GEMS ASSISTED LIVING 3

<p>Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed this statute went into effect on October 1, 2021.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Fall Recovery” dated April 10, 2023. The P&P stated: "This facility shall develop an initial training, conduct, and administer continued competency Training in Fall Prevention and Fall Recovery Program every 6 months.”</p><p><br></p><p><br></p><p>3. A review of E2's personnel record revealed E2 was hired as the manager. The review revealed E2 received training regarding fall prevention and fall recovery on May 20, 2024, and February 20, 2025. However, the review revealed no such training within six months after May 20, 2024.</p><p><br></p><p><br></p><p>4. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed E3 received training regarding fall prevention and fall recovery on February 20, 2024, and February 20, 2025. However, the review revealed no such training within six months after February 20, 2024.</p><p><br></p><p><br></p><p>5. A review of E6’s personnel record revealed E6 was hired as a caregiver. The review revealed E6 did not receive training regarding fall prevention and fall recovery until February 20, 2025, more than eight months after E6 was hired.</p><p><br></p><p><br></p><p>6. A review of E4's, E7’s, and E12’s personnel records revealed E4, E7, and E12 were hired as caregivers. However, the review revealed no documentation demonstrating E4, E7, and E12 received initial training regarding fall prevention and fall recovery.</p><p><br></p><p><br></p><p>7. A review of E8's and E11’s personnel records revealed E8 and E11 were hired as caregivers. However, the review revealed no documentation demonstrating E8 and E11 received initial training regarding fall prevention and fall recovery or continued competency training every six months thereafter.</p><p><br></p><p><br></p><p>8. A review of E9's personnel record revealed E9 was hired as a housekeeper. However, the review revealed no documentation demonstrating E9 received initial training regarding fall prevention and fall recovery.</p><p><br></p><p><br></p><p>9. A review of E10's personnel record revealed E10 was hired as a housekeeper. The review revealed E10 received training regarding fall prevention and fall recovery on February 20, 2024. However, the review revealed no continued competency training every six months thereafter.</p><p><br></p><p><br></p><p>10. In an interview, E1 acknowledged facility personnel failed to administer a training program for all staff regarding fall prevention and fall recovery initially and every six months as required by P&P.</p>

<p>Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for seven of twelve sampled employees. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed this rule went into effect on May 4, 2022.</p><p><br></p><p><br></p><p>2. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.”</p><p><br></p><p><br></p><p>3. A review of facility documentation revealed a policy and procedure titled “TUBERCULOSIS (“TB”) TESTING” dated April 10, 2023. The P&P stated, “This facility provides in-service training and education related to recognizing and symptoms of tuberculosis yearly.”</p><p><br></p><p><br></p><p>4. A review of E3's personnel record revealed E3 was hired before this rule went into effect. However, the review revealed E3 did not receive training and education related to recognizing the signs and symptoms of TB until August 20, 2024.</p><p><br></p><p><br></p><p>5. A review of E4's, E7’s, and E9’s personnel records revealed E4, E7, and E9 were hired after this rule went into effect. However, the review revealed no documentation demonstrating E4, E7, and E9 received training and education related to recognizing the signs and symptoms of TB upon hire.</p><p><br></p><p><br></p><p>6. A review of E8's and E10’s personnel records revealed E8 and E10 were hired after this rule went into effect. However, the review revealed E8 and E10 did not receive training and education related to recognizing the signs and symptoms of TB until August 20, 2024.</p><p><br></p><p><br></p><p>7. A review of E11's personnel record revealed E11 was hired before this rule went into effect. However, the review revealed no documentation demonstrating E11 received training and education related to recognizing the signs and symptoms of TB upon hire or annually thereafter.</p><p><br></p><p><br></p><p>8. In an interview, E1 acknowledged not all employees received annual training and education related to recognizing the signs and symptoms of TB.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A) and (C), for six of twelve sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A.R.S. § 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work."</p><p><br></p><p><br></p><p>2. A.R.S. § 36-411(C)(1-2) 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. 2. Verify the current status of a person's fingerprint clearance card…4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.”</p><p><br></p><p><br></p><p>3. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on April 10, 2024. The POC indicated this deficiency was corrected by E1, E2, O1, and others on April 10, 2024. The POC stated: “Following the survey, all staff fingerprint cards were reviewed. Employees without fingerprint clearance submitted their prints, which the manager cross checked against the public safety website. Moving forward, the manager will ensure that all staff members either have a fingerprint card, or an active application number before starting employment with Gems, or within 20 days of being hired. Employees who did not have a fingerprint card during the survey were either terminated, or sent immediately to get fingerprinted, or given opportunity to submit a good [cause] exemption. Additionally, personal and professional references for all current employees were contacted and verified. This process will now be conducted before a new employee begins employment with Gems.”</p><p><br></p><p><br></p><p>4. A review of facility documentation revealed a policy and procedure (P&P) titled "FINGERPRINT" dated April 10, 2023. The P&P stated: "Owner or Manager of this assisted living facility must require prospective employee to obtain fingerprint clearance, and must make efforts to verify with the Department of Public Safety (DPS) the status of prospective employee’s fingerprint clearance card…The Manager shall obtain documentation of fingerprint clearance for every individual employee or volunteer who works in the facility…The fingerprint card must be current and valid…The timeframe for renewal of Fingerprint shall be monitored." The review further revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT” dated April 10, 2023. The P&P stated: “Upon being hired by the facility the applicant must [provide] 2 Professional/Work References (references to be verified by the facility manager).”</p><p><br></p><p><br></p><p>5. A review of E2's personnel record revealed E2 was hired as the manager. The review revealed a document titled “DPS TELEPHONE FINGER PRINT VERIFICATION” and a printout from the DPS website. However, the document and printout revealed facility personnel did not verify E2’s fingerprint clearance card (FCC) until June 28, 2024, more than one month after E2’s starting date of employment and contrary to the aforementioned POC. The review further revealed a printout from the Adult Protective Services (APS) registry. However, the printout revealed facility personnel misspelled E2’s name and did not verify E2 was not on the APS registry.</p><p><br></p><p><br></p><p>6. A review of E5’s personnel record revealed E5 was hired as a caregiver. The review revealed an application which indicated E5 had previous employers. However, the review revealed no documentation demonstrating facility personnel made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E5’s fitness to work in a residential care institution. The review further revealed a printout from the DPS website. However, the printout revealed facility personnel did not verify E5’s FCC until April 3, 2025, after E5’s starting date of employment.</p><p><br></p><p><br></p><p>7. A review of E6's personnel record revealed E6 was hired as a caregiver. The review revealed a photocopy of E6’s FCC and a printout from the DPS website. However, both documents revealed E6’s FCC expired on March 21, 2025, approximately three weeks before the date of the inspection. The review further revealed no documentation demonstrating E6 applied for a new FCC.</p><p><br></p><p><br></p><p>8. A review of the DPS website revealed E6's FCC expired on March 21, 2025. The review revealed no application for a new FCC.</p><p><br></p><p><br></p><p>9. A review of facility documentation revealed a series of personnel schedules which indicated E6 worked on a regular basis between March 21, 2025, and the date of the inspection.</p><p><br></p><p><br></p><p>10. In an interview, E1 reported E1 had not been aware E6’s FCC was expired. After a phone call with E6, E1 stated, “[E6] said [E6] wasn’t aware it expired.”</p><p><br></p><p><br></p><p>11. A review of E7's personnel record revealed E7 was hired as a caregiver. The review revealed a photocopy of E7’s FCC, dated as expired on January 5, 2023, and a printout from the DPS website which indicated E7 applied for a second FCC on January 19, 2023. However, the printout stated DPS was “Waiting On Applicant Fingerprints.” The review revealed another printout from the DPS website, dated May 19, 2023, which stated DPS was still “Waiting On Applicant Fingerprints.” The review revealed a receipt for fingerprinting services dated May 22, 2023, and a form containing prints of E7’s fingerprints. The form included a handwritten note which stated “Had to Redo prints [as] the last ones mailed in where [<em>sic</em>] not ledgable [<em>sic</em>].The review revealed no current valid FCC or application for a FCC within 20 working days of beginning employment.</p><p><br></p><p><br></p><p>12. A review of the DPS website revealed E7's first FCC expired on January 5, 2023, and E7 reapplied on February 13, 2025, after E7’s ending date of employment. The website further revealed E7’s current FCC was issued on February 21, 2025, and was valid.</p><p><br></p><p><br></p><p>13. A review of Department documentation revealed a Statement of Deficiencies (SOD) for the complaint and compliance inspection conducted on April 10, 2024. The SOD revealed this deficiency was previously cited for E7. The SOD stated the following:</p><p><br></p><p>- “A review of [E7's] personnel record revealed [E7] was hired as a caregiver in 2023. The review revealed a photocopy of [E7's] fingerprint clearance card. However, the card expired on January 5, 2023, before [E7] was hired. The review further revealed a document with a set of [E7’s] fingerprints. The document stated: ‘Fingerprints done 1/5/24 and sent off. Checked 4/3/24 still pending.’ However, the review revealed no application or application number…</p><p><br></p><p>- “A review of the DPS fingerprint clearance card verification website revealed [E7's] fingerprint clearance card expired on January 5, 2023. The website revealed no subsequent application for a fingerprint clearance card submitted by [E7].</p><p><br></p><p>- “In an interview, [O1] reported [E7] re-applied for a fingerprint clearance card. However, [O1] did not provide an application or application number. [O1] stated, ‘We haven't had time to verify.’”</p><p><br></p><p><br></p><p>14. A review of facility documentation revealed a series of personnel schedules which indicated E7 worked on a regular basis between April 2024 and May 2024 and again between November 2024 and January 2025.</p><p><br></p><p><br></p><p>15. A review of E10’s personnel records revealed E10 was hired as a housekeeper. The review revealed a note which stated E10 “Needs Fingerprint card [and] verification.” The review revealed E10’s current FCC and a printout from the DPS website. However, the printout revealed facility personnel did not verify E10’s FCC until August 24, 2024, more than one year after E10’s starting date of employment. The review further revealed no documentation demonstrating facility personnel made documented, good faith efforts to verify that E10 was not on the APS registry.</p><p><br></p><p><br></p><p>16. A review of the APS registry website revealed E10 was not on the registry.</p><p><br></p><p><br></p><p>17. A review of E12's personnel record revealed E12 was hired as a caregiver. The review revealed several hire dates for E12, ranging from 2015 to 2024. The review revealed a printout from the DPS website dated June 6, 2022. The printout revealed E12 applied for a FCC on July 31, 2013. However, the printout stated E12’s FCC was “Not Valid.” The review revealed E12 was most recently hired in 2024 and facility personnel did not verify E12’s FCC upon E12’s most recent hire date. The review further revealed E12 did not have a valid FCC for the entirety of each of E12’s documented terms of employment at this facility.</p><p><br></p><p><br></p><p>18. A review of the DPS website revealed the following:</p><p><br></p><p>- E12's first FCC expired on May 25, 2013;</p><p><br></p><p>- E12 reapplied on July 31, 2013, and the “Current Status” of the application/FCC was “Invalid;”</p><p><br></p><p>- E12 reapplied for a second time on October 16, 2018, and the “Current Status” of the application/FCC was “Invalid;” and</p><p><br></p><p>- E12 reapplied for a third time on February 23, 2023, and the “Current Status” of the application/FCC was “Application Complete - Results mailed to applicant.”</p><p><br></p><p><br></p><p>19. A review of Department documentation revealed a letter from a representative of the Fingerprint Program at the Arizona Department of Health Services Bureau of Special Licensing dated April 22, 2019. The review revealed the letter was sent to AL11108 Gems Assisted Living LLC (a facility owned by the same owner as this facility). The letter stated: “You are hereby notified that a Fingerprint Clearance Card for [E12] was SUSPENDED by the Arizona Department of Public Safety. You must notify your respective ADHS licensing bureau within 14 calendar days confirming the above individual has either: 1. Been suspended or terminated to prevent [E12] from having contact with persons receiving services from your agency; or 2. If eligible, petitioned the Arizona Board of Fingerprinting for a Good Cause Exception; and, provided your agency with a copy of [E12’s] complete application for a Good Cause Exception.” The review revealed a second letter from a representative of the Fingerprint Program at the Arizona Department of Health Services Bureau of Special Licensing, dated March 22, 2023. The review revealed the letter was sent to AL11387 Gems Assisted Living #4 (a facility owned by the same owner as this facility). The letter stated: “You are hereby notified that a Fingerprint Clearance Card for [E12] was DENIED by the Arizona Department of Public Safety. You must notify your respective ADHS licensing bureau within 14 calendar days confirming the above individual has either: 1. Been suspended or terminated to prevent [E12] from having contact with persons receiving services from your agency; or 2. If eligible, petitioned the Arizona Board of Fingerprinting for a Good Cause Exception; and, provided your agency with a copy of [E12’s] complete application for a Good Cause Exception.” The review further revealed facility personnel made no such notifications to ADHS.</p><p><br></p><p><br></p><p>20. A review of facility documentation revealed a series of personnel schedules which indicated E12 worked in August 2024, and October-November 2024.</p><p><br></p><p><br></p><p>21. In an interview, E1 acknowledged the facility was not in compliance with this rule.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of nine sampled caregivers. The deficient practice posed a risk if a manager or a caregiver was unable to meet a resident's needs during an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled "CPR AND FIRST AID” dated April 10, 2023. The P&P stated: "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and that their certification is maintained and [is] current as long as they are employed by this facility.” The review further revealed a series of personnel schedules which indicated E3 worked on a regular basis between May 2024 and September 2024.</p><p><br></p><p><br></p><p>2. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed a first aid and CPR certification dated as expired on May 10, 2024. The review further revealed a current first aid and CPR certification dated as issued on September 5, 2024, nearly four months after E3’s previous certification expired.</p><p><br></p><p><br></p><p>3. In an interview, E1 confirmed E3 worked without first aid and CPR certification for nearly four months.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of nine sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING and RECORD KEEPING” dated April 10, 2023. The P&P stated: “Each employee hired by this facility must have the following on Employee’s file…5. Verification of skills and Knowledge.” The review revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT” dated April 10, 2023. The P&P stated: “Upon being hired by the facility the applicant must [have]...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for.” The review further revealed a series of personnel schedules which indicated E8 worked on a regular basis between July 2024 and November 2024.</p><p><br></p><p><br></p><p>2. A review of E8's personnel record revealed E8 was hired as a caregiver. However, the review revealed no documentation demonstrating the manager ensured E8's skills and knowledge were verified and documented before E8 provided physical health services.</p><p><br></p><p><br></p><p>3. In an interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a manager and a caregiver provided evidence 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 Arizona Administrative Code (A.A.C.) R9-10-113, for two of ten sampled personnel members. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. R9-10-113(A)(2)(a)(i-iii) 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…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…iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)."</p><p><br></p><p><br></p><p>2. R9-10-113(B)(1)(a)(i) and (c)(i-ii) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution.”</p><p><br></p><p><br></p><p>3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel."</p><p><br></p><p><br></p><p>4. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (“TB”) TESTING” dated April 10, 2023. The P&P stated: “1. All individuals including residents of this facility will be screened for infectious tuberculosis…a. All employees and residents of this facility are required to provide one of the following on admission or starting employment Baseline screening that includes…iii. Obtaining documentation of the individual's freedom from infectious tuberculosis…b. Documentation of a negative Mantoux skin test or other tuberculosis screening testwithin [<em>sic</em>] 12 months of the date of employment or residence in the facility. c. A written physician’s statement dated within 12 months of employment or residence in the facility indicating freedom from pulmonary tuberculosis, if the individual has a positive skin test for tuberculosis…6. The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as an employee, providing services to residents, or moving into the facility…8. All documentations shall be maintained for tuberculosis risk assessment, tuberculosis screening test, signs or symptoms of an employee/volunteer and residents.”</p><p><br></p><p><br></p><p>5. A review of E2's personnel record revealed E2 was hired as the manager. The review revealed a positive TST dated as read within 12 months before hire. The review further revealed a written statement indicating E2 was free from infectious tuberculosis, signed by a medical practitioner on June 6, 2024, after E2 began providing services at or on behalf of the assisted living facility.</p><p><br></p><p><br></p><p>6. A review of E5’s personnel record revealed E5 was hired as a caregiver. The review revealed a negative TST dated as read on April 2, 2025, and a second negative TST dated as administered on April 10, 2025, but not yet read.</p><p><br></p><p><br></p><p>7. A review of facility documentation revealed a series of personnel schedules which indicated E2 worked before E2 received the written statement and E5 worked before the E5’s first TST was read.</p><p><br></p><p><br></p><p>8. In an interview, E1 acknowledged E2 and E5 began providing services before providing evidence of freedom from infectious TB.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>Based on documentation review, 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 the facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of a resident and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on April 10, 2024. The POC indicated this deficiency was corrected on September 20, 2024. The POC stated: “All resident records were reviewed and the updated form was sent to PCP to complete and return.”</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed R2 was admitted to the facility before September 20, 2024 (the correction date on the POC). However, the review revealed no documentation in compliance with this rule, contrary to the POC.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported R2 moved from one facility owned by O1 (the owner of this facility), to a second facility owned by O1, to this facility owned by O1. E1 reported not knowing R2 needed documentation in compliance with this rule for each facility, including for this one.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a residency agreement. However, the residency agreement did not include R1's date of occupancy or expected date of occupancy.</p><p><br></p><p><br></p><p>2. In an interview, when the Compliance Officer asked if the residency agreement the Compliance Officer reviewed was R1’s full residency agreement, E1 stated, “Yeah.” When the Compliance Officer informed E1 R1’s residency agreement did not include R1's date of occupancy or expected date of occupancy, E1 stated, “Okay.”</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>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 two of two sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's and R2’s medical records revealed current service plans which indicated R1 and R2 were to receive assistance with dressing. However, the service plans did not include the frequency of assistance with dressing.</p><p><br></p><p><br></p><p>2. In an interview, when the Compliance Officer asked if caregivers assisted R1 and R2 with dressing, E1 stated, “Yes.” E1 acknowledged R1’s and R2’s service plans did not include the frequency of assistance with dressing.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>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 two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's and R2’s medical records revealed current service plans which indicated R1 and R2 were to receive assistance with dressing. The review further revealed documentation of assisted living services provided to R1 and R2 (ADLs) dated April 2025. However, the ADLs revealed no documentation of assistance with dressing for R1 or R2.</p><p><br></p><p><br></p><p>2. In an interview, when the Compliance Officer asked if caregivers assisted R1 and R2 with dressing, E1 stated, “Yes.” E1 reported caregivers assisted R1 and R2 with dressing but did not document it.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.</p>

<p>Based on documentation review and interview, the manager failed to ensure policies and procedures (P&Ps) were implemented for inventorying controlled substances. The deficient practice posed a risk as the standards expected of employees to ensure resident safety were not followed.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a P&P titled "STORING, INVENTORYING AND DISPENSING OF CONTROLLED MEDICATIONS," dated April 10, 2023. The P&P stated: “2. For every medication marked with a ‘C’, a Narcotic Inventory Sheet should be maintained… 5. When assisting a resident in taking a controlled medication, a staff member should: Count the number of tablets/capsules available (e.g., in a bubble-packed card) and enter that number in the ‘Amount on Hand’ column on the form. Draw a line through the ‘Amount Received’ column. Write the number of tablets/capsules to be given at the designated time in the ‘Amount Given’ column. Subtract the number of tablets/ capsules written in the ‘Amount Given’ column from the number in the ‘Amount on Hand’ column. Write the resulting number in the ‘Amount Remaining’ column (this should be the number of tablets/capsules left after the current dose is taken).”</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a narcotics count binder. The review revealed a "Controlled Medication Record" document for each of the observed controlled medications for R1, R2, R4, R5, and R6. However, the documents did not contain columns for the “Amount on Hand” as required per P&P.</p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged facility personnel did not implement the P&P.</p>

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), (C), and (E), for four of five sampled personnel members. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution.

Findings include:

1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work."

2. A.R.S. \'a7 36-411(C)(2) states: "C. Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card."

3. A.R.S. \'a7 36-411(E) states: "E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1 or has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked."

4. A review of facility documentation revealed a policy and procedure titled "FINGERPRINT" dated April 12, 2023. The policy and procedure stated: " The hiring individual will check and document fingerprinting requirements for each employee or volunteer to ensure they have a valid fingerprint card...Owner or Manager of this assisted living facility must require prospective employee to obtain fingerprint clearance, and must make efforts to verify with the Department of Public Safety (DPS) the status of prospective employee's fingerprint clearance card."

5. A review of E3's personnel record revealed E3 was hired as a caregiver in 2021. The review revealed a document titled "NEW HIRE CHECK OFF LIST." The list contained a place to check off whether E3 had a fingerprint clearance card. However, the spot next to "Copy of Fingerprint" was left blank. The review revealed no fingerprint clearance card. However, the review did reveal an "APPLICATION FOR A FINGERPRINT CLEARANCE CARD (non-IVP)", dated April 12, 2022, as well as a "Notice of Denial" from DPS dated October 16, 2023. The review further revealed no documentation demonstrating the governing authority made documented, good faith efforts to verify the status of E3's fingerprint clearance card upon hire.

6. A review of the DPS fingerprint clearance card verification website revealed E3's application was received on April 14, 2022. The website stated, "Application Complete - Results mailed to applicant" and indicated E3 did not have a fingerprint clearance card.

7. In an interview, E1 reported E1 had been asking for E3's fingerprint clearance card for months. E1 reported E3 re-applied for a fingerprint clearance card in October 2023 and was denied again. E1 stated. "We are working on [E3] getting it." E1 reported E3 was in the process of applying for a good cause exception. However, E1 could not produce the application for the good cause exception. E1 stated, "[E3's] not the only one that doesn't have a fingerprint [clearance card]."

8. A review of E4's personnel record revealed E4 was hired as a caregiver in 2023. The review revealed a photocopy of E4's fingerprint clearance card. However, the card expired on January 5, 2023, before E4 was hired. The review further revealed a document with a set of E4's fingerprints. The document stated: "Fingerprints done 1/5/24 and sent off. Checked 4/3/24 still pending." However, the review revealed no application or application number. The review further revealed no documentation demonstrating the governing authority made documented, good faith efforts to verify the status of a E4's fingerprint clearance card upon hire.

9. A review of the DPS fingerprint clearance card verification website revealed E4's fingerprint clearance card expired on January 5, 2023. The website revealed no subsequent application for a fingerprint clearance card submitted by E4.

10. In an interview, E1 reported E4 re-applied for a fingerprint clearance card. However, E1 did not provide an application or application number. E1 stated, "We haven't had time to verify."

11. A review of E5's personnel record revealed E5 was hired as a caregiver in 2023. The review revealed a document titled "NEW HIRE CHECK OFF LIST." The list contained a place to check off whether E5 had a fingerprint clearance card. However, the spot next to "Copy of Fingerprint" was left blank and "Pending/- 11/28/23 Not Found when searched" was written next to it in the margin. The review revealed no fingerprint clearance card. However, the review did reveal an "APPLICATION FOR A FINGERPRINT CLEARANCE CARD (non-IVP)", dated May 22, 2023 (more than 20 days after E5 was hired), as well as a letter to E5 from E2 dated November 28, 2023. The letter stated, "When searching the status of your fingerprint clearance card there is no record of your application...Regrettably, we need to immediately terminate your employment with Gems Assisted Living effective November 28, 2023." However, the review revealed no documentation demonstrating the governing authority made documented, good faith efforts to verify the status of a E5's fingerprint clearance card upon hire.

12. A review of the DPS fingerprint clearance card verification website revealed E5 did not have a fingerprint clearance card. The website revealed E5 applied on December 22, 2020, and was denied on January 29, 2021. The website further revealed the application number on the application dated May 22, 2023, did not belong to E5 and E5 did not re-apply.

13. In an interview, E1 reported E5 was terminated in part due to not having a fingerprint clearance card.

14. A review of E6's personnel record revealed E6 was hired as a caregiver in 2023. The review revealed a photocopy of E6's fingerprint clearance card. However, the card expired on March 24, 2023, shortly after E6 was hired. The review revealed a printout from the DPS fingerprint clearance card verification website dated May 19, 2023, which indicated E6's subsequent application was received on May 19, 2023, and stated, "Waiting On Applicant Fingerprints."

15. A review of the DPS fingerprint clearance card verification website revealed E6's application was received on May 19, 2022. The website stated, "Application Complete - Results mailed to applicant" and indicated E6 did not have a current fingerprint clearance card. Further review revealed the fingerprint clearance card application was denied.

16. In an int

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures covering assistance in the self-administration of medication and medication administration (P&Ps) were implemented to protect the health and safety of a resident. The deficient practice posed a risk to residents who were not prescribed accessible medications.

Findings include:

1. A review of facility documentation revealed a P&P titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: g. Storing medications properly and securely."

2. During the environmental inspection of the facility, the Compliance Officer observed a plastic lock box in the refrigerator. The Compliance Officer observed the lockbox was locked. However, with minimal force, the lid of the box opened approximately four inches in height on one side making the medications inside accessible and not secure as required by P&Ps. Inside the box, the Compliance Officer observed "Lorazepam," "Megestrol Acetate," and "Morphine Sulfate."

3. In an interview, E1 reported the medication box was locked. However, E1 acknowledged the medications were accessible and not entirely secured.

4. A review of facility documentation revealed a P&P titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: f. Taking, reading, and implementing physician medication and treatment orders."

5. A review of R1's and R3's medical records revealed current service plans which indicated R1 and R3 required medication administration services. The review further revealed medication administration records (MARs) dated April 2024 which indicated R1 and R3 received medication administration services for multiple medications in April, some being administered daily. However, the review revealed no signed medication orders for R1 or R3.

6. A review of facility documentation revealed an incident report involving R2 dated October 28, 2023. The incident stated: "[Employee 1] pre-popped medication for all residents. [Employee 2] handed the wrong meds to wrong resident [R2]."

7. In an interview, E1 acknowledged R1's, R2's, and R3's medications were not administered in compliance with a medication order.

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 the facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of a resident.

Findings include:

1. A review of R1's medical record revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints.

2. In an interview, E1 stated, "We're still out of compliance."

Technical assistance was provided on this rule during the complaint inspection conducted on June 16, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: f. Taking, reading, and implementing physician medication and treatment orders."

2. A review of R1's and R3's medical records revealed current service plans which indicated R1 and R3 required medication administration services. The review further revealed medication administration records (MARs) dated April 2024 which indicated R1 and R3 received medication administration services for multiple medications in April, some being administered daily. However, the review revealed no signed medication orders for R1 or R3.

3. A review of facility documentation revealed an incident report involving R2 dated October 28, 2023. The incident stated: "[Employee 1] pre-popped medication for all residents. [Employee 2] handed the wrong meds to wrong resident [R2]."

4. In an interview, E1 acknowledged R1's, R2's, and R3's medications were not administered in compliance with a medication order.