VISIONS SENIOR LIVING AT APACHE JUNCTION 1

INSP-0158002

Complete

Date: 8/19/2025 - 8/20/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-09-19

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00141183 conducted on August 19, 2025:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and

Evidence/Findings:

Based on documentation review, record review, and interview, for one of six employees reviewed, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411(C)(1) states, "Each residential care institution, nursing care institution and home health agency 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 did not include documentation of the facility's good-faith effort to contact E4's previous employers. 3. In an interview, the finding was reviewed with E2 and no additional information was provided.

Temporary Solution:

Documentation of good faith effort was not in E4 personnel record by previous
manager upon hiring of personnel. Moving forward, new management will be checking and
reviewing previous employers to obtain information or recommendations that may be relevant to
a person's fitness to work at vision assisted living.

Permanent Solution:

Moving forward a file checklist will be initiated to monitor all
requirements for personnel. Initiated on Aug 25, 2025

Person Responsible:

Dana Pulec, manager

Deficiency #2

Rule/Regulation Violated:

R9-10-803.A.3.b.i-ii. Administration A. A governing authority shall: 3. Designate, in writing, a manager who: b. Except for the manager of an adult foster care home, has either a: i. Certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or ii. A temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06;

Evidence/Findings:

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk to the health and safety of residents as there was not a qualified manager to implement policies and procedures or provide direction to personnel. Findings include: 1. A review of Department documentation revealed the previous manager resigned from the facility effective July 15, 2025. 2. During the environmental inspection of the facility, the Compliance Officer did not observe a manager's certificate posted at the facility. 3. In an interview, E2 reported E2 was issued a temporary Certified Assisted Living Facility Manager (ALM-T-004049) effective July 25, 2025. E2 reported the facility had gaps with no manager from July 16, 2025, to July 24, 2025. 4. A review of the Nursing Care Institution Administrators and Assisted Living Facility Managers website revealed E2's temporary manager's certificate was revoked as of August 7, 2025. 5. In an interview, E2 reported the facility had a gap with no manager from August 8, 2025, to August 14, 2025. E2 reported the facility hired a new manager effective August 15. 6. In an exit interview, the findings were reviewed with E2 and no additional information was provided. This is a repeat deficiency from the inspection conducted on July 16, 2025.

Temporary Solution:

Dana Pulec was acting as temporary manager. Temporary managers license was
revoked on August 7, 2025 due to not passing the state exam. Dana Pulev rescheduled for
retake of state exam the following month on September 4, 2025. During this time Owners
pursued a permanent another manager while Dana Pulec was preparing for her retake of state
exam.

Permanent Solution:

Since September 4, 2025 Dana Pulec has passed her state exam
and is now the permanent manager. Initiated on Aug 25, 2025

Person Responsible:

Dana Pulec, Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-803.A.7. Administration A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;

Evidence/Findings:

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I), when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A review of Department documentation revealed O1 was no longer the manager of the facility effective July 15, 2025. 2. While on-site for compliance inspection, the Compliance Officer observed a conspicuously posted notice from the Board of Arizona Nursing Care Institution Administrators documenting R2 as a "Certified Assisted Living Facility Manager-Temporary" issued on July 25, 2025, and expired on December 22, 2025. 3. In an interview, E2 reported the facility hired E1 as the new manager effective August 15, 2025. However, E2 was unaware if the governing authority notified the Department of the change in manager. 4. A review of Department documentation revealed the facility did not notify the Department of the change in the manager according to A.R.S. § 36-425(I). 5. In an interview, E2 acknowledged the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager; 6. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Temporary Solution:

More than one qualified staff member with managerial training will be available in
case a temporary manager is needed.

Permanent Solution:

: A written polity has been added to the facilities compliance manual
requiring: A written notice to AZDHS upon appointment or confirmation of a license manager.
Copy of submission of notice to AZDHS in the absence of a manager by owner. Initiated on Aug
25, 2025

Person Responsible:

Dana Pulec, manager

Deficiency #4

Rule/Regulation Violated:

R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of six employees reviewed. The deficient practice posed a potential TB exposure risk to residents. 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E5's personnel record revealed no evidence of freedom from infectious tuberculosis on or before the date of hire. 4. A review of E5's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E5 had signs or symptoms of TB on or before the date of hire. 5. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Temporary Solution:

Using our checklist to make sure all documentation is verified and in the employee file upon hiring staff.

Permanent Solution:

A nurse has been hired to reassure compliance for the TD for new
hires. Initiated on Aug 25, 2025

Person Responsible:

Dana Pulec, manager

Deficiency #5

Rule/Regulation Violated:

R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties; ii. The individual’s education and experience applicable to the individual’s job duties; iii. The individual’s completed orientation and in-service education required by policies and procedures; iv. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Compliance with the requirements in A.R.S. § 36-411(A) and (C); and x. The certificate of completion, according to R9-10-126;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a personnel record was available for one of six employees reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. The deficient practice posed a risk as required information could not be verified for E1. Findings include: 1. The Compliance Officer requested E1's personnel record. However, it was not available for review. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided. This is a repeat deficiency from the on-site inspection completed September 4, 2024.

Temporary Solution:

Moving forward a checklist will be used to assure compliance with personnel
records.

Permanent Solution:

A final checklist was established and put into effect. Initiated on Aug
25, 2025

Person Responsible:

Dana Pulec, manager

Deficiency #6

Rule/Regulation Violated:

R9-10-808.A.4.b.iii. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: iii. At least once every three months for a resident receiving directed care services; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for two of five residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services dated March 6, 2025. However, a service plan dated after March 6, 2025 was not available for review. 2. A review of R3's medical record revealed a written service plan for directed care services dated March 6, 2025. However, a service plan dated after March 6, 2025 was not available for review. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Temporary Solution:

Permanent manager in place to monitor service plan deadlines.

Permanent Solution:

Permanent manager and a permanent nurse on staff to establish
service plans for compliance based on level of care. Initiated on Aug 25, 2025

Person Responsible:

Dana Pulec, Manager

Deficiency #7

Rule/Regulation Violated:

R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for two of five sampled residents' records that were reviewed who had resided at the assisted living facility for more than 12 months. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R2's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2023. 3. A review of R4's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2022. 4. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Temporary Solution:

Moving forward the new manager will utilize a chart checklist to verify notification
of the availability of the vaccination of FLU and PNE will be made available to residents on site
annually.

Permanent Solution:

Moving forward manager will be monitoring an annual check and
documentation of availability of FLU and PNE to each resident in the file checklist. Initiated on
Aug 25, 2025

Person Responsible:

Dana Pulec, manager

Deficiency #8

Rule/Regulation Violated:

R9-10-819.A.3.a-d. Emergency and Safety Standards A. A manager shall ensure that: 3. Documentation of the disaster plan review required in subsection (A)(2) includes: a. The date and time of the disaster plan review; b. The name of each employee or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the disaster plan review included the time of the disaster plan review, a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan review dated February 28, 2025. However, the disaster plan review did not include documentation of the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an exit interview, the findings were reviewed with E2 and no additional infomration was provided.

Temporary Solution:

Disaster Plan has been established every 3 months including time of disaster
plan, a critique, and recommendations of improvements if applicable. As presented 2/24/25,
5/25/25 completed by the previous manager and 8/19/25 by the current manager.

Permanent Solution:

: Please see the file attached for proof of completion. Initiated on Aug
25, 2025

Person Responsible:

Dana Pulec, manager

INSP-0136245

Enforcement

Date: 7/16/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-08-22

Summary:

The following deficiency was found during the on-site investigation of complaints 00104451, 00136706, 00104908, and 00104450 conducted on July 16, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.3.a. Administration A. A governing authority shall: 3. Designate, in writing, a manager who: a. Is 21 years of age or older; and

Evidence/Findings:

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk if the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of Department documentation revealed O1 was no longer the manager of the facility effective July 15, 2025. 2. While on-site for the complaint investigation, the Compliance Officer observed there was no acting manager's license conspicuously posted. 3. In an interview, E1 reported O1 had been the facility manager until July 15, 2025. 4. In an interview, E1 acknowledged the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

INSP-0054492

Complete

Date: 9/4/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-09-19

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00215292 conducted on September 4, 2024:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
1. Established, documented, and implemented to protect the health and safety of a resident that:
a. Cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers;
b. Cover orientation and in-service education for employees and volunteers;
c. Include how an employee may submit a complaint related to resident care;
d. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11;
e. Except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including:
i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation;
ii. The qualifications for an individual to provide cardiopulmonary resuscitation training;
iii. The time-frame for renewal of cardiopulmonary resuscitation training; and
iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training;
f. Cover first aid training;
g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;
h. Cover staffing and recordkeeping;
i. Cover resident acceptance and resident rights;
j. Cover termination of residency, including:
i. Termination initiated by the manager of an assisted living facility, and
ii. Termination initiated by a resident or the resident's representative;
k. Cover the provision of assisted living services, including:
i. Coordinating the provision of assisted living services,
ii. Making vaccination for influenza and pneumonia available to residents according to A.R.S. § 36-406(1)(d), and
iii. Obtaining resident preferences for food and the provision of

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established and documented. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards, and the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. The facility's policies and procedures were not available for review.

2. In an interview, E2 reported the policies and procedures were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged policy and procedures were not available for review.

Deficiency #2

Rule/Regulation Violated:

A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
a. A method to identify, document, and evaluate incidents;
b. A method to collect data to evaluate services provided to residents;
c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care;
d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and
e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a plan was established, documented, and implemented for an ongoing quality management program. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. The facility's quality management documentation was not available for review.

2. In an interview, E2 reported the quality management documents were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged the quality management program was not available for review.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a personnel record was available for each employee that was requested. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. The Compliance Officer requested E1's and E2's personnel records. However, they were not available for review.

2. In an interview, E2 reported the personnel records were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged E1's and E2's personnel records were not available for review.

Deficiency #4

Rule/Regulation Violated:

D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes:
1. The individual's name;
2. Terms of occupancy, including:
a. Date of occupancy or expected date of occupancy,
b. Resident responsibilities, and
c. Responsibilities of the assisted living facility;
3. A list of the services to be provided by the assisted living facility to the resident;
4. A list of the services available from the assisted living facility at an additional fee or charge;
5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours;
6. The policy for refunding fees, charges, or deposits;
7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan;
8. The policy and procedure for an assisted living facility to terminate residency;
9. The complaint process; and
10. The manager's signature and date signed.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for two of seven residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. A review of R1's medical record revealed no documentation of a residency agreement.

2. A review of R2's medical record revealed no documentation of a residency agreement.

3. In an interview, E2 reported R1's and R2's residency agreements were locked in an office where E2 did not have access to retrieve the documents. E1 acknowledged R1's and R2's residency agreements were not available for review.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider.

2. The Compliance Officer requested to review R1's medical record; however, no medical record was provided for review.

3. In an interview, E2 reported R1's medical record was locked in an office where E2 did not have access to retrieve R1's documents. E2 acknowledged R1's medical record was not available for review.

Deficiency #6

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order. The deficient practice posed a risk to the health and safety of R2 as medications were not administered as ordered.

Findings include:

1. A review of R2's medical record revealed R2 received medication administration.

2. A review of R2's medical record revealed a medication administration record (MAR) for August 2024. The MAR indicated Albuterol Sulfate 90 MCG was "awaiting Medication" for August 3rd, 4th, 5th, and 6th.

3. A review of R2's MAR notes for August revealed a medication for Fluticasone Prop (120 sprays) "N/A" on August 11, 20024. Then on August 12, 2024 it stated "medication unavailable". Then on August 13 to August 29 it stated "awaiting medication" with the exception of August 25th which stated "unavailable"

4. A review of R2's medication orders revealed Albuterol Sulfate 90MCG was originally ordered by the doctor on July 9, 2023 and it was to be administered three times a day.

5. A review of R2's medication orders revealed Flutocasone Prop (120 sprays) was originally ordered by the doctor on June 28, 2023 and it was to be administered once a day

6. In an interview, E2 confirmed when the MAR notes stated "awaiting Medication" R2 did not receive the medication as the facility was waiting for a refill for the medication.

7. In an interview, E3 acknowledged medications were not administered as ordered.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

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. The deficient practice posed a risk as required the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. Disaster drills were not available for review.

2. In an interview, E2 reported the disaster drills were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged disaster drills were not available for review.

Deficiency #8

Rule/Regulation Violated:

A. A manager shall ensure that
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and
b. Includes all individuals on the premises except for:
i. A resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident, and
ii. Sufficient caregivers to ensure the health and safety of residents not evacuated according to subsection (A)(5)(b)(i);

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an evacuation drills for employees and residents was conducted at least once every six months. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection.

Findings include:

1. Evacuation drills were not available for review.

2. In an interview, E2 reported the evacuation drills were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged evacuation drills were not available for review.

INSP-0054490

Complete

Date: 9/20/2023 - 9/21/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-10-11

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00189555, AZ00190550, AZ00191111, AZ00191749, AZ00191750, and AZ00191751 conducted on September 20, 2023 and September 21, 2023:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to develop and 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.

Findings include:

1. A review of facility documentation revealed an education program for fall prevention and fall recovery. The program included the initial training and continued competency components.

2. A review of E4's personnel record revealed documentation of fall prevention and fall recovery training was not available for review.

3. In an interview, E1 acknowledged E4's personnel record did not include documentation of fall prevention and fall recovery training. E1 was unaware E4's job position required the training.

Deficiency #2

Rule/Regulation Violated:

A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two caregivers sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population.

Findings include:

1. A review of E3's personnel record revealed E3 was hired as a caregiver in September 2023. The record included a copy of a fingerprint clearance card, which was issued in August 2016 and expired in August 2022. In addition, the record included verification of E3's submission of a fingerprint clearance card application in February 2023. The verification indicated E3's fingerprint clearance card was issued in March 2023 and would expire in March 2029.

2. A review of the Department of Public Safety's fingerprint clearance card verification website, on September 20, 2023, revealed E3's fingerprint clearance card was not valid.

3. In an interview, E1 reported E3 never submitted a copy of E3's current fingerprint clearance card. E1 reported being unaware E3's fingerprint clearance card was invalid. E1 reported E3 was removed from the facility's work schedule until the issue was resolved.

Deficiency #3

Rule/Regulation Violated:

B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of five residents admitted in 2023. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R4's medical record revealed a document titled "Physician Plan of Care" (dated January 14, 2023). However, the document indicated R4 required continuous medical services.

2. In an interview, E1 reported R4 was expected to receive directed care services.

3. In an interview, E1 acknowledged R4's medical record indicated R4 required continuous medical services. E1 indicated someone should have caught the error. E1 was aware individuals requiring continuous medical services require services beyond the scope of services the facility is licensed to provide.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
g. Documents the services provided in the resident's medical record; and

Evidence/Findings:

Based on record review, interview, and documentation review, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of eight sampled residents with a service plan. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R3's medical record revealed a service plan dated August 1, 2022. The plan stated R3 was to receive the following services at the indicated frequencies:
-Apply lotion daily
-Weekly skin check
-Care staff to remind/escort R3 to all mealtimes and to encourage eating to promote proper nutrition;
-Will encourage resident to eat and offer fluids every two hours;
-Care staff to encourage drinking fluids at mealtimes and in between meals with snack to support adequate hydration
-Care staff to assist R3 with dressing/undressing twice per day;
-Assist with dental devices twice per day;
-Care staff will check R3's whereabouts and safety regularly, throughout the day, around the clock (six times per day); and
-Care staff to do safety checks approximately every two hours to ensure resident safety.

2. A review of R3's medical record revealed a sample of documents (June-August 2023) titled, "Visions Assisted Living [Activities of Daily Living] Sheet." However, the document indicated R3 received assistance with safety checks once per day, rather than every two hours as indicated in the service plan. R3 was offered and encouraged to drink fluids, once per day rather than every two hours according to the service plan.

3. A review of R4's medical record revealed a service plan dated January 20, 2023. The plan stated R4 was to receive the following services at the indicated frequencies:
-Facility to provide assistance with toileting and monitor skin for breakdown/significant changes five times per day;
-Care staff will check R4's whereabouts and safety regularly, throughout the day, around the clock (six times per day); and
-Care staff to offer and encourage activities to promote socialization and cognitive stimulation two times per day.

4. A review of R4's medical record revealed a document (dated February 2023) titled, "Visions Assisted Living [Activities of Daily Living] Sheet." Under the heading, "Assist [with] Toileting," the documentation indicated R4 received assistance with toileting once per day from February 1-February 28, 2023 and not five times per day as indicated in the service plan. The document indicated R4 received assistance with safety checks once per day; although, R4's service plan indicated six safety checks per day. R4 was offered and encouraged to engage in activities once per day on February 1-6, 2023 and February 10-28, 2023. However, R6's service plan indicated this service would be provided twice per day.

5. A review of R6's medical record revealed a service plan dated January 29, 2023. The plan stated R6 was to receive the following services at the indicated frequencies:
-Care staff to check and change R6 approximately every two hours for incontinence (six times per day);
-Care staff to assist R6 with dressing/undressing twice per day;
-Care staff to assist R6 with grooming twice per day;
-Care staff to assist R6 with oral care twice per day;
-Care staff will check R6's whereabouts and safety regularly, throughout the day, around the clock (six times per day); and
-Care staff to offer and encourage activities to promote socialization and cognitive stimulation three times per day.

6. A review of R6's medical record revealed a sample of documents (December 2022-February 2023 titled, "Visions Assisted Living [Activities of Daily Living] Sheet." Under the heading, "Assist [with] Toileting," the documentation indicated R6 was assisted with toileting once per day from December 1, 2022-February 28, 2023. However, the document did not indicate R6 was assisted with incontinence approximately every two hours, according to R6's service plan. The documents indicate R6 received assistance with dressing and grooming, including combing hair, shaving, oral care, safety checks, and offering and encouraging activities once per day. However, R6's service plan indicated these services would be provided twice per day.

7. A review of R7's medical record revealed a service plan dated February 13, 2023. The plan stated R7 was to receive the following services at the indicated frequencies:
-Care staff to check R7's skin weekly;
-Care staff to remind/escort R7 to all mealtimes and to encourage eating to promote proper nutrition;
-Care staff to encourage drinking fluids at mealtimes and in between meals with snack to support adequate hydration
-Care staff to assist R7 with dressing/undressing twice per day;
-Care staff to assist R7 with grooming twice per day;
-Care staff to assist R7 with oral care twice per day; and
-Care staff will check R7's whereabouts and safety regularly, throughout the day, around the clock (six times per day).

8. A review of R7's medical record revealed a sample of documents (December 2022-February 2023 titled, "Visions Assisted Living [Activities of Daily Living] Sheet." The documents indicated R7 received assistance with dressing and grooming, including combing hair, shaving, oral care, safety checks, and offering and encouraging activities once per day. However, R7's service plan indicated these services would be provided twice per day.

9. A review of R8's medical record revealed a service plan dated June 26, 2023. The plan stated R8 was to receive the following services at the indicated frequencies:
-Care staff to check and change R8 approximately every two hours for incontinence;
-Care staff to assist R8 with dressing/undressing twice per day; and
-Care staff to assist R8 with grooming twice per day.

10. A review of R8's medical record revealed a sample of documents (dated June-August 2023) titled, "Visions Assisted Living [Activities of Daily Living] Sheet." Under the heading, "Assist [with] Toileting," the documentation indicated R8 received assistance with toileting once per day from June 16, 2023-August 31, 2023. However, the document did not indicate R8 was checked for incontinence and changed every two hours. The document indicated R8 received assistance with dressing and grooming, including combing hair, shaving, oral care, and denture care once per day. However, R8's service plan indicated these services would be provided twice per day.

11. In an interview, E1 reported the caregivers' initials or other symbols included in the aforementioned documentation indicated the assisted living services were provided according to the frequency set in the service plan. However, there was no legend on the document to indicate the meaning of the symbols used.

12. A documentation review revealed a policy (policies and procedures reviewed January 9, 2023) titled, "Provision of Services." The policy stated, "A manager shall ensure that a caregiver or assistant caregiver ...Documents the services provided in the resident ' s [Activities of Daily Living, Medication Administration Record], Service Notes, or medical record."

13. In an interview, E1 acknowledged the caregivers did nor document the services provided to the aforementioned residents, according to their service plans.

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact or primary care provider, for one of one resident sampled who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

R9-10-101.110. "Immediate" means without delay.

1. A review of Department documentation revealed R5 sustained an injury at the assisted living facility and was transported by emergency medical services to [hospital] on January 21, 2023.

2. A review of R5's medical record revealed documentation the resident's primary care provider or emergency contact was immediately notified was not available for review.

3. In an interview, E1 reported R5 was a resident for less than 24 hours. R5 was admitted without medications and as a result R5 became combative with staff. Emergency Medical Services were called and R5 was transferred to a geriatric psychiatric unit. E1 believed R5's primary care provider or emergency contact was notified. However, E1 acknowledged documentation was not available for review.

Deficiency #6

Rule/Regulation Violated:

D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
a. The date and time of the accident, emergency, or injury;
b. A description of the accident, emergency, or injury;
c. The names of individuals who observed the accident, emergency, or injury;
d. The actions taken by the caregiver or assistant caregiver;
e. The individuals notified by the caregiver or assistant caregiver; and
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

1. A review of Department documentation revealed R5 sustained an injury at the assisted living facility and was transported by emergency medical services to [hospital] on January 21, 2023.

2. A review of R5's medical record revealed documentation include the date and time of the emergency; a description of the emergency; the names of individuals who observed the emergency; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; or any action taken to prevent the emergency from occurring in the future was not available for review.

3. In an interview, E1 reported R5 was a resident for less than 24 hours. R5 was admitted without medications and as a result R5 became combative with staff. Emergency Medical Services were called and R5 was transferred to a geriatric psychiatric unit. However, E1 acknowledged documentation with the criteria required by the Rule was not available for review.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
1. The premises and equipment used at the assisted living facility are:
a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure the premises was cleaned and disinfected to prevent, minimize, and control illness or infection.

Findings include:

1. The Compliance Officer observed debris and dirt on the floor in R1's, R2's, and R3's bedrooms.

2. The Compliance Officer observed the sink in R2's bathroom was sticky and covered with dirt.

3. The Compliance Officer observed brown smears, resembling feces, on the walls of R1's and R3's bedroom. The base of R3's toilet also had several brown smears, resembling feces.

4. A documentation review revealed policy and procedures reviewed on January 9, 2023. A policy titled "Environmental" stated "Facility premises and equipment used there in are in working order, used and cleaned according to the manufacturer's recommendations and, if applicable, disinfected as needed to prevent, minimize, and control illness or infection."

5. In an interview, E1 acknowledged R1's, R2's, and R3's bedrooms and bathrooms were not cleaned and disinfected to prevent, minimize, and control illness or infection. E1 reported it was embarrassing to see the state of the residents' rooms and bathrooms.

VISIONS SENIOR LIVING AT APACHE JUNCTION 1

Facility Information

Inspection History

INSP-0158002

Summary:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0136245

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0054492

Summary:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated: