SPRINGDALE VILLAGE ASSISTED LIVING

<p>Based on observation and interview the manager failed to ensure the premises and equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1 . On a tour of the facility, the Compliance Officer observed a section of flooring missing, which posed a risk of trip hazard for a resident or other individual.</p><p><br></p><p><br></p><p>2 . In an interview, E1 acknowledged that the facility is under construction and the premises were not free of a condition or situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p><p><br></p><p>This is a repeat deficiency from a Complaint inspection conducted on March 1, 2025, Complaint/Compliance inspection conducted on November 19, 2024, and Annual Compliance inspection conducted on October 26, 2023.</p>

<p>Based on observation and interview, the manager failed to ensure that medications were stored in a locked room, closet, cabinet or self -contained unit used only for medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1 . During a tour of the facility, the Compliance Officer was able to access a medication cart that was located in the hallway, outside resident rooms and was unlocked with no staff at the medication cart.</p><p><br></p><p><br></p><p>2 . In an interview, E1 acknowledged that the medication cart was not locked, appropriately, and was accessible to others in the area.</p>

<p>Based on Observation, Document review and interview, the manager failed to ensure that a fire alarm system was installed according to the National Fire Protection Association 72 and in working order. </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1 . During a tour of the facility, the Compliance Officer observed the fire panel with a trouble alert code.</p><p><br></p><p><br></p><p>2 . A review of facility documentation revealed a policy - Fire Down Policy. E1 reported that one staff was assigned to complete room and facility checks every 30 -60 min.</p><p><br></p><p><br></p><p>3 . In an interview, E1 acknowledged that the fire sprinkler system was not functioning properly and the facility had a plan in place to check on residents and was working on the repairs required by the Fire Marshall. </p>

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

Findings include:

1. A.R.S. \'a7 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. Review of E1's personnel record revealed no documentation of good faith efforts to contact previous employers.

3. Review of E2's personnel record revealed no documentation of good faith efforts to contact previous employers.

4. Review of E3's personnel record revealed no documentation of good faith efforts to contact previous employers.

5. In an interview, E1 acknowledged E1's, E2's, and E3's personnel records contained no documentation of good faith efforts to 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.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established or documented to protect the health and safety of a resident that covered how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Findings include:

1. A review of the facility's policies and procedures did not contain an established or documented policy and procedure that covered how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

2. In an interview, E1 acknowledged that policies and procedures were not established or documented to protect the health and safety of a resident that covered how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

Findings include:

1. A review of the facility's policy and procedure manual revealed documentation of a review of the facility's policies and procedures on March 27, 2019 . However, no additional documentation of review was available for Compliance Officer review.

2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included: an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.

Findings include:

1. While on-site for the compliance and complaint inspection, the Compliance Officers requested the facility's quality management documentation at 10:30 AM. However, no documentation was provided for Compliance Officer review.

2. In an interview, E1 acknowledged the facility's quality management report was not provided for Compliance Officer review.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of three personnel sampled. The deficient practice posed a potential illness 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 E2's personnel record revealed a hire date of October 12, 2011.

3. While on-site for the compliance and complaint inspection, the Compliance Officers requested E2's documentation of freedom from infectious TB; however, no documentation available for review.

4. A review of E3's personnel record revealed a hire date of October 13, 2021.

5. While on-site for the compliance and complaint inspection, the Compliance Officers requested E3's documentation of freedom from infectious TB; however, no documentation available for review.

6. In an interview, E1 acknowledged E2 and E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for three of six residents sampled. The deficient practice posed a TB exposure risk to residents.

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 R4's (admitted 2023) medical record did not include documentation of evidence of freedom from infectious TB.

3. A review of R5's (admitted 2019) medical record did not include documentation of evidence of freedom from infectious TB.

4. A review of R6's (admitted 2021) medical record did not include documentation of evidence of freedom from infectious TB.

5. In an interview, E1 acknowledged R4's, R5's, and R6's medical records did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for three of six residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. While on-site for the compliance and complaint inspection, the Compliance Officers requested R4's, R5's, and R6's medical records with all required documents at 10:30 AM. However, the medical records provided did not include documentation signed by a medical practitioner that included if R4, R5, or R6 required continuous medical services, continuous or intermittent nursing services, or restraints.

2. In an interview, E1 acknowledged R4's, R5's, and R6's medical records did not contain documentation signed by a medical practitioner that included if R4, R5, or R6 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R4, R5, and R6 were accepted into the facility.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility there was a documented residency agreement with the assisted living facility, for three of six residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. While on-site for the compliance and complaint inspection, the Compliance Officers requested R4's, R5's, and R6's medical records with all required documents at 10:30 AM. However, the medical records provided did not include a documented residency agreement with the assisted living facility for R4, R5, and R6.

2. In an interview, E1 acknowledged R4's, R5's, and R6's medical records did not include documentation of a residency agreement with the assisted living facility.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for two of six residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated August 3, 2022. However, documentation of an updated service plan was not available for Compliance Officer review.

2. A review of R4's medical record revealed a service plan dated March 24, 2023. Based on R4's termination date, an update was required. However, documentation of an updated service plan was not available for Compliance Officer review.

3. In an interview, E1 acknowledged R1's and R4's medical records did not include a service plan updated at least once every six months.

Based on record review and interview, the manager failed to ensure that a resident's written service plan was signed by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for three of six residents sampled.

Findings include:

1. A review of R4's medical record revealed a service plan dated March 27, 2023. However, the service plan did not include a signature from R4 or R4's representative, the manager, and the nurse who reviewed the service plan.

2. A review of R5's medical record revealed a service plan dated July 6, 2023. However, the service plan did not include a signature from R5 or R5's representative, the manager, and the nurse who reviewed the service plan.

3. A review of R6's medical record revealed a service plan dated December 1, 2023. However, the service plan did not include a signature from R6 or R6's representative, the manager, and the nurse who reviewed the service plan.

4. In an interview, E1 acknowledged R4's, R5's, and R6's service plans were not signed by the resident or resident's representative, the manager, and the nurse who reviewed the service plan.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order.

Findings include:

1. A review of R1's medical record revealed R1 received medication administration.

2. A review of R1's medication administration record (MAR) for November 2024 revealed the administration of Pantoprazole Sodium 40 milligrams (mg), 1 tablet by mouth (po) daily (qd), and indicated 1 tablet was administered at 8:00 AM November 1, 2024 - present.

3. A review of R1's MAR for November 2024 revealed the administration of Senna 8.6 mg, 1 tablet po twice a day (bid), and indicated 1 tablet was administered at 8:00 AM and 8:00 PM November 1, 2024 - present.

4. A review of R1's medical record did not include a medication order for the following medications:
- Pantoprazole Sodium 40 mg, 1 tablet po qd; and
- Senna 8.6 mg, 1 tablet po bid.

5. In an interview, E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B), for three of six residents sampled.

Findings include:

1. R9-10-818(B) states, "A manager shall ensure that: A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident ' s acceptance by the assisted living facility, and the resident ' s orientation is documented."

2. A review of R4's medical record did not include documentation of R4's orientation to exits from the assisted living facility.

3. A review of R5's medical record did not include documentation of R5's orientation to exits from the assisted living facility.

4. A review of R6's medical record did not include documentation of R6's orientation to exits from the assisted living facility.

5. In an interview, E1 acknowledged that R4's, R5's, and R6's medical records did not contain documentation of R4's, R5's, and R6's orientation to exits from the assisted living facility required in R9-10-818(B).

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Medication Administration." However, the policy, dated March 27, 2019, was not signed by a medical practitioner, registered nurse, or pharmacist.

2. In an interview, E1 acknowledged the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on observation and interview, the manager failed to ensure food was protected from potential contamination which posed a health and safety risk.

Findings include:

1. During an environmental inspection, the Compliance Officers observed the following:
- In R3's room, the resident's refrigerator was not maintained in a clean condition. The Compliance Officers observed a thick yellow and brown substance on bottom shelf underneath the drawers;
- In the "overflow snack" room, in the freezer, the Compliance Officers observed dark brown food chunks throughout the bottom shelf;
- In the "overflow snack" room, in the freezer, the Compliance Officers observed an uncovered container of an unknown substance; and
- In the "overflow snack" room, in the refrigerator, on the bottom and top shelves of the door, the Compliance Officers observed multiple red sticky spots.

2. In an interview, E1 acknowledged food was not protected from potential contamination. E1 acknowledged that the resident's refrigerator was not in clean condition.

Based on observation and interview, the manager failed to ensure facility equipment and food contact surfaces were clean. The deficient practice posed a health and safety risk to residents if food was not stored in a clean manner.

Findings include:

1. During an environmental inspection, the Compliance Officers observed the following:
- In the unlocked kitchen area, there were utensils and dishes stored uncovered in a dirty, rusty, metal unlocked cabinet. On the shelves of the cabinet, there were rusty metal flakes with dirt and debris along the shelf;
- In the unlocked kitchen on the drink preparation area, there were dirty cloths lying to the right of the drink machine;
- In the unlocked kitchen area, next to the drink preparation area, there was a large orange industrial fan with a heavy build-up of dirt debris on the blades and front cover;
- In the unlocked kitchen area, there was a large hole in the wall, under the serving counter with dust, dirt and debris;
- In the unlocked kitchen area, the air system unit was uncovered and the unit was exposed with rusty metal and dirt and debris in the wall area;
- In the unlocked kitchen area, the air system vents had a thick layer of grayish colored substance that appeared to be dust;
- In the hallway, there was a table with plates, eating and serving utensils under a cloth; and
- In the hallway, there were a steam table with an exposed serving preparation area.

2. In an interview, with E1 acknowledged the equipment and food contact surfaces were not in a clean condition.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of the facility's personnel schedule revealed there were three shifts.

2. A review of the facility's disaster drills revealed documentation of a disaster drills conducted the following days and shifts:
- October 25, 2024 on first shift;
- May 20, 2024 on second shift;
- April 18, 2024 on second shift;
- March 24, 2024 on third shift;
- February 14, 2024 on first shift; and
- January 22, 2024 on second shift.
However, no additional documentation of disaster drills were available for Compliance Officer review.

3. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of the facility's evacuation drill documentation revealed an evacuation drill conducted on January 13, 2024. However, no residents were documented as evacuated during the conducted drill.

2. In an interview, E4 reported no evacuation drills which included employees and residents were conducted within the last six months. E4 also reported being newly hired and unaware of the Arizona requirements.

3. In an interview, E1 acknowledged that an evacuation drill for employees and residents was not conducted at least once every six months.

Based on observation and interview, the manager failed to ensure the premises were cleaned.

Findings include:

1. During the environmental inspection, the Compliance Officers observed the following:
- The hallway carpets had large dark soiled areas throughout the facility;
- In the dining area, the portable sink had a brownish colored substance that appeared to be rust in the basin;
- In the dining area, next to the portable sink, there was a black trash can with no lid;
- In R2's bathroom, there was a dirty brief in the trash can with no lid;
- In R2's bathroom, there was a thick black ring inside the toilet bowl;
- In R3's bathroom, there was a towel on the floor in front of the toilet and shower, with spots of blood observed;
- In R3's bathroom, in the door entry, there were spots of smeared blood;
- In R3's bathroom, there was a trash can with no lid that contained bloody tissues;
- In R3's bathroom, the room was not in a clean condition and had an odor; and
- In the snack room, under the sink there was red bucket containing a cloudy white liquid.
All of these observations gave the appearance that the facility was not kept clean.

2. During an interview, E1 acknowledged the facility was not clean.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officers observed the swimming pool not in use and the gate was unlocked.

2. In an interview, E1 reported a resident had taken apart the lock and acknowledged the swimming pool gate was not locked when the swimming pool was not in use.

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to residents, for eight of eight sampled personnel records reviewed.

Findings include:

1. Review of the facility's documents revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all staff.

2. Review of eight sampled personnel records revealed there was no documentation that E1, E2, E3, E4, E5, E6, E7, and E8 had completed the required training.

3. In an interview, E1 and E2 acknowledged the facility did not have documentation that all the sampled employees had completed fall prevention and fall recovery training as required.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employees to have a valid fingerprint clearance card or fingerprint clearance card application within 20 working days of hire for one of eight sampled personnel records reviewed, which posted a safety risk.

Findings include:

1. Review of E6's personnel record, who was hired on July 19, 2023, contained no documentation of a fingerprint clearance card. There was an incomplete form regarding a fingerprint clearance card application in E6's personnel record that appeared to have been mailed August 11, 2023. There was no documentation that E6 had a fingerprint clearance card that was verified with the Department of Public Safety (DPS) or DPS website at the time of hire nor anytime since. There was no documentation the facility had verified on the DPS website the fingerprint application had been received. E6 was hired as a housekeeper. Part of E6's responsibilities was cleaning residents' units.

2. During an interview, E1 acknowledged there was no documentation from the DPS website nor any other documented evidence that E6 had a fingerprint clearance card that was valid.

3. After the exit from the compliance inspection, the compliance officer contact DPS requesting the criminal specialist, O1, to search in the DPS database if E6 had a fingerprint clearance card or application. O1 searched by name, date of birth, and social security number. O1 reported there was no fingerprint application. DPS had received a money order and fingerprints, however, there was no application. O1 reported the money order and fingerprints were returned on August 24, 2023; no other new documents had been received.

This is a repeat deficiency from the compliance inspection conducted on September 27-28, 2022.

Based on record review and interview, the manager failed to ensure one of eight sampled employees' records contained current medical documentation of freedom from infectious tuberculosis (TB), as specified in R9-10-113; which posed a health and safety risk.

Finding Include:

1. Review of the randomly selected sampled personnel records revealed that E7's record contained no medical documentation of a skin test or any other test that determined if the E7 was free from infectious TB at the time of hire nor anytime since. Based on the date of hire this was required.

2. In an interview, E1 and E2 acknowledged there was no documentation of TB screening for E7 as required.

Based on records reviewed and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive, which posed a health and safety risk for one of six sampled residents.

Findings include:

1. Review of R2's current service plan dated March 3, 2023, stated "supervisory" care services. However, this service plan states R2 "sometimes needs help with socks".

2. In an interview, E1 and E2 acknowledged R2 received, as needed, hands-on assistance to put on R2's socks. E1 reported R2's service plan should have indicated personal care services.

This is a repeat deficiency from the compliance inspection conducted on September 27-28, 2022.

Based on record review and interview, the manager failed to ensure that one of five sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk.

Findings include:

1. Review of R1's medical record revealed that R1 required personal care services. The service plan was not updated during the past twelve months. The most recent service plan was dated August 11, 2022.

2. In an interview, E1 and E2 acknowledged R1's service plan had not been updated as required. E1 and E2 reported R1 was receiving personal care services.

This is a repeat deficiency from the compliance inspection conducted on September 14-15, 2021 and September 27-28, 2022.

Based on record review and interview, the manager failed to ensure the written service plan when initially developed and when updated, for one of three sampled residents receiving medication administration services, was signed and dated by a nurse or medical practitioner when updated, which could pose a health risk to the resident.

Findings include:

1. Review of R5's current service plan dated April 24, 2023 stated the resident required personal care and medication administration services. However, the service plan was not signed and dated by a nurse or medical practitioner.

2. In an interview, E1 and E2 acknowledged the R5 was receiving medication administration services and R5's current service plan had not been signed and dated by a nurse or medical practitioner.

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 vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccination available to a resident on site on a yearly basis; for five of five sampled residents' records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk.

Findings include:

1. Based on the dates of acceptance, R1's, R3's, R4's, R5's, and R6's medical records did not contain documentation to indicate these sampled residents had received the pneumonia vaccine. There was no other documentation available in their medical records to indicate the vaccine was offered, given, refused, or contraindicated within the past 12 months.

2. In an interview, E1 and E2 acknowledged there was no documentation available that these residents had received the pneumonia vaccine or it had been made available to them during the past 12 months.

Based on record review and interview, the manager failed to ensure that two of two sampled residents who was unable to ambulate even with assistance, the residents' primary care providers (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provide personal care services.

Findings include:

1. In an interview, E2 reported R3 and R6 were both unable to ambulate even with assistance for the past twelve months.

2. Review of R3's medical record revealed a documented determination that was completed on May 26, 2023. During the past twelve months the determination was not updated at least every six months throughout the duration of the resident's condition. This determination should have been based on a current resident's examination and the facility's scope of services that the resident's needs could be met.

3. Review of R6's medical record revealed a documented determination that was completed on June 2, 2023. During the past twelve months the determination was not updated at least every six months throughout the duration of the resident's condition. This determination should have been based on a current resident's examination and the facility's scope of services that the resident's needs could be met.

4. In an interview, E1 and E2 acknowledged the determinations for R3 and R6 were not completed as required.

This is a repeat deficiency from the compliance inspections conducted on September 14-15, 2021 and September 27-28, 2022.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Findings include:

1. During a tour of randomly selected residents' units, E2 and the compliance officer observed in R6's unit the wall corners to the entrance into the kitchen area were broken down to the framing where the metal corners were exposed. These jagged broken areas could cause the resident or other individual to suffer physical injury if the resident's skin rubbed against this area.

2. In an interview, E2 acknowledged the walls in R6's kitchen entrance area were not in good repair which could result in injury.

This is a repeat deficiency from the complaint investigation conducted on July 20, 2023.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was accessible in units being used by five residents receiving personal care services.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R1's, R2's, R3's, R4's, and R5's residential units each had a pull-cord call system attached to the wall. The Compliance Officer observed the pull-cord system was not within reach to alert employees to a resident's needs or emergencies when the residents were in their beds.

2. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed each of the residents were receiving personal care services. A review of R2's, R3's, and R4's medical records revealed R2, R3, and R4 were unable to ambulate without assistance.

3. In an interview, R3 reported R3 did not use the pull-cord system as it was "difficult to walk." R3 reported R3 used R3's cell phone when R3 needed assistance from facility staff.

4. In an interview, R4 reported R4 had trouble standing without assistance. R4 reported R4 could not reach the pull-cord, but R4 thought the alert system was "probably broken anyways."

5. In an interview, E1 reported E1 had been reaching out to management to get approval for a medical alert lanyard system since E1 started working as a manager at the facility, but had yet to get approval for the new system. E1 acknowledged there was no bell, intercom, or other mechanical means accessible to alert employees of the needs of personal care residents.

Based on observation, documentation review, and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed a single elevator which ran between the assisted living building's first and second floors. The Compliance Officer observed a "Certificate of Inspection" posted on the wall of the elevator which stated, "On 11/1/2017 an applicable inspection of elevator or other type equipment State Ser. # 1240 was performed as required by A.R.S 23-491.05. The elevator...was found then/or later to comply with the standards and regulations adopted pursuant to A.R.S. Title 23, Chapter 2, Article 12."

2. A review of facility documentation revealed quarterly invoices from an elevator maintenance company for "Preventative elevator maintenance performed monthly." The most recent available invoice was for maintenance performed monthly "during the 4th quarter, 2022." However, there was no documentation of invoices for elevator maintenance services performed in 2023.

3. Further review of facility documentation revealed an inspection report from "The Industrial Commission of Arizona Division of Occupational Safety Health Elevator Section" dated February 8, 2023. The inspection report detailed the results of an inspection conducted by O1 on January 27, 2023, and stated, "This Correction Order describes violations of a standard or regulation promulgated in accordance with Arizona Revised statutes 23-491.01. You must correct the violations referred to in this Correction Order unless, pursuant to A.R.S. 23-491.10 (a), you request a hearing to contest any or all of the below listed violations." The document detailed the following violations found during the inspection on January 27, 2023: "Rule 8.11.1.6...Violation: Incorrect test tag; Section 8.9...Violation: No code data tag; Rule 112.4(b)/2.13.4.2.3...Violation: Door close pressure over 30 pounds, Annual test overdue; Rule 8.6.4.8.2...Violation: Remove the box of rims and tires from the machine room." The document further stated: "Corrections to be completed by abatement date: March 10, 2023...No conveyance shall be operated in this State without a current Certificate of Inspection. Upon failure of an owner or operator to comply with the requirements of this Correction Order, the Commision can enjoin the owner or operator from engaging in further acts in violation of this Correction Order."

4. In an interview, E3 reported corrections to the violations stated in the aforementioned documents were not completed by the abatement date of March 10, 2023, and were not completed as of the date of the survey (July 20, 2023). E3 reported the facility had not requested a hearing to contest the violations noted in the Correction Order. E3 reported the facility had several outstanding invoices with the company who performed elevator maintenance for the facility, and the company had suspended maintenance services for lack of payment. E3 reported E3 had been attempting to get the facility's business office to pay the overdue invoices "since the beginning of the year" so elevator maintenance services could be restored, and the facility could come into compliance with the Correction Order issued by The Industrial Commision of Arizona. E3 reported overdue invoices were recently paid and the elevator maintenance company was "coming out tomorrow (July 21, 2023) to resume services, and the issue would be resolved." E3 provided the Compliance Officer with a printout of email exchanges between E3, O2, and O3.

5. A review of the aforementioned printed email exchanges provided by E3 revealed an email from O2 to E3, dated March 15, 2023. The email stated, "I have not received any form of payment since August of 2022. Services are still suspended until we get payment on account services will still be suspended. I have sent numerous emails and no response. We will look at the correction orders, and anything that needs to be taken care of on our end will be taken care of once we resolve the past due issue on your account." An email sent from E3 to O3 on March 15, 2023 stated, "Hi [O3], We are past our date on our correction of violations, and service is still suspended...any help would be appreciated..." No emails dated after March 15, 2023 were provided for review.

6. In an interview, R1 reported R1 was unable to get to the first floor using the stairs. R1 reported R1 needed to use the elevator each time R1 went for a meal. R1 reported feeling unsafe on the elevator, but "had no choice" but to use it. R1 reported the elevator broke down on July 4, 2023, and residents were unable to use it for "more than an hour." R1 also reported hearing a caregiver got stuck in the elevator "a couple of months ago."

7. In an interview, R2 reported R2 used the elevator to go to meals. R2 reported R2 was scared of the elevator as R2 had heard "people get trapped in there."

8. In an interview, E1 reported the elevator had "no major problems" in 2023. However, E1 confirmed R1's account of the elevator breaking down on July 4, 2023. E1 reported it was only out of commission for "less than an hour" because "a sock had gotten stuck in it." E1 reported E1 was aware the elevator had not passed a recent inspection conducted by the industrial commission of Arizona, but reported E3 was "working on getting it fixed." E1 suggested the Compliance Officer speak with E3 as E1 was not in charge of facility maintenance. E1 acknowledged the condition of the building's elevator presented a condition or situation which may cause a resident or other individual to suffer physical injury.

9. In a separate interview, E2 reported E2 was uncomfortable riding the elevator and "always takes the stairs." E2 acknowledged the condition of the building's elevator presented a condition or situation which may cause a resident or other individual to suffer physical injury.