MERRILL GARDENS AT ANTHEM

INSP-0131569

Complete

Date: 5/14/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-06-05

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00129033 conducted on May 14, 2025:

Deficiencies Found: 5

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.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for three of five sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1) and (4) states: "C. 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…4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E1's personnel record revealed E1 was hired as the manager before March 31, 2025. The review revealed a “TEAM MEMBER DOCUMENT CHECK LIST” which indicated facility personnel verified E1 was not on the Adult Protective Services (APS) registry on May 9, 2025. The review revealed a printout from the APS registry which confirmed facility personnel did not verify E1 was not on the APS registry until May 9, 2025. 3. In an interview, E1 reported facility personnel verified E1 was not on the APS registry in November 2024. However, E1 reported the verification had not been documented and printed until facility personnel checked the registry again on May 9, 2025. 4. A review of E5’s personnel record revealed E5 was hired as a caregiver. The review revealed an application and resume which indicated E5 had previous employers. However, the review revealed facility personnel contacted E5’s previous co-workers and not E5’s previous employers. 5. A review of E6’s personnel record revealed E6 was hired as a caregiver. The review revealed an application which indicated E6 had previous employers. However, the review revealed facility personnel contacted E6’s family and friends and not E6’s previous employers. The review revealed E6’s driver license and fingerprint clearance card which confirmed E6’s legal name. The review further revealed a printout from the APS registry which indicated facility personnel used E6’s middle name and not E6’s legal first name to verify E6 was not on the APS registry. 6. A review of the APS registry website revealed E6 was not on the registry. 7. In an interview, E1 acknowledged facility personnel did not use the correct name to verify E6 was not on the APS registry. E1 acknowledged facility personnel contacted friends, family, and previous co-workers and not previous employers for E5 and E6.

Temporary Solution:

Every staff member record/file has been updated with an employer reference check
and will continue to comply with new hires.

All past and current staff members include an APS check search executed by last name and date of birth per the surveyor who completed the audit.

Permanent Solution:

All files moving forward will be searched by their last name and DOB.

Person Responsible:

Lori Schuldt

Deficiency #2

Rule/Regulation Violated:

R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of five sampled applicable personnel members. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed a “TEAM MEMBER DOCUMENT CHECK LIST” which indicated E4’s first aid and CPR training certification expired on April 18, 2025. The review revealed a first aid and CPR training certification dated as expired on April 18, 2025, and a current first aid and CPR training certification dated as issued on May 2, 2025. However, the certifications revealed E4 did not have first aid and CPR training certification for approximately two weeks. 2. A review of facility documentation revealed a series of personnel schedules which indicated E4 worked on April 20-23 and 27-29, 2025, and May 1, 2025, without first aid and CPR training certification. 3. In an interview, E1 confirmed E4 did not have first aid and CPR training certification for approximately two weeks.

Temporary Solution:

We are now in compliance. All staff members are up to date with their CPR certifications.

In addition we modified tracking for CPR expiration dates. Staff members are reminded 60 days in advance of their CPR expiration dates as well required to submit a current CPR certification 30 days before expiration.

Permanent Solution:

All CPR certifications are required to be submitted 30 days prior expiration.

Person Responsible:

Lori Schuldt

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.3.c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for one of ten sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated April 29, 2025. The service plan indicated R1 was to receive assistance with dressing, toileting, and transferring. However, the service plan did not include the frequency of these services. 2. In an interview, E1 stated, “We don’t have frequencies on there.”

Temporary Solution:

Starting with new move ins after July, the nurse will add frequencies to the notes in the service plans.

Permanent Solution:

Frequencies will be added to careplans starting with move ins 8/1/25

Person Responsible:

Heidi Tamayo

Deficiency #4

Rule/Regulation Violated:

R9-10-808.C.1.g. Service Plans 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 and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of ten sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated April 29, 2025. The service plan revealed R1 was to receive assistance with dressing, toileting, and transferring. The review revealed documentation of assisted living services provided to R1 (ADLs) dated April 2025. However, the ADLs revealed no documentation of dressing, toileting, and transferring provided to R1 during the 2:00 PM to 10:00 PM shift on April 28, 2025. 2. In an interview, E1 reported R1 had not been out of the community between 2:00 PM and 10:00 PM on April 28, 2025. E1 reported the aforementioned services were provided but were not documented.

Temporary Solution:

ADLs are now being completed electronically and will alert staff if any documentation was missed.

Permanent Solution:

ADLs are no longer on paper but all electronic.

Person Responsible:

Heidi Tamayo

Deficiency #5

Rule/Regulation Violated:

R9-10-818.A.4. Emergency and Safety Standards 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 if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills conducted within the last 12 months. 2. In an interview, E1 confirmed facility personnel had not conducted disaster drills for employees within the last 12 months. E1 reported not remembering the last time facility personnel had conducted a disaster drill.

Temporary Solution:

Bob will receive training from a Maintenance Director form a sister facility and will run a drill as part of the training

Permanent Solution:

Bob will create a drills schedule and run these per state guidelines.

Person Responsible:

Robert Dykhuizen

No deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00185014 conducted on May 24, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.

Facility Information

Inspection History

INSP-0131569

Summary:

Deficiencies Found: 5

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:

INSP-0077564

Summary: