BROOKDALE BAYWOOD

<p>Based on record review, observation, and interview, the manager failed to <span style="background-color: rgb(255, 255, 255);">ensure safeguards existed to prevent unauthorized access to resident medical records.</span></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During a facility's tour with E1, the compliance office observed R2 to be seated at the computer and using Excel in E2's office; there was no other staff present.</p><p><br></p><p><br></p><p>2. In an interview, R2 reported that R2 was at E2's desk to create CD labels for the CDs next to R2.</p><p><br></p><p><br></p><p>3. With E1's permission, the compliance officer (CO) sat at E2's computer that R2 was using. The CO clicked on E2's Okta account, which was accessible without requiring authentication safeguards to access the database. The CO then proceeded to click a tab titled "RIM/MIMO," which provided the CO access to current and past residents' names, dates of birth, gender, last four digits of the residents' social security numbers, age, cell phone numbers, and recurring charges for selected agreements.</p><p><br></p><p><br></p><p>4. In an interview, E1 acknowledged that E1 failed to ensure<span style="background-color: rgb(255, 255, 255);"> safeguards existed to prevent unauthorized access to resident medical records.</span></p>

<p>Based on record review and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of R2’s medical record revealed an incident report dated February 28, 2025. The documentation indicated E1 was made aware of an allegation of abuse witnessed by R2’s representative. However, there was no documentation of the immediate notification of a peace officer or Adult Protective Services. </p><p><br></p><p><br></p><p>2. In an interview, E1 reported the facility did not notify a peace officer or Adult Protective Services of the incident after the investigation. E1 acknowledged after E1 had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, E1 failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454.</p>

<p>Based on observation, 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 before the individual began providing services, for six of ten personnel sampled. The deficient practice posed a potential illness 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 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><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><br></p><p>3. A review of facility documentation revealed E1, E3, E4, E6, E7, and E10 are current employees of the facility. </p><p><br></p><p><br></p><p>4. <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. However, the tests were read after E1 began providing services. </span></p><p><br></p><p><br></p><p>5. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">A review of E3's personnel record revealed two negative TB skin tests. However, the tests were read after E3 began providing services. </span></p><p><br></p><p><br></p><p>6. A review of E4's personnel record revealed two negative TB skin tests. However, the tests were read after E4 began providing services. </p><p><br></p><p><br></p><p>7. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">A review of E6's personnel record revealed two negative TB skin tests. However, the tests were read after E6 began providing services. </span></p><p><br></p><p><br></p><p>8. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">A review of E7's personnel record revealed two negative TB skin tests. However, the tests were read after E7 began providing services. </span></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">9. A review of E10's personnel record revealed two negative TB skin tests. However, the tests were read after E10 began providing services. </span></p><p><br></p><p><br></p><p>10. In an interview, E1 acknowledged <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">E3, E4, E6, E7, and E10 </span>did not provide evidence of freedom from infectious TB as specified in R9-10-113 before <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">E3, E4, E6, E7, and E10</span> began providing services.</p><p><br></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for six of ten residents sampled. The deficient practice posed a potential illness 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 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><br></p><p>2. A review of R2's (admitted 2024) medical record revealed documentation of R2's evidence of freedom from infectious TB; however, this documentation was not completed within seven days of R2's admission into the facility. R2's medical record also did not include documentation of a completed screening to assess R2's risk of prior exposure to infectious TB and if R2 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R2's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>3. A review of R5's (admitted 2024) medical record revealed did not include documentation of a completed screening to assess R5's risk of prior exposure to infectious TB and if R5 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R5's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>4. A review of R6's (admitted 2024) medical record revealed did not include documentation of a completed screening to assess R6's risk of prior exposure to infectious TB and if R6 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R6's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>5. A review of R7's (admitted 2025) medical record revealed did not include documentation of a completed screening to assess R7's risk of prior exposure to infectious TB and if R7 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R7's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>6. A review of R8's (admitted 2021) medical record revealed did not include documentation of a completed screening to assess R8's risk of prior exposure to infectious TB and if R8 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R8's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>7. A review of R9's (admitted 2024) medical record revealed did not include documentation of a completed screening to assess R9's risk of prior exposure to infectious TB and if R9 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R9's date of admission, this documentation was required. </p><p><br></p><p><br></p><p>8. In an interview, E1 acknowledged R2's, R5's, R6's, R7's, R8's and R9's medical records did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113. </p>

<p>Based on observation, record review, and interview, the manager failed to ensure that a resident was not treated with dignity, respect, and consideration.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed R6's bedroom to have feces trailing on the floor and splattered onto the walls.</p><p><br></p><p><br></p><p>2. The Compliance Officers observed E12 in R6's room following the accident, at approximately 11:20 AM.</p><p><br></p><p><br></p><p>3. At approximately 11:30 AM, the Compliance Officers observed R6 asleep in R6's bed, and R6's room not to be clean. T<span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">he Compliance Officers requested care staff to assist R6 in cleaning up after the accident. </span></p><p><br></p><p><br></p><p>4. At approximately 11:40 AM, the Compliance Officer also observed E12 assisting R6 out of bed, and to the facility's spa area. The Compliance Officers also observed R6 to have feces dried on R6's legs.</p><p><br></p><p><br></p><p>5. In an interview, E12 reported no care staff had been available to clean up R6 before the Compliance Officers' requests; however, the Compliance Officers observed E12 in the bedroom with R6 following the incident.</p><p><br></p><p><br></p><p>6. A review of R6's medical record revealed a service plan, dated December 21, 2024. The service plan stated, "The resident has frequent incontinence of bowel and incontinent of urine as well. Resident wear SIZE SMALL briefs provided by Arizona long term care. Staff to assist as needed with uncontained accidents, as well as assisting with changing protective undergarments/pull-ups and application of barrier cream as needed to maintain the highest level of skin integrity. However, during times of defecation and or urination in inappropriate places staff are to provide physical assistance."</p><p><br></p><p><br></p><p>7. In an interview, E1 acknowledged R6 was not treated with dignity, respect, and consideration.</p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.</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 the facility was licensed to provide directed care services. </p><p><br></p><p><br></p><p>2. During an environmental tour of the facility, the Compliance Officers observed the facility to have a secured memory care unit. However, the doors from the secured area to the facility’s outdoor patio did not contain a way to control or alert employees of the egress of a resident from the facility. </p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.</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 one of ten 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><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a medication order dated May 2, 2023 for Novolog FlexPen Subcutaneous Solution Pen Injector 100 units unit/milliliter (mL), inject 5 units subcutaneously with meals, inject if blood sugar (BS) is over 300.</p><p><br></p><p><br></p><p>2. A review of R1's medication administration record (MAR) for April 2025, revealed R1 was administered Novolog FlexPen 5 units on the following dates and times:</p><ul><li>April 1, 2025 at 6:00 AM;</li><li>April 2, 2025 at 6:00 AM and 4:00 PM;</li><li>April 3, 2025 at 6:00 AM;</li><li>April 4, 2025 at 6:00 AM and 11:00 AM;</li><li>April 5, 2025 - April 6, 2025 at 11:00 AM and 4:00 PM;</li><li>April 7, 2025 at 6:00 AM, 11:00 AM, and 4:00 PM;</li><li>April 8, 2025 at 6:00 AM;</li><li>April 9, 2025 at 6:00 AM and 4:00 PM;</li><li>April 10, 2025 at 6:00 AM;</li><li>April 11, 2025 at 6:00 AM and 11:00 AM;</li><li>April 12, 2025 at 11:00 AM;</li><li>April 13, 2025 at 11:00 AM and 4:00 PM;</li><li>April 14, 2025 at 6:00 AM, 11:00 AM, and 4:00 PM;</li><li>April 15, 2025 at 6:00 AM and 4:00 PM; and</li><li>April 16, 2025 at 6:00 AM.</li></ul><p>However, the BS readings associated with the aforementioned dates and times did not indicate the administration of Novolog FlexPen 5 units was necessary.</p><p><br></p><p><br></p><p>3. In an interview, E11 acknowledged medication administered to R1 was not administered in compliance with a medication order.</p><p><br></p><p><br></p><p>This is a repeat deficiency from the complaint investigation conducted on December 5, 2024.</p>

<p>Based on observation, record review, and interview, the manager failed to ensure that medication stored by the facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed a container of Systane Lubricant Eye Drops on R7's nightstand. </p><p><br></p><p><br></p><p>2. A review of R7’s medical record revealed a service plan dated March 29, 2025. The service plan indicated R7 required directed care services and stated, “Staff places prescribed medications at the scheduled time and places them in a cup and hands the cup along with a glass of water or juice to the resident. Observes medications being swallowed and then documents on the MAR that the resident has taken the medications. All other routes of administration are administered according to md order.”</p><p><br></p><p><br></p><p>3. In an interview, E1 reported R7’s family brought the medication for R7’s use without the facility’s knowledge. E1 acknowledged medication stored by the facility was not stored in a separate locked room, closet, cabinet or self-contained unit used only for medication storage. </p>

<p>Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was maintained for at least 12 months after the date of the drill and included an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of facility evacuation drill documentation revealed a drill was conducted on November 26, 2024. However, the documentation did not include an identification of residents needing assistance for evacuation and an identification of the residents who were not evacuated. </p><p><br></p><p><br></p><p>2. In an interview, E13 reported the facility used a resident roster to document the aforementioned information; however, the documentation was not maintained. E1 acknowledged that documentation of each evacuation drill was not maintained for at least 12 months after the date of the drill which included an identification of the residents needing assistance for evacuation and an identification of residents who were not evacuated.  </p>

<p>Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver documented the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of R4’s medical record revealed a progress note dated April 14, 2025, which indicated R4 suffered an emergency which resulted in R4 needing medical services. However, this report did not include the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the emergency from occurring in the future. </p><p><br></p><p><br></p><p>2. In an interview, E1 reported the facility was unaware the incident with R4 met the requirements for the required documentation. E1 acknowledged that when R4 had an accident, emergency, or injury that resulted in R4 needing medical services, a caregiver failed to documented the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. </p><p><br></p>

<p>Based on observation, record review, and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice poses a health and safety risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers the following materials stored in R7's bathroom:</p><ul><li>Degree Ultraclear Antiperspirant Deodorant Spray;</li><li>Crest Pro-Health Advanced Mouth Wash; and</li><li>DermaVera Skin & Hair Cleanser.</li></ul><p><br></p><p><br></p><p>2. A review of R7's medical record revealed R7 required directed care services.</p><p><br></p><p><br></p><p>3. The Compliance Officers observed an electric razor stored on the counter next to R8's sink.</p><p><br></p><p><br></p><p>4. A review of R8's medical record revealed R8 required directed care services.</p><p><br></p><p><br></p><p>5. In an interview, E1 acknowledged the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p><p><br></p><p>This is a repeat deficiency from the compliance and complaint inspection conducted on March 6, 2024.</p>

Based on record review and interview, the manager failed to ensure that if an assisted living facility provides medication administration, a medication administered to a resident is administered in compliance with a medication order. 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 R3's medical record revealed a document titled "Personal Service Plan," from August 2024, reporting R3 was to receive Medication Administration services.

2. A review of R3's medical record revealed a document titled "Incident Investigation." The document reported R3 had been administered the following medication from R2's medication supply on November 10, 2024:
- "Zofran 4mg"
However, the incident investigation reported that R3 did not have a medication order for the medication prior to November 14, 2024.

3. A review of R2's medical record revealed R2 had a current order dated August 15, 2024 for Ondansetron HCl Oral Tablet (generic brand medication for Zofran) 4 milligram (MG).

4. A review of R3's medical record revealed a medication administration record (MAR) documenting medications administered during the month of November 2024. A review of the MAR revealed the following medication order was added November 14, 2024:
- Ondansetron HCl Oral Tablet 4MG - Give 1 tablet by mouth every 8 hours as needed for Nausea/Vomiting.
However, the facility did not have a medication order for the Ondansetron HCl Oral Tablet 4MG when it was administered to R3 on November 10, 2024.

5. A review of R3's medical record revealed a medication orders including the following medication and parameters dated August 19, 2024:
- "Losartan Potassium Tablet 100MG - Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if SBP is less than 110"

6. A review of R3's medication administration record (MAR) revealed Losartan Potassium Tablet 100MG was administered on November 20, 2024. However, R3's SBP was recorded as 90/58.

7. During an interview E1 acknowledged R3's medication was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive for two of four residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A review of R2's medical record revealed a current service plan, dated September 4, 2024. The written service plan did not include documentation of the level of service R2 was expected to receive.

2. A review of R3's medical record revealed a current service plan, dated September 4, 2024. The written service plan did not include documentation of the level of service R3 was expected to receive.

3. In an interview, E1 acknowledged R2's and R3's service plans did not include the level of service R2 and R3 were expected to receive.

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

Findings include:

1. A review of R1's medical record revealed a service plan (dated August 3, 2024) that indicated R1 would receive the following services:
- Assistance with medication administration, as needed (PRN);
- Blood sugar monitoring, three or more times a week;
- Oversight to confirm the relationship of insulin dosage to fluctuating blood sugar readings;
- Beverages offered with every meal and with all activities;
- Fluids encouraged throughout the day with hydration stations to prevent dehydration and promote skin hydration;
- Provide set-up, selection or laying out of showering supplies and safety devices, PRN;
- Assistance with showering, twice a week; and
- Skin checks, with showers and quarterly.

2. A review of R1's activities of daily living (ADL) documentation, for the month of July 2024, revealed missing documentation of ADL completion on the following dates:
- July 13, 2024 - July 14, 2024, during the evening and night shifts;
- July 15, 2024, during all three shifts;
- July 16, 2024 -July 20, 2024, during the evening and night shifts;
- July 21, 2024 - July 22, 2024, during all three shifts;
- July 23, 2024, during the evening and night shifts;
- July 24, 2024, during the night shift;
- July 25, 2024, during the evening and night shifts;
- July 26, 2024 - July 27, 2024, during the night shift;
- July 28, 2024 - July 29, 2024, during all three shifts; and
- July 30, 2024 - July 31, 2024, during the evening and night shifts.

3. A review of R3's medical record revealed a service plan (dated September 4, 2024) that indicated R3 would receive the following services:
- Assistance with medication administration, PRN;
- Beverages offered with every meal and with all activities;
- Fluids encouraged throughout the day with hydration stations to prevent dehydration and promote skin hydration;
- Provide set-up, selection or laying out of showering supplies and safety devices, PRN;
- Two-person assistance with dressing, PRN;
- Two-person assistance with grooming activities, PRN;
- Two-person assistance with showering, twice a week;
- Incontinence care;
- Two-person transfer support;
- Wound care, managed by hospice; and
- Skin checks, with showers and quarterly.

4. A review of R3's ADL documentation, for the months of July and August 2024, revealed missing documentation of ADL completion on the following dates:
- July 1, 2024 - July 12, 2024, during the evening shift;
- July 13, 2024, during the morning shift;
- July 18, 2024, during the evening shift;
- July 22, 2024 - July 25, 2024, during the evening shift;
- July 26, 2024, during the morning shift;
- July 27, 2024 - July 28, 2024, during the morning and evening shifts;
- July 29, 2024 - July 30, 2024, during the evening shift;
- July 31, 2024, during the morning and evening shifts; and
- August 31, 2024, during the morning shift.

5. A review of R4's medical record revealed a service plan (dated April 4, 2024) that indicated R4 would receive the following services:
- Assistance with medication administration, PRN;
- Beverages offered with every meal and with all activities;
- Fluids encouraged throughout the day with hydration stations to prevent dehydration and promote skin hydration;
- Assistance with the set-up, selection or laying out of clothes;
- Provide set-up, selection or laying out of showering supplies and safety devices, twice a day and PRN;
- One-person assistance with showering, twice a week; and
- Skin checks, with showers and quarterly.

6. A review of R4's ADL documentation, for the month of July 2024, revealed missing documentation of ADL completion on the following dates:
- July 2, 2024, during the evening and night shifts;
- July 4, 2024, during the evening shift;
- July 8, 2024, during the morning and evening shifts;
- July 9, 2024, during all three shifts;
- July 11, 2024, during the evening shift;
- July 14, 2024 - July 15, 2024, during the evening shift;
- July 16, 2024, during the evening and night shifts;
- July 17, 2024, during the evening shift;
- July 21, 2024, during the morning and evening shifts;
- July 23, 2024, during all three shifts;
- July 27, 2024, during the morning shift;
- July 29, 2024, during the morning shift;
- July 30, 2024, during the evening and night shifts; and
- July 31, 2024, during the evening shift.

7. In an interview, E2 reported R1, R3, and R4 received all ADL services in the months of July and August 2024. However, documentation of the services provided was not available for Compliance Officer review. E2 acknowledged a caregiver failed to document the services provided in R1's, R3's, and R4's medical record.

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

Findings include:

1. Review of R1's medical record revealed written service plans dated May 17, 2023 and January 3, 2024. The service plans stated the resident required personal care services. The service plan should have been updated no later than November of 2023.

2. Review of R4's medical record revealed written service plans dated July 20, 2023 and February 1, 2024. The service plans stated the resident required personal care services. The service plan should have been updated no later than January of 2024.

3. Review of R7's medical record revealed one written service plan in the past twelve months dated September 20, 2023. The service plan stated the resident required personal care services. Based on the date of the previous service plan, this service plan should have been updated no later than July of 2023.

4. In an interview, E2 acknowledged the sampled service plans did not appear to have been updated as required for these sampled residents receiving personal care services.

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

Findings include:

1. Review of R9's medical record revealed that R9's written service plans updates during the past twelve months were on May 22, 2023, September 25, 2023, and January 8, 2024. All the service plans stated the resident required directed care services.

2. Review of R10's medical record revealed that R10's written service plan updates during the past twelve months on May 21, 2023, September 25, 2023, October 26, 2023 and January 15, 2024. All the service plans stated the resident required directed care services.

3. In an interview, E2 acknowledged the sampled residents' service plans did not appear to have been updated at least every three months as required for a resident receiving directed care services.

This is a repeat deficiency from the compliance inspections conducted on March 30-31, 2022, and April 11-12, 2023.

Based on record review and interview, the manager failed to ensure six of ten sampled residents' written service plans reviewed when initially developed and updated was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Review of R5's medical record and service plans revealed the resident required personal care and medication administration services. Based on the date of acceptance, R5's initial service plan was not signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. The current service plan dated November 3, 2023 had not been signed and dated by the resident or the representative and the manager who reviewed the service plan.

2. Review of R6's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan updated on February 24, 2024 had not been signed and dated by the resident or the representative and the nurse or medical practitioner who reviewed the service plan.

3. Review of R7's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan updated on September 20, 2023 had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

4. Review of R8's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan updated on February 2, 2024 had not been signed and dated by the resident or the representative who reviewed the service plan.

5. Review of R9's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan updated on January 8, 2024 had not been signed and dated by the resident or the representative and the manager who reviewed the service plan.

6. Review of R10's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan updated on January 5, 2024 had not been signed and dated by the resident or the representative and the nurse or medical practitioner who reviewed the service plan.

7. In an interview, E2 acknowledged that the sampled residents' service plans had not been signed and dated as required by those who had reviewed each service plan.

This is a repeat deficiency from the compliance inspection conducted on April 11-12, 2023.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza (flu) and pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of three sampled residents records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk.

Findings include:

1. Based on the date of acceptance and review of R10's medical record, the compliance officer requested and was not provided documentation to indicate R10 had received the flu and pneumonia vaccines. There was no other documentation available in R10's medical record to indicate the vaccines were offered, given, refused, or contraindicated within the past 12 months.

2. In an interview, E1 and E2 acknowledged there was no documentation available the flu and pneumonia vaccines had been made available to R10 during the past 12 months.

This is a repeat deficiency from the compliance inspections conducted on March 30-31, 2022, and April 11-12, 2023.

Based on record review and interview, the manager failed to ensure that for one of two sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' 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 residents' condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services. This deficiency posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. During an interview, E2 reported that R10 had been unable to ambulate even with assistance for "a long time".

2. Review of R10's medical record contained no documented determinations from a medical practitioner at the time of acceptance and updated at least every six months throughout the duration of the residents' condition. These determinations should have been based on a current resident's examination and the facility's scope of services that the resident's needs could be met. R10's service plan stated the resident required directed care services.

3. In an interview, E1 and E2 acknowledged there were no documented determinations completed as required for R10 who were unable to ambulate even with assistance.

This is a repeat deficiency from the compliance inspections conducted on March 30-31, 2022, and April 11-12, 2023.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by four of four sampled residents receiving directed care services which posed a safety risk.

Findings include:

1. During a facility tour of randomly selected residents' in the memory care bedrooms, E2 and the compliance officer observed R8's, R9's, R10's, and R14's bedrooms were not equipped with a call bell, intercom, or other mechanical means available for the resident to alert employees of the residents' needs or emergencies. Review of R8's, R9's, R10's, and R14's record revealed the residents were receiving directed care services. R8, R10, and R14 were unable to ambulate even with assistance.

2. In an interview, E2 acknowledged the residents had no means to alert employees of the residents' needs or emergencies. E2 reported, "I was told memory care did not need any call system."

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury which posed a health and safety risk.

Findings include:

1. During a facility tour of the randomly selected residents' units and bedrooms, E2 and the compliance officer observed R5's bed had two three-quarter length bedrails, one on each side of the bed. One side of the bed in the up position was against the wall. The other side of the bed where R5 could exit from the bed had a bedrail also in the up position. R5 stated that R5 "scoots to the bottom of the bed to exit the bed". R5 reported the R5 has a "tendency to fall out of bed". R5 reported that R5 could not independently lower the bedrails.

2. In an interview, E1 and E2 acknowledged the bedrail could cause R5 injury if the resident went up and over the bedrail and fell on the floor or R5 got entangled in the bedrail while exiting the bed.

3. In R14's bedroom, E1, E2, and the compliance officer observed R14 in bed. One side of the bed was up against the wall. On the side of the bed that R14 could exit the bed, there were pillows propped up against R14 to prevent R14 from exiting the bed. R14 was not interviewable due to cognitive limitations.

4. In an interview, E1 and E2 acknowledged the pillow could cause R14 physical injury if the resident rolled up and over the pillows onto the floor.

This is a repeat deficiency from the compliance inspection conducted on April 11-12, 2023

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers away from the kitchen, which posed a health risk.

Findings include:

1. During a tour of the facility's central kitchen, E1 and the compliance officer observed a container full of soiled linen being stored uncovered in the facility's kitchen.

2. In an interview, the kitchen staff reported the "cover is broke". E1 acknowledged the soiled linen was not being stored in a closed container away from the kitchen.

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

Findings include:

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

2. Review of nine sampled personnel records revealed there was no documentation that E9 had completed the required training.

3. In an interview, E1 acknowledged the facility did not have documentation that E9 had completed fall prevention and fall recovery training as required. E1 reported E9 worked in dietary and agreed dietary staff also needed to complete the training.

Based on record review and interview, the manager failed to ensure two of twelve sampled residents' service plan were updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition which could pose a health and safety risk for the care of the resident.

Findings include:

1. Review of R2's current service plan dated February 10, 2023 stated the resident required personal care services and was able to ambulate with assistance. In an interview, E2 reported that since the first part of March (2023) R2 was now unable to ambulate even with assistance. E2 acknowledged the significant change in the resident's physical condition, however, the service plan was not updated within fourteen days.

2. Review of R9's current service plan dated December 28, 2022 stated the resident required personal care services and was able to ambulate with assistance. On February 2, 2023 there was a determination that documented the resident was unable to walk. In an interview, E2 reported that since February R9 does not walk and remains in bed. E2 acknowledged this significant change in the resident's physical condition, however, the service plan was not updated.

3. In an interview, E1 and E2 acknowledged that R2's and R9's service plans were not updated as required within 14 calendar days of a significant change in residents' condition.

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 sampled residents receiving directed care services which posed a health and safety risk to the resident.

Findings include:

1. Review of R3's medical record revealed a written service plan for directed care services that had been completed on May 11, 2022, February 2, 2023 and April 9, 2023. Based on the date of acceptance, there were no other service plans available for review for the past 12 months.

2. Review of R5's medical record revealed a written service plan for directed care services that had been completed on May 5, 2022, December 2, 2022, and February 21, 2023. Based on the date of acceptance, there were no other service plans available for review for the past 12 months.

3. During an interview, E1 and E2 acknowledged these sampled residents who had been receiving directed care services for the past 12 months did not have their services plans updated at least every three months.

This a repeat deficiency from the compliance inspection conducted on March 30-31, 2022.

Based on record review and interview, the manager failed to ensure one of thirteen sampled residents' written service plans reviewed when initially developed and updated was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Review of R12's medical record and service plans revealed the resident required directed care and medication administration services. There were service plans that were printed from the computer that were dated October 6, 2022, October 20, 2022, and November 5, 2022 that had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

2. In an interview, E1 acknowledged that R12's service plans had not been signed and dated as required.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of four residents' records reviewed who had resided at the assisted living facility for more than 12 months which posed a health and safety risk.

Findings include:

1. Review of R3's medical record provided no documentation to indicate R3 had been offered the flu and pneumonia vaccines during the past 12 months. There was no other documentation available in R3's medical record to indicate the vaccines were offered, given, refused or contraindicated. Based on the resident's date of acceptance, this documentation was required.

2. In an interview, E1 and E2 acknowledged there was no documentation available that the flu and pneumonia vaccines had been made available to R3 during the past 12 months.

This is a repeat deficiency from the compliance inspection conducted on March 30-31, 2022.

Based on record review and interview, the manager failed to ensure that for three of seven sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' 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 residents' condition to determine if the residents' needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. During an interview, E2 reported that R2, R3, and R5 were unable to ambulate even with assistance. R2 had not been able to ambulate since about early March (2023). R3 and R5 have been unable to ambulate for the past year.

2. Review of R2's medical record contained no documented determination from the resident's medical practitioner since the onset of R2's change in condition. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required personal care services.

3. Review of R3's medical record contained one documented determination completed on February 24, 2023. In an interview, E2 report R3 had been unable to ambulate for the past year. E2 acknowledged that R3's medical record did not contain a documented determination from R3's medical practitioner at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services.

4. Review of R5's medical record contained two determination forms that contained a signature by a medical practitioner. One form had a letterhead that was dated August 12, 2022. The other determination form had a stamped signature of a medical practitioner that was not dated at all. There was no other documented information on these two forms. E2 acknowledge there was no documented determination from the resident's medical practitioner that was updated at least every six months throughout the duration of the residents' condition. These determinations should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services.

5. In interviews, E1 and E2 acknowledged there were no determinations completed as required for these sampled residents who were unable to ambulate even with assistance.

This is a repeat deficiency from the compliance inspection conducted on March 30-31, 2022.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection which posed a health and safety risk.

Findings include:

1. During a facility tour of randomly selected residents' units, E1, E3, and the compliance officer observed in R6's unit there was a pungent urine odor which gave the impression that R6's unit was not kept clean. R6 was not in the unit at the time of the observation.

2. E1, E3, and the compliance officer observed in R8's unit the resident's entire bathroom floor was extremely sticky to walk on which gave the impression that R8's bathroom floor was not kept clean. R8 was not in the bathroom at the time of the observation.

3. In an interview, E1 and E3 acknowledged R6's unit and R8's bathroom did not seem to be kept clean.

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

Findings include:

1. During the tour of R12's bedroom, E1 and the compliance officer observed R12 was laying in bed. One side of the bed was against the bedroom wall. The other side of the bed, where the R12 could exit from, had two large pillows propped up end to end from the head board to the foot board along the edge of the mattress, approximately ten inches higher above the mattress. E1 and the compliance officer observed R12 trying to throw R12's legs over these pillows, attempting to try and get out of bed. Review of R12's medical record revealed that R12 was unable to ambulate even with assistance and could not independently exit the bed safely.

2. In an interview E1 acknowledged the injury that R12 could obtain from the exiting the bed being raised higher from the floor.