care started on February 4, 2026, after R1 returned from a hospital after a fall, at which time R1 was transferred to the skilled nursing facility on the premises for rehabilitation and wound care. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for one of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: A review of R2's medical record revealed a service plan dated January 31, 2026, for personal care services, including the provision of bathing services. The service plan stated, "Assistance needed twice a week. Assistance required - transfers in/out; steadying; to wash self; to dry self; shampooing/rinsing/drying hair; applying lotion. Date Initiated: 09/04/2025." A review of R2's medical record revealed documentation titled "Point of Care Audit Report," which documented the services provided to R2 since January 1, 2026. However, documentation of bathing services provided to R2 were not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site complaint inspection conducted on March 12, 2025 and the on-site compliance and complaint inspection conducted on October 24, 2025.”

“Based on documentation review and interview, when the assisted living center contacted an emergency responder on behalf of a resident, the assisted living center failed to provide a written document which included whether the resident received medication services, basic information about the resident's physical and mental conditions and basic medical history, or 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. Findings include: 1. A review of facility documentation revealed copies of two packets provided to emergency responders for R5. However, the packets did not include whether the resident received medication services, basic information about the resident's physical and mental conditions and basic medical history, or 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. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for one of three sampled caregivers, a caregivers skills and knowledge were verified and documented before the caregiver provided physical health services. Findings include: 1. A review of E6's personnel record revealed E6 was hired as a caregiver in October of 2025. However, E6's personnel record did not include documentation of verification of E6's skills and knowledge. 2. A review of E6's timecard revealed E6 worked the overnight shift on November 24, 2025, November 28, 2025 and December 1, 2025. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, for one of four sampled personal care residents, the manager failed to ensure a service plan was updated at least once very six months for a resident receiving personal care services. Findings include: 1. A review of R5's medical record revealed a service plan, updated May 22, 2025, for personal care services. However, a service plan updated on or before November 2025 was not available for review. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure incident reports accurately documented the date and time of and accident, emergency, or injury, the description of an accident, emergency, or injury, the actions taken by the caregiver, the individuals notified by the caregiver, or any actions taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R5's medical record revealed an incident report, dated October 25, 2025 at 11 PM. The incident report stated R5 had a fall. The incident report stated the attending physician was notified; however, the physician's name and the time of the notification were not filled out. The incident report had a section to document notification of R5's representative; however, that section was left blank. The incident report stated, "heard banging, went down hallway, call light on, resident on floor, said [R5] fell, (L) elbow bruised bleeding, (L) shoulder hurts, (4) ribs sore hurting. Under a section labeled, "type of injury," the incident report stated, "Laceration, Hematoma, Swelling, (L) side elbow head bumped." A body chart had marks on the left side, left elbow, left shoulder, and the left side of the head. Under a section labeled, "recommended steps to prevent reoccurrence," the incident report stated, "Follow up rapid ray came to community did x-ray." the follow up section also stated, "Then resident got sent out," however, this statement was crossed out and initialed. Additionally, all subsequent progress notes, medical records and documentation mention only injuries to R5's right arm. 2. A review of R5's medical record revealed documentation of an X-ray dated on October 26, 2025 was not available for review. 3. A review of R5's medical record revealed an incident report dated October 28, 2025 at 19:40. The incident report stated R5 had an unobserved fall. The incident report documented notification of the attending physician and representative. The incident report stated first aid was not administered and R5 was not taken to a hospital. The incident report stated, "walked in resident's room appear that [R5] slid off bed. Nurse [illegible] assess [R5], [R5] was ok. No appear injurys at this time (sic). Resident sleeping now in bed. [Representative] was notified as well as NP. Under a section labeled "type of injury," the incident report stated, "none apparent," and the body chart was not filled out. However, based on the previous incident report, several injuries would have been apparent. 3. A review of R5's medical record revealed a progress note dated October 29, 2025 at 18:24. The progress note was entered by E1 and stated, "please get a urine specimen on resident. All of the supplies and paperwork are in the med room. thank you." 4. A review of R5's medical record revealed a progress note dated October 29, 2025 at 21:22. The progress note was entered by E1 and stated, "Resident has a large lump on [R5]'s R shoulder blade. Communications with [R5's representative]. [R5's representative] is very concerned about this and the increased confusion. Resident had had two falls in the last 3 days. Spoke with NP and other staff. PT will do an evaluation in the near future on the resident. We will get an X-ray of R scapula. UA will be done. Referral for PT is completed and we will try to get a hospital bed. Resident seems to be slipping off the edge of [R5's] bed. A fall mat as well. Please follow up with family with updates." 5. A review of R5's medical record revealed a progress note dated October 30, 2025 at 04:21. The progress note stated, "Pt sliding out of bed. Stated that [R5] wants to go to the bathroom but keeps falling out of bed and very scared. Pt was unable to lift [their] rt arm, due to pain and bruising. Pt. has also stated that [R5] thinks [R5's] arm is broke. To be on the safe side I removed [R5] from [their room] to [a different room] (just [R5's] bedding so that [R5] wont fall out of my site (sic). Gave medication (PRN) for pain." 6. A review of facility documentation revealed a copy of a packet given to an emergency responder on October 30, 2025. The packet stated, "X ray taken of right shoulder blade and right arm. [mobile radiology] recommended [R5] be sent out.... Had fall yesterday 10/29/25 @ 8:45 PM - Ordered STAT x-ray - taken on 10/30/25 @ 11:20 AM." The packet include a copy of the October 28, 2025 incident report stating no injuries observed. 7. A review of R5's medical record revealed an x-ray dated 10/30/2025. The x-ray findings stated, "Right Shoulder/Prox Humerus Xray...There is an acute fracture proximal humerus seen. There is an increase in the acromiohumeral space suggesting a possible joint effusion. There is no focal bone lesion. Alignment is anatomic. There is no soft tissue swelling or foreign body identified." 8. A review of facility documentation revealed a copy of a packet given to an emergency responder on October 31, 2025. The packet stated, "[Representative] wants [R5] send out for another x-ray of all of right side." 9. In an interview, E1 reported E1 is only aware of one on-site X-ray conducted on October 30, 2025, after which R5 was immediately sent out. E1 reported an incident report for a fall on October 29, 2025, as mentioned by the emergency transfer form, was not available for review. 10. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the assisted living home failed to maintain written documentation of emergency responder (EMS) information that included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). 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 a hospital discharge summary from an emergency department visit on August 6, 2025. However, written documentation of EMS information was not available for review. 2. A review of R4's medical record revealed a hospital discharge summary from an emergency department visit on July 24, 2025. However, written documentation of EMS information was not available for review. 3. A review of R7's medical record revealed a hospital discharge summary from an emergency department visit on October 17, 2025. However, written documentation of EMS information was not available for review. 4. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement opioid treatment policies and procedures. Findings include: 1. A review of the facility's policies and procedures revealed an Opioid policy, compliant with the rules in R9-10-120.F, were not available for review. 2. A review of R7's medical record revealed a service plan, dated May 27, 2025 for directed care services including medication administration. 3. A review of R7's medical record revealed a Medication Administration Record (MAR) dated October 2025, which documented the administration of Tramadol to R7 on each day in October 2025. The MAR documented an assessment of R7's need for opioid administration. However, documentation of monitoring of R7 after each administration of Tramadol was not available for review. 4. A review of R7's medical record revealed documentation of monitoring of R7 after receiving administration of the opioid medication was not available for review. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, for five of seven sampled residents, the manager failed to ensure a resident provided a complete baseline screening for infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy. Findings include: 1. A review of R3's medical record revealed a test for TB dated within seven days of R3's acceptance. However, baseline screening to include a symptom screen and risk assessment were not completed until more than seven days after R3's date of acceptance. 2. A review of R4's medical record revealed a test for TB dated within seven days of R4's acceptance. However, baseline screening to include a symptom screen and risk assessment were not completed until more than seven days after R4's date of acceptance. 3. A review of R5's medical record revealed a test for TB dated within seven days of R5's acceptance. However, baseline screening to include a symptom screen and risk assessment were not completed until more than seven days after R5's date of acceptance. 4. A review of R6's medical record revealed a test for TB dated within seven days of R6's acceptance. However, baseline screening to include a symptom screen and risk assessment were not completed until more than seven days after R6's date of acceptance. 5. A review of R7's medical record revealed a test for TB was not available for review. Additionally, baseline screening to include a symptom screen and risk assessment were not completed until more than seven days after R7's date of acceptance. 6. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for two of seven sampled residents, the resident submitted documentation dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints. Findings include: 1. A review of R6's medical record revealed documentation, dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints, was not available for review. 2. A review of R7's medical record revealed documentation, dated within 90 days prior to admission, signed by a registered nurse or medical practitioner, stating whether the resident would require continuous medical services, continuous or intermittent nursing services, or restraints, was not available for review. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, before or at the time of an individual's acceptance by an assisted living facility, the manager failed to ensure there was a documented residency agreement which included the managers signature and date signed, for five of seven sampled residents. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, the residency agreement was signed by a manager after R2's date of acceptance. 2. A review of R3's medical record revealed a residency agreement. However, the residency agreement was signed by a manager after R3's date of acceptance. 3. A review of R4's medical record revealed a residency agreement. However, the residency agreement was not signed by the manager. 4. A review of R5's medical record revealed a residency agreement. However, the residency agreement was not signed by the manager. 5. A review of R6's medical record revealed a residency agreement. However, the residency agreement was not signed by the manager. 6. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for two of seven sampled residents, a resident's service plan was completed no later than 14 calendar days after the resident's date of acceptance. Findings include: 1. A review of R2's and R4's medical records revealed initial service plans were completed more than fourteen days after each resident's date of acceptance. R2's initial service plan was dated 36 calendar days after acceptance and R4's initial service plan was dated 53 calendar days after acceptance. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for four of seven sampled residents, a resident had a service plan which accurately included the amount, type and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan, dated May 29, 2025, for personal care services. The service plan stated R1 would receive medication administration for all medications. However, the service plan did not state R1 self-administered any medications. 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated October 2025. The MAR indicated R1 self-administered "Miconazole" daily. 3. A review of R2's medical record revealed a service plan, dated January 1, 2025, for personal care services. The service plan stated R2 required assistance with bathing. However, the service plan did not include the frequency of the showering service. 4. A review of R3's medical record revealed a service plan, dated July 31, 2024, for personal care services including medication administration for all medications. The service plan stated R3 required assistance with bathing. However, the service plan did not include the frequency of the showering service, and did not state R3 was authorized to self-administer any medications. 5. A review of R3's medical record revealed a MAR dated October 2025. The MAR indicated R3 self-administered, "Clotrimazole" daily. 6. A review of R4's medical record revealed a service plan dated May 14, 2025 for personal care services. The service plan stated, "Resident will remain independent with showers for now per family." 7. A review of R4's task administration record (TAR), dated October 2025 revealed showers were scheduled twice per week in the row titled, "The resident requires assistance for bathing/showering," and staff had documented providing assistance on four of seven scheduled shower days. 8. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure service plans were updated on time, for one of five sampled resident's receiving personal care services, and for one of one sampled resident receiving directed care services. Findings include: 1. A review of R2's medical record revealed a service plan, dated January 1, 2025, for personal care services. However, an updated service plan, dated on or before July 1, 2025, was not available for review. 2. A review of R2's medical record revealed a service plan, dated July 8, 2023, for directed care services. R2's medical record documented updates on September 11, 2024 (14 months), January 24, 2025 (4 months), and May 27, 2025 (4 months), each of which exceeded three months between updates. Additionally, the most recent service plan, dated May 27, 2025, was dated more than three months prior to the on-site inspection. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for two of seven sampled residents, a resident's service plan was signed and dated by the manager. Findings include: 1. A review of R1's medical record revealed a current service plan dated May 29, 2025. However, the service plan had not been signed and dated by the manager. 2. A review of R6's medical record revealed a current service plan, dated October 9, 2025. However, the service plan had not been signed and dated by the manager. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in their medical record, for three of seven sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record revealed a service plan dated January, 1, 2025 for personal care services. The service plan stated R2 required assistance bathing, however, the service plan did not state the frequency this service would be provided to R2. 2. A review of R2's medical record revealed documentation of showering provided to R2. For the month of August, 2025, assistance with showering was documented to have been provided on August 1, August 3, August 22, and August 29. 3. A review of R6's medical record revealed a service plan dated October 9, 2025 for personal care services. The service plan stated R6 required assistance with catheter care and assistance to get to the dining room for meals. 4. A review of R6's medical record revealed documentation of services provided to R6 in October 2025. However, documentation of catheter care was not available for review, and documentation of meal attendance had multiple gaps or omissions where the documentation had not been completed. 5. A review of R7's medical record revealed a service plan dated May 27, 2025 for directed care services. The service plan documented multiple services R7 required on a daily basis. 6. A review of R7's medical record revealed a hospital discharge summary which indicated R7 was in the hospital between October 17, 2025 and October 21, 2025. 7. A review of R7's medical record revealed documentation of services provided to R7 in October 2025. However, this documentation continued through the period of October 17 through October 21 for all services, despite R7 being out of the facility at this time. 8. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site complaint inspection conducted March 12, 2025.”

“Based on record review and interview, for one of one sampled non-ambulatory residents, the manager failed to terminate residency or obtain documentation from the resident requested to remain at the facility and from the resident's primary care practitioner stating they had reviewed the facility's scope of services, had examined the resident within 30 days prior to the statement, and the resident's needs could be met facility, at the onset of the condition and every six months throughout the duration of the condition. Findings include: 1. A review of R6's medical record revealed R6 was non-ambulatory since prior to admission at the facility and continued to be non-ambulatory throughout the date of the on-site inspection. However, documentation of a notice of termination of R6's residency was not available for review. 2. A review of R6's medical record revealed documentation from R6 requesting to remain at the facility despite being non-ambulatory was not available for review. 3. A review of R6's medical record revealed documentation from R6's primary care physician, dated before R6's date of admission, stating the physician had reviewed the facility's scope of services, had examined R6 within 30 days prior to the statement, and stating the facility could meet R6's needs, was not available for review. 4. A review of R6's medical record revealed documentation from R6's primary care physician, dated six months after R6's date of admission, stating the physician had reviewed the facility's scope of services, had examined R6 within 30 days prior to the statement, and stating the facility could meet R6's needs, was not available for review. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of disaster drills for the twelve months prior to the on-site inspection revealed disaster drills had been conducted and documented on each shift on March 25, 2025. However, documentation for disaster drills required to be conducted by December 2024, June 2025, and September 2025 were not available for review. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“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. Findings include: 1. A review of facility evacuation drills revealed an evacuation drill had been conducted and documented on May 1, 2025. However, documentation of an evacuation drill conducted in November 2024 was not provided for review. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury resulting in the resident needing medical services.  The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R2's medical record revealed a hospital discharge summary dated August 6, 2025. However, an incident report documenting R2's emergency, to include documentation of the immediate notification of R2's emergency contact and primary care provider, were not available for review. 2. A review of R4's medical record revealed a hospital discharge summary dated October 3, 2025. However, an incident report documenting R4's emergency, to include documentation of the immediate notification of R4's emergency contact and primary care provider, were not available for review. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure an incident report was generated when a resident had an accident, emergency, or injury resulting in the resident needing medical services.  The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R2's medical record revealed a hospital discharge summary dated August 6, 2025. However, an incident report documenting R2's emergency was not available for review. 2. A review of R4's medical record revealed a hospital discharge summary dated October 3, 2025. However, an incident report documenting R4's emergency was not available for review. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, for one of two residents sampled, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months.   Findings include: A review of R1's medical record revealed a service plan, dated September 6, 2024, for directed care services. However, service plan updates dated on or before December 6, 2024 and March 6, 2025 were not available for review. In an interview, E1 acknowledged that R1's record did not include a written service plan update dated at least once every three months.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled.   Findings include:   1. A review of R1’s and R2’s medical records revealed each resident had a service plan describing the services which would be provided to each resident.   2. A review of R1’s and R2’s medical records revealed electronic documentation titled, “Documentation Survey Report,” (ADL) which documented the services provided to each resident on each day. However, the ADLs included multiple gaps, for each resident, where required services had not been documented to have been provided.   3. In an interview, E1 acknowledged the services provided to each resident had not been accurately documented on the provided ADL forms”

“Based on record review, documentation review, and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, for one of two sampled residents. Findings include: A review of R2's medical record revealed a service plan, dated October 30, 2024, for directed care services including medication administration. A review of R2's medical record revealed an order, dated January 21, 2025, which included, "Haloperidol 2mg/ml, Administer 0.25 ml (0.5 mg) PO Q2 hrs for agitation & anxiety." A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated January 2025. The eMAR documented "Haloperidol Lactate Oral Concentrate 2 MG/ML..." had been administered as ordered on January 23, 2025 at 07:00. A review of R2's medical record revealed an incident report dated January 23, 2025 with the incident type, "Employee Medication Error." An attached narrative stated, "....the caregiver did not attempt to enter [R2's] room...at all during the time that the medication was to be given....[the caregiver] admitted to not giving the medication." In an interview, E1 acknowledged a medication had not been administered to R2 as ordered.”

“Based on record review, observation, and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, for two of four directed care residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed two service plans with dates of June 18, 2024, and September 6, 2024, for directed care services. The Compliance Officer observed the following: In the section "Resident/Family" stated R1's name. In the section "Responsible Party/Relationship" stated "self". In the "Signature" stated R1's signature not R1's representative as required for a directed care resident. 2. A review of R2's medical record revealed a service plan with a date of June 27, 2024, for directed care services. The Compliance Officer observed the following: In the section "Resident/Family Name" stated R2's POA's name. In the section "Responsible Party/Relationship" stated "self". In the section "Signature" R2 signed and dated POA's name. 3. In an interview, E1 acknowledged the POA's for R1, and R2 did not sign and date the service plans as required for directed care residents.”

“Based on documentation review, record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and was accurately documented in the resident's medical record, for two of eight resident's records sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Administration". This document stated "... Confirming the medication is taken as ordered by the resident's medical practitioner by confirming (checking the medication against the MAR). 2. A review of R1's medical record revealed an order for the following medication: "Cholecalciferol Oral Tablet 25 MCG (1000 UT) give 1 tablet by mouth one time a day", and Uloric Oral Tablet 40 MG (Febuxostat) give 1 tablet by mouth one time a day". 3. A review of R1's medication administration record (MAR) dated September 2024 revealed no documentation of the administration of "Cholecalciferol Oral Tablet 25 MCG" was given on September 5 and 8 2024, at 0600, and "Uloric Oral Tablet 40 MG was not given on September 5 and 8, 2024, at 0600. 4. A review of R7's medical record revealed an order for the following medication: "Levothyroxine Sodium Tablet 112 MCG, give 1 tablet by mouth one time a day", and Pantoprazole Sodium Oral Tablet 40 MG give 1 tablet by mouth one time a day". 5. A review of R7's medication administration record (MAR) dated September 2024 revealed no documentation of the administration of "Levothyroxine Sodium Tablet 112 MCG on September 8, 2024, at 0600, and "Pantoprazole Sodium Oral Tablet 40 MG" on September 8, 2024, at 0600. 6. In an interview, E1 acknowledged medications for R1 and R7 were not administered in compliance with a medication order, and were not accurately documented in the resident's medical record.”

“Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented for storing medication. The deficient practice posed a health risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Administration". This document stated "... Medication storage: Includes one or more of the following; Resident's medication is safely stored in a locked, self-contained med-cart used only for medication. Medication is stored according to the instructions on the medication container; Medication requiring refrigeration are kept in a separate refrigerator either in the locked med room or in the nurse's office. Confirming the medication is taken as ordered by the resident's medical practitioner by confirming (checking the medication against the MAR) that: The resident taking the medication is the individual stated on the medication container label or if a medication organizer (mediset) is used, on the medical practioner's order. The dosage of the medication is the same as stated on the label or container, ensure and reassure the resident that the dosage is correct". 2. During the facility tour, the Compliance Officer observed in the facility's medication room a small refrigerator containing medication. The Compliance Officer observed a package of five "Bisacodyl Rectal Suppository 10 MG" were not in a labeled package to indicate who the medication belonged to. Present in the room was a med tech who stated we have a few who take that medication and continued to look this information up on a computer. The med tech stated the medication belonged to R8. 3. A review of R8's medical record revealed R8 was prescribed this medication. 4. During an interview, E1 acknowledged the facility did not store the medication per the facility's policy and procedure on storing 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 and includes all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. A review of the facility's documentation revealed an evacuation drills for employees and residents was unavailable for review that included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. 2. In an interview, E1 acknowledged no documentation was available for review that included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. Technical assistance was provided during the on-site compliance inspection conducted on August 8, 2023.”

“Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of facility documentation revealed documentation of tuberculosis infection activities required in R9-10-113.A.2.a-f were available for review. 2. A review of R1, R2, R3, R4, R5, R6, R7, and R8's medical records revealed documentation of recognizing the signs and symptoms of tuberculosis was unavailable for review. 3. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was unavailable for review. 4. In an interview, E1 reported the health care institution had not documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided during the on-site compliance inspection completed on August 8, 2024.”