SCOTTSDALE VILLAGE SQUARE

<p>Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for three of three personnel sampled. The deficient practice posed a health and safety risk for residents. </p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of the facility's policies and procedures did not include a training program for all staff regarding fall prevention and fall recovery.</p><p><br></p><p>2. A review of E1’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. </p><p><br></p><p>3. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A review of E2’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">4. A review of E3’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. </span></p><p><br></p><p>5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p>This is a repeat deficiency from the compliance and complaint inspection conducted on January 4, 2023. </p>

<p>Based on documentation review, record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for BLANK of BKANK personnel sampled. The deficient practice posed a risk if E1, E2, and E3 were a danger to a vulnerable population.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A.R.S. § 36-411(C) 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. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee."</p><p><br></p><p>2. A review of E's personnel record revealed documentation of professional references, however, documentation of the facility's good faith effort to contact previous employers was not available.</p><p><br></p><p>5. A review of the E's personnel record revealed documentation of a valid fingerprint clearance card (FPCC). However, the status of E's FPCC was not verified as required.</p><p><br></p><p>8. A review of E's personnel record did not include documentation of verification that E was not on the adult protective services registry.</p><p><br></p><p>11. In an exit interview, the findings were reviewed with E, and no additional information was provided.</p><p><br></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that policies and procedures were implemented 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. </p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of the facility’s policies and procedures revealed a policy titled “Clinical-08 Psychiatric Crisis.” The policy stated, “6. An Incident Report is completed for all psychiatric crises and given to the Resident Care Director.</p><p><br></p><p>2. A review of R3’s medical record did not include documentation of an incident report. </p><p><br></p><p>3. In an interview, E1 reported an incident occurred regarding R3 and R2 on October 8, 2025; however, an incident report was not completed. </p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. </p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for two of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of the facility’s policies and procedures did not include a policy regaarding the verification of a caregivers’ skills and knowledge. </p><p><br></p><p>2. A review of E2’s personnel record did not include documentation of the verification of E2’s skills and knowledge. </p><p><br></p><p>3. A review of E3’s personnel record did not include documentation of the verification of E3’s skills and knowledge. </p><p><br></p><p>4. In an interview, E1 reported E2 and E3 have provided physical health services at the facility. </p><p><br></p><p>5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. </p>

<p>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 three of three personnel sampled. The deficient practice posed a potential illness risk to residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>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)..."</p><p><br></p><p>2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin T est) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."</p><p><br></p><p>3. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">A review of E1's personnel record revealed two negative TB skin tests that were less than 12 months old. However, no documentation of a TB signs and symptoms screening and risk assessment signed by a registered nurse (RN) was available. Based on E1’s date of hire, this documentation was required.</span></p><p><br></p><p>4. A review of E2's personnel record did not include documentation of E3's freedom from infectious TB. Based on E2's date of hire, this documentation was required.</p><p><br></p><p>5. A review of E3's personnel record revealed a negative TB skin test that was more than 12 months old, and a negative TB skin test that was less than 12 months old. However, no additional documentation of freedom from infectious TB was available for review. Based on E3’s date of hire, this documentation was required.</p><p><br></p><p>6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p>This is a repeat deficiency from the compliance and complaint inspection conducted on January 16, 2025.</p>

<p>Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of E3's personnel record did not include documentation of a valid CPR and First Aid certification.</p><p><br></p><p>2. In an interview, E1 reported E3 was a current employee and provided physical health services at the facility.</p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

<p>Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and was reviewed and updated at least once every three months for a resident receiving directed care services, for one of six residents sampled. </p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of R6's medical record revealed that R6 received directed care services. </p><p><br></p><p>2. A review of R6's medical record revealed a service plan dated June 2, 2025. However, no further documentation of a current, updated service plan was available for Compliance Officer review. </p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p>This is a repeat deficiency from the complaint inspection conducted on August 1, 2024. </p>

<p><span style="font-size: 12px;">Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the residents' medical record for six of six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.</span></p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R1's service plan revealed R1 required the following services:</p><ul><li>Total assistance with showering;</li><li>Standby assistance with dressing;</li><li>Escorts to meals;</li><li>Standby assistance with transfers; and</li><li>Housekeeping services.</li></ul><p><br></p><p>2. A review of R1's activities of daily living (ADL) documentation for October 2025 revealed missing documentation of all aforementioned services provided to R1 October 1, 2025 - October 12, 2025.</p><p><br></p><p>3. A review of R2's service plan revealed R2 required the following services:</p><ul><li>Wake-up call;</li><li>Escorts to meals; and</li><li>Housekeeping services.</li></ul><p><br></p><p>4. A review of R2's ADL documentation for October 2025 revealed missing documentation of all aforementioned services provided to R2 October 1, 2025 - October 12, 2025. </p><p><br></p><p>5. A review of R3's service plan revealed R3 required the following services:</p><ul><li>Wake-up call; and</li><li>Housekeeping services.</li></ul><p><br></p><p>6. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A review of R3's ADL documentation for October 2025 revealed missing documentation of all aforementioned services provided to R3 October 1, 2025 - October 12, 2025. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">7. </span>A review of R4's service plan revealed R4 required the following services:</p><ul><li>Wake-up call; and</li><li>Housekeeping services.</li></ul><p><br></p><p>8. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A review of R4's ADL documentation for October 2025 revealed missing documentation of all aforementioned services provided to R4 October 1, 2025 - October 12, 2025. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">9. </span>A review of R5's service plan revealed R5 required the following services:</p><ul><li>Wake-up call;</li><li>Standby assistance with showering;</li><li>Escorts to meals; and</li><li>Housekeeping services.</li></ul><p><br></p><p>10. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A review of R5's ADL documentation for October 2025 revealed missing documentation of all aforementioned services provided to R5 October 1, 2025 - October 12, 2025. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">11. </span>A review of R6's service plan revealed R6 required the following services:</p><ul><li>Wake-up call;</li><li>Grooming reminders;</li><li>Total assistance with showering;</li><li>Total assistance with dressing; and</li><li>Housekeeping services.</li></ul><p><br></p><p>12. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A review of R6's ADL documentation for October 2025, revealed missing documentation of all aforementioned services provided to R6 October 1, 2025 - October 12, 2025. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">13. In an interview, E1 reported all aforementioned services were provided to R1, R2, R3, R4, R5, and R6 according to their service plans. </span></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">14. In an exit interview, the findings were reviewed with E1, and no additional information was provided. </span></p><p><br></p><p>This is a repeat deficiency from the complaint inspection conducted on February 5, 2024.</p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of six residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of R4's medical record revealed a medication order, dated February 4, 2025, for Gabapentin 300 milligrams (mg), one capsule by mouth (PO) twice a day (bid). </p><p><br></p><p>2. A review of R4's medication administration record (MAR) for October 2025 revealed Gabapentin 300 mg was held due to "pending delivery" on the following dates and times: </p><ul><li>October 2, 2025 - October 4, 2025 at 8:00 PM; </li><li>October 5, 2025, at 8:00 AM and 8:00 PM; </li><li>October 6, 2025, at 8:00 PM; </li><li>October 7, 2025, at 8:00 AM; </li><li>October 9, 2025, at 8:00 AM; and</li><li>October 10, 2025 - October 12, 2025 at 8:00 PM. </li></ul><p><br></p><p>3. A review of R4's MAR for October 2025 revealed Gabapentin 300 mg was administered on the following dates and times:</p><ul><li>October 6, 2025, at 8:00 AM;</li><li>October 7, 2025, at 8:00 PM;</li><li>October 8, 2025, at 8:00 AM and 8:00 PM; and</li><li>October 9, 2025, at 8:00 PM.</li></ul><p><br></p><p>4. In an interview, E1 reported R4's medications were available for administration as of October 2, 2025.</p><p><br></p><p>5. A review of R5's medical record revealed medication orders for the following medications:</p><ul><li>Atorvastatin Calcium 40 mg, 1 tablet po at bedtime (qhs);</li><li>Mometasone Furoate 50 micrograms (mcg), 2 sprays into each nostril every day (qd);</li><li>Myrbetriq 25 mg, 1 tablet po qd;</li><li>Prednisone 1 mg, 3 tablets po qd;</li><li>Pregabalin 100 mg, 1 capsule po bid;</li><li>Pregabalin 75 mg, 1 capsule po bid; and</li><li>Spironolactone 50 mg, 1 tablet po qd.</li></ul><p><br></p><p>6. A review of R5's MAR for October 2025 revealed <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">Atorvastatin Calcium 40 mg was held</span> due to "pending delivery" October 5, 2025 - October 10, 2025, at 8:00 PM.</p><p><br></p><p>7. A review of R5's MAR for October 2025 revealed <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">Atorvastatin Calcium 40 mg was administered October 3, 2025 - October 4, 2025, at 8:00 PM. </span></p><p><br></p><p>8. A review of R5's MAR for October 2025 revealed Mometasone Furoate 50 mcg was held October 11, 2025, at 8:00 AM for "pending delivery."</p><p><br></p><p>9. A review of R5's MAR for October 2025 revealed <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">Myrbetriq 25 mg was held October 7, 2025, at 8:00 AM for "pending delivery."</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">10. A review of R5's MAR for October 2025 revealed Prednisone 1 mg was held October 7, 2025, at 8:00 AM for "pending delivery."</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">11. A review of R5's MAR for October 2025 revealed Pregabalin 100 mg was held on the following dates for "duplicate":</span></p><ul><li>October 5, 2025, at 8:00 AM;</li><li>October 8, 2025 - October 10, 2025, at 8:00 AM and 8:00 PM;</li><li>October 11, 2025, at 8:00 AM; and</li><li>October 14, 2025.</li></ul><p>However, R5's medication orders revealed two orders for Pregabalin.</p><p><br></p><p>12. A review of R5's MAR for October 2025 revealed Pregabalin 75 mg was held on the following dates for "duplicate":</p><ul><li>October 3, 2025 - October 6, 2025, at 8:00 PM;</li><li>October 7, 2025, at 8:00 AM and 8:00 PM;</li><li>October 12, 2025, at 8:00 AM;</li><li>October 13, 2025, at 8:00 AM and 8:00 PM; and</li><li>October 14, 2025, at 8:00 AM.</li></ul><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">However, R5's medication orders revealed two orders for Pregabalin. </span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">13. A review of R5's MAR for October 2025 revealed Spironolactone 50 mg was held on October 5, 2025, due to "pending."</span></p><p><br></p><p>14. In an interview, E1 reported a full medication audit was performed for R5 on October 2, 2025, and all medications were available.</p><p><br></p><p>15. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p>This is a repeat deficiency from the complaint inspection conducted on August 1, 2024, and the compliance and complaint inspection conducted on January 16, 2025.</p>

<p>Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for two of six residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of R5's medical record revealed medication orders for the following medications:</p><ul><li>Aspirin 81 milligrams (mg), 1 tablet by mouth (po) daily (qd);</li><li>Donepezil HCL 5 mg, 1 tablet po every morning;</li><li>Duloxetine HCL 60 mg, 1 tablet po twice a day (bid);</li><li>Eliquis 5 mg, 1 tablet po bid;</li><li>Esomeprazole Magnesium 20 mg, 1 capsule po qd;</li><li>Estradiol 1 mg, 1 tablet po qd;</li><li>Metoprolol Succinate 50 mg, 1 tablet po qd;</li><li>Mometasone Furoate 50 micrograms (mcg), 1 tablet po qd;</li><li>Myrbetriq 25 mg, 1 tablet po qd;</li><li>Potassium Chloride 10 milliequivalent (mEq), 1 capsule po bid;</li><li>Prednisone 1 mg, 3 tablets po qd;</li><li>Pregabalin 100 mg, 1 capsule po bid;</li><li>Pregabalin 75 mg, 1 capsule po bid; and</li><li>Spironolactone 50 mg, 1 tablet po qd.</li></ul><p><br></p><p>2. A review of R5's medication administration record (MAR) for October 2025 did not include documentation of the administration of all aforementioned medications on the following dates and times:</p><ul><li>October 3, 2025 - October 4, 2025, at 8:00 AM; and</li><li>October 6, 2025, at 8:00 AM.</li></ul><p><br></p><p>3. In an interview, E1 reported a full medication audit was performed for R5 on October 2, 2025, and all medications were available.</p><p><br></p><p>4. In an interview, R5 reported R5 had received all aforementioned medications October 3, 2025 - October 6, 2025.</p><p><br></p><p>5. A review of R6's medical record revealed a medication order, dated February 28, 2025, for Midodrine HCL 2.5 mg, 1 tablet three times a day (tid).</p><p><br></p><p>6. A review of R6's MAR for October 2025 did not include documentation of administration of Midodrine HCL 2.5 mg on the following dates and times:</p><ul><li>October 2, 2025, at 10:00 PM;</li><li>October 5, 2025 - October 6, 2025, at 10:00 PM;</li><li>October 8, 2025 - October 9, 2025, at 10:00 PM; and</li><li>October 12, 2025, at 10:00 PM.</li></ul><p><br></p><p>7. In an interview, E1 reported R6 typically refuses medication in the evenings; however, the documentation of this refusal or administration was not available for review.</p><p><br></p><p>8. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

<p><span style="font-size: 12px;">Based on documentation review, interview, and observation, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk if the assisted living facility was unable to ensure compliance with applicable Rules. </span></p><p><span style="font-size: 12px;"> </span></p><p><span style="font-size: 12px;">Findings include: </span></p><p><span style="font-size: 12px;"> </span></p><p><span style="font-size: 12px;">1. A review of Department documentation revealed the previous manager for the facility resigned effective August 15, 2025.</span></p><p><br></p><p><span style="font-size: 12px;">2. In an interview, E1 reported E1 had taken over as the temporary manager of the facility effective August 30, 2025. </span></p><p><br></p><p><span style="font-size: 12px;">3. The Compliance Officer observed that an assisted living facility manager certificate was not conspicuously posted in the facility during a complaint investigation conducted on September 5, 2025.</span></p><p><br></p><p><span style="font-size: 12px;">4. In an interview, E1 acknowledged the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. </span></p><p><br></p><p><span style="font-size: 12px;">5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </span></p>

<p><span style="font-size: 10pt;">Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee was maintained for at least 24 months after the last date the individual provided services in or for the assisted living facility, for one of one former employee sampled. The deficient practice posed a risk as required information could not be verified for O1. </span></p><p><br></p><p><span style="font-size: 10pt;">Findings include:</span></p><p><br></p><p><span style="font-size: 10pt;">1. In an interview, E1 reported O1 being the previous manager of the facility. </span></p><p><br></p><p><span style="font-size: 10pt;">2. A review of personnel records revealed a personnel record for O1 was not available for review at the time of inspection. </span></p><p><br></p><p><span style="font-size: 10pt;">3. In an interview, E1 reported O1 had a personnel record for O1 but was unable to locate it.</span></p><p><br></p><p><span style="font-size: 10pt;">4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </span></p>

<p><span style="font-size: 12px;">Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months for one of two residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident.</span></p><p><span style="font-size: 12px;"> </span></p><p><span style="font-size: 12px;">Findings include:</span></p><p><span style="font-size: 12px;"></span></p><p><span style="font-size: 12px;">1. A review of R3's medical record revealed a written service plan for directed care services dated March 4, 2025. However, evidence of an updated service plan after March 4, 2025, was unavailable for review. </span></p><p><br></p><p><span style="font-size: 12px;">2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. </span></p>

<p><span style="font-size: 10pt;">Based on records review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for two of three sampled resident records that were reviewed who had resided at the assisted living facility for more than 12 months. The deficient practice posed a potential illness risk to residents.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">Findings include:</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">2. A review of R2's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2023.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">3. A review of R3's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2022.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</span></p><p><span style="font-size: 10pt;"> </span></p>

Based on documentation review, record review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration.

Findings include:

1. A review of facility documentation revealed an incident report dated January 28, 2025, involving R1 and E2. In the report, E2 had been identified via video screenshots as the individual seen in R1's residential unit engaging in sexual behavior with R1.

2. A review of E2's personnel record revealed a hire date of December 25, 2024, and an Adult Protective Services (APS) Registry check of E2 prior to E2's hire date, which indicated there were no records or incidents found for E2.

3. Further review of E2's personnel record revealed a number of new hire/orientation documents, which included the following, completed and signed by E2:
- A document titled "Medication Technician," which include a position description and job duties of a Medication Technician. The document stated, "This position provides direct care ...to the residents in a manner that meets or exceeds Community expectations ..." An "Essential Function" of this role was to "Contribute to Community relationships by demonstrating cooperation and professional conduct with residents ..." One of the listed "Accountabilities" was to "Respect Resident's Rights." On the final page of the document was a statement that read, "I have read and I understand this job description, and have been given a copy." E2's name was hand-printed and signed on December 24, 2024;
- A Human Resources Policy 5.03 titled "Orientation and Training." The document stated, "Initial orientation is designed to educate all employees about: A. Resident care and service ... C. The expectations and responsibilities of staff members ... 3. Employee orientation must comply with applicable state/local regulations and should include at least: ... C. Company policies.";
- A Clinical Policy and Procedure Manual titled "GP03 - Abuse, Neglect, and Exploitation." The policy stated, "Resident abuse, neglect, and exploitation are prohibited... j. Any staff member participating in the abuse will be referred to Human Resources for decisions on disciplinary actions.";
- A document signed by E2 on December 24, 2024, indicating E2 "acknowledged receipt of training on the topics listed above and [E2's] responsibility to read, understand, and comply with such policies and procedures," along with acknowledgment of review of the Employee Handbook;
- A document titled "Arizona All Staff Assisted Living Orientation Course Record." The document listed "Orientation Topics to be Completed," which included Customer Service, Resident Rights & Elder Abuse, and Sexual Harassment Prevention. E2 initialed as completing each of the aforementioned courses on December 25, 2024, then signed the form indicating confirmation of completion of the courses; and
- A document titled "Employee Orientation." The form included "1. Orientation to the characteristics and needs of the assisted living facility's residents ... 3. Promotion of resident dignity, independence, self-determination, privacy, choice and resident rights ... 5. Internal facility requirements and the assisted living facility's policies and procedures." The form indicated E2 completed the orientation on December 25, 2024.

4. A review of the facility's policies and procedures included a policy titled, "Prohibiting of Sexual Relations." The policy stated, "The community prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. Staff will report to management any knowledge of a sexual relationship between any employee and a resident."

5. In an interview, R1 reported E2 was sometimes dismissive and acted indifferent towards R1, but that other times E2 was more attentive. R1 stated that E2 would enter R1's apartment whether E2 was invited or not. R1 stated that even when R1 didn't want E2 to come inside R1's apartment, R1 didn't know how to say no and couldn't make up a lie about being busy because E2 was R1's caregiver and knew the truth. R1 was unable to state how many times E2 had engaged in inappropriate relations with R1, but reported E2 had "just given [R1] a kiss" during at least one or two other encounters. R1 reported it was hard to keep track of different occurrences and for R1 to remember all of the details, then stated, "because I'm in my 90's." [Note: R1 is 78 years old.] When specifically asked if R1 was treated with dignity, respect, and consideration, R1 reported R1 had not been treated with dignity, respect, and consideration by E2. R1 reported all R1 wanted was "some company," and that R1 "wanted [E2] to come in and have a Pepsi." R1 stated R1 did not want to engage in any sexual relations with E2. R1 also stated R1 felt embarrassed about what happened with E2 but didn't know what to do about it.

6. Aside from the incident with E2, R1 reported being very happy and satisfied with R1's residency at the facility. Aside from E2, R1 reported that R1 had positive experiences with other caregivers and felt well cared for and treated with respect.

7. In an interview, O1 reported E2 took advantage of R1. O1 reported E2 was supposed to be R1's caregiver but instead used R1's vulnerable cognitive state to coerce R1 into sexual acts.

8. In an interview, E1 reported that E1, E3, and E5 collectively all did everything possible to protect R1's rights and the well being of the entire community rights when hiring E2. During the hiring process, E1 reported E2 had positive reference checks and no record of incidents on the APS registry, and E2 completed all of the appropriate on-boarding training. While E1 conducted all of the required steps for hiring E2 to ensure E2 was qualified, suitable, and appropriate for employment as a Medication Technician, E1 acknowledged that E1 was unable to ensure E2 treated R1 with dignity, respect, and consideration.

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for five of eight applicable residents sampled. The deficient practice posed a potential TB infection risk to residents.

Findings include:

1. A review of R1's medical record revealed documentation of a chest x-ray, which indicated no evidence of TB. However, there was not a previous positive TB test to indicate the need for a chest x-ray. In addition, R1's medical record did not contain the TB screening questionnaire. Based on R1's date of admission, this documentation should have been available for review in the medical record.

2. A review of R2's medical record revealed documentation of having a TB test done but no documentation of the test itself, and no TB screening questionnaire. Based on R2's date of admission, this documentation should have been available for review in the medical record.

3. A review of R4's medical record revealed documentation of a TB skin test; however, no documentation of the TB screening questionnaire. Based on R4's date of admission, this documentation should have been available for review in the medical record.

4. A review of R6's medical record revealed documentation of a chest x-ray, which indicated no evidence of TB. However, there was not a previous positive TB test to indicate the need for a chest x-ray. In addition, R6's medical record did not contain the TB screening questionnaire. Based on R6's date of admission, this documentation should have been available for review in the medical record.

5. A review of R7's medical record revealed documentation of a chest x-ray, which indicated no evidence of TB. However, there was not a previous positive TB test to indicate the need for a chest x-ray. In addition, R7's medical record did not contain the TB screening questionnaire. Based on R7's date of admission, this documentation should have been available for review in the medical record.

6. In an interview, E1 and E2 reported E1 and E2 believed only documentation indicating a resident did not have evidence of TB was the requirement for admission. E1 and E2 acknowledged the resident records did not contain the required documentation pertaining to TB infection control.

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

Findings include:

1. A review of R2's, R6's, R7's, R8's, and R9's current service plans revealed R2, R6, R7, R8, and R9 received medication administration.

2. In an interview, E1 reported that R10's "chart" (medical record) had been one of several that were allegedly taken by a previous employee (O1) who is currently under police investigation.

3. A review of facility documentation revealed a "Victim Copy" of the incident report information from the Scottsdale Police Department, which listed Scottsdale Village Square as the victim of theft of laptops, resident charts, computers, and miscellaneous items. The suspect in the case is O1. E1 then provided a manilla envelope with the remaining documentation for R10 that E1 was able to put together from a previous Mercy Care request for information for a quality care review regarding medication administration.

4. A review of R10's remaining medical documentation revealed a service plan dated January 26, 2024, which indicated R10 received medication administration.

5. In an interview, E1 reported that R10 self-administered all of R10's medications per doctor's orders, except for Oxycodone, which was what R10's service plan was referring to where it stated R10 received medication administration.

6. A review of R10's medical documentation revealed an electronically signed medication order dated May 7, 2024, for "Oxycodone HCl 5 milligrams (mg) Tablet. Directions: 1 tablet as needed Orally 1 time daily As needed (PRN) for 30 days" and a second electronically signed medication order dated July 10, 2024, for "Oxycodone 5 mg Capsule. Directions: Take 1 capsule every day by oral route as needed." Also on the second order dated July 10, 2024, there was documentation in a section under the dosing instructions that stated, "HOA/Notes: discontinue prior dosing 1 tablet orally daily at bedtime as needed." While there was no medication order available for review for the month of June, the order from July implies that the dosing instructions for June were for 1 tablet by mouth daily at bedtime PRN. In addition, the detailed order information documented on the MAR for the June order to include the prescriber, an RX #, dosing instructions, and the date the order written, indicated an order had been received at the time. However, it was not available for review at the time of the inspection.

7. A review of R10's medical documentation revealed a July 2024 medication administration record (MAR). There were two sections of the MAR for Oxycodone as noted below:

- "Oxycodone HCL 5 MG Tablet. Take 1 tablet by mouth once daily at bedtime as needed. Orig: 27-Jun-2024. Stop Date: 10-Jul-2024;" and
- "Oxycodone HCL 5 MG Capsule. Take 1 capsule by mouth once daily as needed. Orig: 10-Jul-2024. Stop Date: 7-Aug-2024."

8. Under the section "Oxycodone HCL 5 MG Tablet. Take 1 tablet by mouth once daily at bedtime as needed. Orig: 27-Jun-2024. Stop Date: 10-Jul-2024," the MAR indicated R10 was administered the oxycodone twice on the following dates and times rather than once at bedtime as needed:
- July 5, 2024, Oxycodone 5mg was administered at 12:09 PM and 9:48 PM; and
- July 7, 2024, Oxycodone 5mg was administered at 8:18 AM and 4:51 PM.

9. Under the section "Oxycodone HCL 5 MG Capsule. Take 1 capsule by mouth once daily as needed. Orig: 10-Jul-2024. Stop Date: 7-Aug-2024," the MAR indicated R10 was administered the oxycodone two and three times on the following dates and times rather than once daily as needed:
- July 12, 2024, Oxycodone 5mg was administered at 1:19 AM and 10:25 AM;
- July 17, 2024, Oxycodone 5mg was administered at 10:04 AM and 4:44 PM; and
- July 20, 2024, Oxycodone 5mg was administered at 12:00 AM, 10:04 AM, and 9:44 PM.

10. A review of the facility's policies and procedures revealed a policy titled "MP02 - Medication Services." The policy stated, "2. Med Techs can administer medications in accordance with the state regulations authorized by a medical practitioner." The policy referenced "R9-10-816," and further stated, "Properly trained Med Techs may administer medications in accordance with state regulations with authorization by a medical practitioner to administer medication under the direction of the medical practitioner."

11. Further review of the facility's policies and procedures revealed another policy titled, "MP14 - Documenting Medication Pass." The policy stated, "2.a. All medications are administered per physician orders."

12. During an overall review of R10's medical documentation, the Compliance Officer observed that O1 was the staff member who developed R10's service plan, as well as the staff member who had signed off on receiving/reviewing both of the aforementioned medication orders for the oxycodone. O1 is also the staff member who allegedly "stole" R10's medical record.

13. A review of department documentation revealed Mercy Care was unable to substantiate harm to R10 due to the aforementioned medication errors.

14. In an interview, E1 acknowledged R10's remaining medical documentation did not include a signed medication order from June 27, 2024, and that medication for R10 was not administered in compliance with the medication orders.

15. This is a repeat deficiency from the complaint investigation conducted August 1, 2024.

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager.

Findings include:

1. Review of Department records revealed O1 listed as the manager.

2. In an interview, E1 reported O1's was no longer the manager.

3. During an environmental inspection of the facility, the Compliance Officer observed E1's manager's certificate posted near the front door of the facility.

4. Review of E1's personnel record revealed a hire date of June 25, 2024.

5. In an interview, E1 reported that the manager had changed to the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, but did not notify the Department of Health. E1 reported E1 was the current manager and acknowledged the Department was not notified in writing of the changes in managers.

This is a repeat deficiency from the on-site compliance inspection conducted on January 4, 2023 and the complaint investigation conducted on June 30, 2022.

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

Findings include:

1. A.R.S. \'a7 36-411.C states: "C. Owners 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."

2. A review of E2's personnel record revealed a document signed by O1 on December 26, 2023, titled "Reference Check Audit" which stated "Personnel file reviewed and no reference checks were conducted at time of hire." No other documention showing that the owner had made a good faith effort to contact previous employers to obtain information or recommendations was available.

3. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411.C.1 for E2 was not available for review.

Based on record review and interview the administrator failed to document the actions taken to prevent an alleged incident of abuse from occurring in the future, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for a resident who resided in the assisted living facility.

Findings include:

1. Review of R7's medical record revealed an incident report dated April 8, 2024 which documented, "[R7's] arms were tied together by [R7's] jacket sleeves. [R7] was wearing a jacket, the jacket sleeves pulled past [R7's] hands the sleeve ends were tied individually then tied together in front of [R7's] stomach." The incident report contained a section titled "Action Taken or Planned", which stated "Resident was assessed for injuries, none noted." However, it did not document the actions taken to prevent an alleged incident of abuse from occurring in the future.

2. During an interview, E1 reported that a caregiver had been found to be responsible for R7's arms being tied, and that caregiver was fired, and acknowledged that the facility did not document actions taken by the manager to prevent the suspected abuse from occurring in the future.

Based on 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 two of two caregivers sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs.

Findings include:

1. Review of E2's personnel record revealed E2 was hired October 10, 2023 and a caregiver.

2. Review of E4's personnel record revealed E4 was hired June 20, 2024 as a caregiver.

3. Review of E2's and E4's personnel records revealed no documentation that E2's and E4's skills and knowledge were verified.

4. In an interview, E1 acknowledged that the manager failed to ensure that caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services.

Based on documentation review, record review, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver or an assistant caregiver received orientation that is specific to the duties to be performed by the caregiver or assistant caregiver, for two of four employees reviewed. The deficient practice posed a health and safety risk to the residents

Findings include:

1. R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

2. Review of E2's personnel record revealed a hire date of October 10, 2023.

3. Review of E4's personnel record reveled a hire date of June 20, 2024.

4. Review of E2's personnel record revealed no documentation to demonstrate E2 completed orientation prior to providing services to residents.

5. Review of E4's personnel record revealed no documentation to demonstrate E4 completed orientation prior to providing services to residents.

6. During an interview, E1 reported that staff complete orientation online and any documentation would be in the online system, however, E1 was unable to provide documentation for review. E1 acknowledged E2's and E4's record did not include documentation of the completed orientation.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of two residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. Review of R2's medical record revealed a current written service plan for directed care services dated April 18, 2024. However, a service plan after April 18, 2024 was not available for review.

2. Review of R3's medical record revealed a current written service plan for directed care services dated April 18, 2024. However, a service plan after April 18, 2024 was not available for review.

3. In an interview, E1 acknowledged R2 and R3 received directed care services and the service plan was not updated at least once every three months.

This is a repeat deficiency from the on-site compliance inspection conducted on January 4, 2023.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for four of five residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided.

Findings include:

1. Review of R1's record revealed a current written service plan for personal care services dated May 6, 2024. However, this service plan did not include a signature and date resident or representative.

2. Review of R2's record revealed a current written service plan for directed care services dated April 18, 2024.. However, this service plan did not include a signature and date from the resident or representative.

3. Review of R3's record revealed a current written service plan for directed care services dated April 18, 2024.. However, this service plan did not include a signature and date from the resident or representative.

4. Review of R4's record revealed a current written service plan for directed care services dated June 3, 2024. However, this service plan did not include a signature and date from the resident or representative.

5. In an interview, E1 acknowledged R1's, R2's, R3's and R4's service plans did not include a signature and date from the resident or representative.

Technical assistance was provided during the compliance inspection on January 4, 2023.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for two of five residents reviewed. The deficient practice posed a risk if the service plans were not developed to articulate decisions and agreements.

Findings include:

1. Review of R1's record revealed a current written service plan for personal care services dated May 6, 2024. However, this service plan did not include a signature and date from the manager.

2. Review of R4's record revealed a current written service plan for directed care services dated June 3, 2024. However, this service plan did not include a signature and date from the manager.

3. In an interview, E1 acknowledged R1's and R4's service plan did not contain a signature and date from the manager.

Technical assistance was provided during the compliance inspection on January 4, 2023.

Based on documentation review, record review and interview, the manager failed to ensure that except when relocation was necessary based on a change in the resident's condition as documented in the resident's service plan, a resident was able to refuse relocation within the assisted living facility.

Findings include:

1. Review of Department documentation revealed an incident which reported that R4 had been moved out of R4's residential unit to a different part of the facility without R4's or R4's representatives consent.

2. Review of R4's medical record revealed R4's most recent service plan for directed care services dated June 3, 2024. The service plan did not document a requirement for R4 to be relocated within the facility and was not signed by R4 or R4's representative.

3. Review of R4's medical revealed no documentation showing that R4 or R4's representative had consented to the relocation.

4. In an interview, E1 reported that R4 had been relocated in the facility due to a decline in behavior. E1 acknowledged that there was no documentation showing that a resident was able to refuse relocation within the assisted living facility.

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

Findings include:

1. Review of R1's medical record revealed a current written service plan dated May 6, 2024. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed no documentation of signed written or verbal medication orders.

3. Review of R1's July 2024 medication administration record (MAR) indicated the following:
-Amlodipine Besylate 10mg tab was administered once a day at 8am July 1-31;
-Aspirin 81mg tab was administered once a day at 8am July 1-31;
-Atorvastatin 40mg tab was administered once a day at 8pm July 1-31;
-Clopidogrel 75mg tab was administered once a day at 8am July 1-31;
-Donepezil HCL 5mg tab was administered once a day at 8pm July 1-31;
-Jardiance 25mg tab was administered once a day at 8am July 1-31;
-Lantus Solostar 100 units/ml was administered once a day at 8pm July 1-31;
-Memantine HCL 10 mg tab was administered once a day at 8am July 1-31;
-Metoprolol SUCC ER 50mg tab was administered once a day at 8am July 1-31;
-Tamsulosin HCL 0.4mg capsule was administered once a day at 8pm July 1-31.

4. In an interview, E3 reported that R1's medical provider sends medication orders directly to the pharmacy, and that the facility did not receive copies. E3 and R1 reported that R1 received the medications documented in the MAR. E1 acknowledged the medications were not administered in compliance with an available medication order.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employers to verify that fingerprint clearance cards were valid for one of two sampled personnel records reviewed, which posted a safety risk.

Findings include:

1. Review of E3's personnel record, who was hired on February 2, 2024 as a caregiver, included a copy of a fingerprint clearance card. There was no documentation the facility had verified on the DPS website that the fingerprint clearance card was valid at the time of hire nor any time since.

2. In an interview, E1 acknowledged that E3's fingerprint clearance card had not been verified with DPS as a valid fingerprint card.

3. The compliance officer verified on the DPS website that E3 had a valid fingerprint clearance card.

Based on observation and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident.

Findings include:

A.A.C. R9-10-101(199) states restraint "means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body."

1. At the time of the complaint investigation, E1 and E2 reported the night shift caregivers had found, during first rounds on April 8, 2024, R1 had a jacket on with the sleeves past the resident's hands with ends tied and then both hands in the jacket sleeves had been tied together. Resident was untied and checked for injuries.

2. Review of R1's medical record revealed documentation that R1 is unable to ambulate even with assistance, required directed care and medication administration services.

3. During the interview, E1 and E2 acknowledged that R1 had been subjected to restraints.

Based on record review and interview during the complaint investigation, the manager failed to ensure that for one sampled resident who was unable to ambulate even with assistance, the resident's primary care provider (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 which was 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 provided directed care services.

Findings include:

1. In an interview, E2 reported that R1 was unable to ambulate even with assistance at least since January 2024.

2. Review of R1's medical record found no documented determination completed at the date of acceptance or within 30 days prior to acceptance nor anytime since by the resident's medical practitioner. There was no documented determination completed by R1's medical practitioner at least every six months throughout the duration of the resident's condition. Each determination should have been based on a current examination of the resident, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility.

2. In an interview, E1 and E2 acknowledged there was no documentation of the required determination available for review.

Based on record review and interview, the manager failed to ensure the caregiver providing services documented the services provided in the resident's medical record, for one of one sampled resident, which posed a health and safety risk.

Findings include:

1. Review of R2's medical record revealed the service plan stated the resident required directed care and medication administration services. E2 needed assistance with bathing. There was no documentation of the services provided for R2 in January 2024.

2. During an interview, E2 acknowledged R2's medical record did not include documentation of the services provided to R2 in January.

Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

1. A review of facility documentation revealed a PowerPoint presentation print-out titled "Fall Prevention" dated November 22, 2022. The policy stated "...Draw sheet; gait belt, hoyer lift techniques...Moving the patient using a draw-sheet.." The document included steps for fall prevention and fall recovery.

2. In an interview, E11 reported the "Fall Prevention" documentation was the facility's fall prevention and fall recovery training program for staff.

3. A review of facility documentation revealed a document titled "In-service: Fall Prevention Hosted by United Hospice & ALM" dated November 22, 2022. The document included E2's, E4's, and E5's printed names and signatures, indicating E2, E4, and E5 attended the in-service training. However, the document did not include E3's, E6's, or E7's printed names or signatures.

4. In an interview, E11 reported the printed names and signatures on the document "In-service: Fall Prevention Hosted by United Hospice & ALM" were the names of the staff who attended the fall prevention and fall recovery training.

5. A review of E3's, E6's, and E7's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

6. In an interview, E1 reported to be unsure if E3, E6, and E7 completed fall prevention and fall recovery training. E1 acknowledged the facility had not administered a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, observation, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed E1 was the assisted living manager as of June 22, 2022.

2. The Compliance Officer observed E2's manager's license posted on a wall, with an issue date of June 8, 2022.

3. In an interview, E1 reported E2 was the facility's manager as of July 19, 2022.

4. A review of Department documentation revealed the governing authority failed to notify the Department when there was a change in the manager and identify the name and qualifications of the new manager.

5. In an interview, E1 acknowledged the facility did notify the Department of a change in the facility's manager.

This is a repeat deficiency from a complaint investigation conducted on June 30, 2022.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the following was not provided for review: Documentation the Department was notified of the change in manager; a written service plan for R3; a written service plan to include the level of service the resident was expected to receive for R6; a written service plan reviewed and updated at least once every six months for R5; a written service plan reviewed and updated at least once every three months for R4 and R7; documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for R1, R2, R4, and R7; and a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of Department documentation revealed the governing authority failed to notify the Department when there was a change in the manager and identify the name and qualifications of the new manager.

2. A review of R3's (admitted in 2022) medical record revealed a written service plan was not available for review. Based on R3's admission date, a service plan was required.

3. A review of R6's medical record revealed a written service plan dated in 2022. However, R6's written service plan did not include the level of service R6 was expected to receive.

4. A review of R5's medical record, revealed a service plan dated in 2022 for personal care services. However, a reviewed and updated service plan every six months for R5 not available for review.

5. A review of R4's medical record revealed a written service plan for directed care services dated in 2022. However, a reviewed and updated service plan every three months for R4 was not available for review.

6. A review of R7's medical record revealed a written service plan for directed care services dated in 2022. However, a reviewed and updated service plan every three months for R7 was not available for review.

7. A review of R1's medical record revealed a service plan dated in 2022. The service plan stated R1 received directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

8. A review of R2's medical record revealed a service plan dated in 2022. The service plan stated R2 received directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated.

9. A review of R4's medical record revealed a service plan dated in 2022. The service plan stated R4 received directed care services. However, the service plan did not include documentation of R4's weight or documentation from a medical practitioner stating weighing R4 was contraindicated.

10. A review of R7's medical record revealed a service plan dated in 2022. The service plan stated R7 received directed care services. However, the service plan did not include documentation of R7's weight or documentation from a medical practitioner stating weighing R7 was contraindicated.

11. A review of E3's, E6's, and E7's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

12. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of seven residents sampled. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R3's (admitted in 2022) medical record revealed a written service plan was not available for review. Based on R3's admission date, a service plan was required.

2. In an interview, E1 reported to not know why a service plan for R3 was not completed. E1 acknowledged a service plan for R3 was not completed no later than 14 calendar days after R3's date of acceptance.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for one of seven residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R6's medical record revealed a written service plan dated in 2022. However, R6's written service plan did not include the level of service R6 was expected to receive.

2. In an interview, E1 reported E1 believed R6 received personal care services. E1 acknowledged R6's written service plan did not include the level of service R6 was expected to receive.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of two residents sampled who received personal care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R5's (admitted in 2014) medical record, revealed a service plan dated in 2022 for personal care services. However, a reviewed and updated service plan as least once every six months was not available for review.

2. In an interview, E1 acknowledged R5's service plan was not updated at least once every six months.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for two of four residents sampled who received directed care serivces. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R4's (accepted in 2021) medical record revealed a written service plan for directed care services dated in 2022. However, a reviewed and updated service plan every three months for R4 was not available for review.

2. A review of R7's (accepted in 2019) medical record revealed a written service plan for directed care services dated in 2022. However, a reviewed and updated service plan every three months for R7 was not available for review.

3. In an interview, E1 acknowledged R4's and R7's service plans were not updated at least once every three months.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for four of four residents sampled who received directed care services. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan dated in 2022. The service plan stated R1 received directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

2. A review of R2's medical record revealed a service plan dated in 2022. The service plan stated R2 received directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated.

3. A review of R4's medical record revealed a service plan dated in 2022. The service plan stated R4 received directed care services. However, the service plan did not include documentation of R4's weight or documentation from a medical practitioner stating weighing R4 was contraindicated.

4. A review of R7's medical record revealed a service plan dated in 2022. The service plan stated R7 received directed care services. However, the service plan did not include documentation of R7's weight or documentation from a medical practitioner stating weighing R7 was contraindicated.

5. In an interview, E1 acknowledged R1's, R2's, R4's, and R7's service plan did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.