BROOKDALE DESERT RIDGE

INSP-0159758

Complete

Date: 9/16/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-09-23

Summary:

No deficiencies were found during the on-site investigation of complaints 00143040, 00144184, 00144623, and 00144713 conducted on September 16, 2025.

✓ No deficiencies cited during this inspection.

INSP-0136343

Complete

Date: 7/30/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-08-29

Summary:

The following deficiencies were found during the on-site investigation of complaint 0000136637 conducted on July 30, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-803.K.2. Administration K. A manager shall provide written notification to the Department of a resident’s: 2. Self-injury, within two working days after the resident inflicts a self-injury that requires immediate intervention by an emergency services provider.;

Evidence/Findings:

Based on interview and documentation review, the manager failed to provide written notification to the Department of a resident’s self-injury, within two working days after the resident inflicted a self-injury that requires immediate intervention by an emergency services provider, for one of three sampled residents. Findings include: 1. In an interview, E1 reported R3 had an accident, emergency, or injury that resulted in R3 needing medical services on July 14, 2025. 2. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report dated July 14-15, 2025. The report stated: “[E3] enters [R3’s] room and resident appeared to be sleeping and snoring. [E3] approaches and attempts to wake [R3] for [R3’s] afternoon meds and [R3] does not wake. [E3] attempts several times shaking [R3’s] shoulder and rubbing [R3’s] leg without response. [E3] calls for assistance and hospice nurse [O1] enters room and [E3 and O1] continue to try to rouse [R3] and upon rolling [R3] to [R3’s] back [E3 and O1] find pills stuck to [R3’s] face, lips and the inside of [R3’s] mouth. At this time [E3 and O1] are unable to get a response and call 911…07/15/2025 - Approximately 1000am - Spoke to [individual] at Suncrest Hospice - [R3] is recovered and back to baseline.” 3. In an interview, E1 reported E1 originally thought the incident constituted self injury. However, E1 confirmed E1 reported the self injury to Adult Protective Services and not to the Department. E1 reported R1’s family later commented about the incident, not believing it was a case of self injury. E1 reported the hospital found no traces of opioids or of an overdose.

Temporary Solution:

Executive Director (ED) was retrained on 8/11/25 by District Director of Clinical Services on reporting self-injuries within 2 working days after a resident inflicts a self-injury that requires immediate intervention by an emergency services provider. District Director of Clinical Services provided training to management staff on 8/11/25 on this reporting requirement.

Permanent Solution:

Person Responsible:

Sylvia Mulshine Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-811.C.13.a-d. Medical Records C. A manager shall ensure that a resident’s medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;

Evidence/Findings:

Based on record review, interview, and observation, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance, the dosage, and the name and signature of the individual administering the medication, for one of three sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1’s medical record revealed an unsigned medication order for “MIRTAZAPINE 15 ORAL TABLET 0.5 tab PO QHS x 8 days then increase to 1 tab PO QHS 30 day(s)” dated July 8, 2025. The review revealed a medication administration record (MAR) dated July 2025. The MAR revealed the following: - On July 9-13, 2025, facility personnel administered R1 one half-tablet of mirtazapine 15 mg (7.5 mg); - On July 14-16, 2025, facility personnel did not administer R1 one half-tablet of mirtazapine 15 mg (7.5 mg), with notes to “See Med Note;” - On July 17, 2025, facility personnel did not administer R1 one tablet of mirtazapine 15 mg, with notes to “See Med Note;” - On July 18, 2025, facility personnel administered R1 one tablet of mirtazapine 15 mg; - On July 19-20, 2025, facility personnel did not administer R1 one tablet of mirtazapine 15 mg; and - On July 21-29, 2025, facility personnel administered R1 one tablet of mirtazapine 15 mg. The MAR revealed documentation demonstrating facility personnel administered a total of five half-tablets and 10 full tablets. The review further revealed an “Alert Charting Note” dated July 17, 2025, at 9:40 PM created by E2. The note stated: “Called [R1’s family member] about non payment of pharmacy bill. Confirmed that [R1’s family member] will get in touch with [R1’s other family member] to settle the matter. [R1’s family member] promised to settle the matter by the close of the business. 2. In an interview, E1 reported the pharmacy did not deliver the medication on time because the pharmacy bill had not been paid at the time. E1 reported E1 did not know exactly when the medication was delivered. 3. The Compliance Officer observed R1’s pharmacy-provided multi-dose package of mirtazapine. The package revealed the medication was delivered on July 22, 2025, and only eight tablets had been administered, in contrast with the 15 and a half tablets documented as administered on the MAR. 4. In a telephonic interview, E2 reported the mirtazapine had not been delivered for several days after July 8, 2025. E2 reported the medication was not administered on those dates, though E2 reported not remembering the exact dates. E2 stated the medication was “not given” on July 18, 2025, even though it was documented by E2 as administered. E2 reported having not administered half-tablets of the medication to R1. E2 confirmed E2 administered only full tablets of the medication to R1. E2 stated the issues with the administration and documentation constituted a “med error.”

Temporary Solution:

Re-training provided to Med Techs and Nurses on 9/1/25 by Health and Wellness Director on proper documentation that includes medication administered to the resident that including the date and time of administration, the dosage, and the name and signature of the individual administering the medication. Health and Wellness Director or designee will review MARs for documentation compliance and missed medications documentation routinely.

Permanent Solution:

Person Responsible:

Sylvia Mulshine Executive Director and Rochelle Mayo Health and Wellness Director

Deficiency #3

Rule/Regulation Violated:

R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication administration record (MAR) dated July 2025. The MAR revealed facility personnel administered mirtazapine to R1 on July 9-13, 18, and 21-29, 2025. However, the review revealed no signed medication order for the mirtazapine. 2. In an interview, E1 confirmed caregivers administered R1’s mirtazapine. 3. In a telephonic interview, E2 confirmed E2 administered R1’s mirtazapine during E2’s shifts on July 9-13 and 21-29, 2025. 4. A review of R3’s medical record revealed a current service plan which indicated R3 received medication administration. The review revealed a MAR dated July 2025. The MAR revealed facility personnel administered multiple medications on a daily basis to R3 on July 1-14, 2025. However, the review revealed no signed medication orders.

Temporary Solution:

All residents are receiving their medications as ordered by 10/24/2025

Permanent Solution:

All residents are receiving their medications as ordered by 10/24/2025

Person Responsible:

Sylvia Mulshine Executive Director and Rochelle Mayo Health and Wellness Director

Deficiency #4

Rule/Regulation Violated:

R9-10-819.D.1. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 1. Immediately notifies the resident’s emergency contact and primary care provider; and

Evidence/Findings:

Based on interview and documentation review, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider (PCP) when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. In an interview, E1 reported R3 had an accident, emergency, or injury that resulted in R3 needing medical services on July 14, 2025. 2. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report dated July 14-15, 2025. The report revealed R3 had an accident, emergency, or injury that resulted in R3 needing medical services. The report revealed no documentation demonstrating whether facility personnel contacted R3’s PCP. 3. In an interview, when the Compliance Officer asked if R3’s PCP was hospice, E1 reported it was not. E1 confirmed R3 had a PCP separate from hospice. E1 reported facility personnel contacted R3’ hospice when the incident occurred and not R3’s PCP. When the Compliance Officer asked if E1 had documentation of notification of R3’s PCP immediately following the incident, E1 stated, “We don’t.” This is a repeat citation from the complaint and compliance inspections completed on July 31, 2024, and August 24, 2023.

Temporary Solution:

Health and Wellness Director reviewed incidents and notifications being made to PCP and all others required on 10/24/25.

Permanent Solution:

Health and Wellness Director reviewed incidents and notifications being made to PCP and all others required on 10/24/25.

Person Responsible:

Sylvia Mulshine Executive Director and Rochelle Mayo Health and Wellness Director

INSP-0135643

POC

Date: 7/7/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-08-14

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00135347 and 00122654 conducted on July 7, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-808.C.1.a. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident’s service plan;

Evidence/Findings:

Based on record review and interviews, the manager failed to ensure that a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan for one of two residents reviewed. The deficient practice posed a risk as service plan to directed services was not followed. Findings include: 1. A review of R8's service plan revealed a service plan for Personal Care services that included incontinence care with changing every two hours or as needed. 2. A review of a progress note dated March 9, 2025, revealed that R8 requested incontinence care assistance from E8 around 1am. E8's progress note stated "resident wanted to be changed but was not that wet, resident told to wait two hours for scheduled change." The resident requested for assistance a second time around 3:30 am and was assisted by E8. 3. A review of the facility's Policies and Procedures titled, "Scope of Services', stated, "Personal Care services includes assistance with activities of daily living that can be performed by persons without professional skills or professional training. Additionally, it includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a licensed nurse or as otherwise provided by law." 4. During the exit interview, E1 acknowledged that a caregiver or an assistant caregiver failed to provide a resident with the assisted living services in the resident's service plan.

Temporary Solution:

Executive Director (ED) and Health and Wellness Director (HWD) will conduct re-training with all care partners on following Personal Service Plan on 8/25/25 ED and Health and Wellness Director will conduct re-training with all care partners on incontinence care 8/25/25.

Permanent Solution:

Person Responsible:

Sylvia Mulshine Executive Director; Rochelle Mayo, Health and Wellness Director

Deficiency #2

Rule/Regulation Violated:

R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of injury and violated a resident's rights. Findings include: 1. A review of R8's service plan revealed that the resident received Personal Care services, which included incontinence care. 2. A review of a progress note dated March 9, 2025, revealed that R8 requested incontinence care assistance from E8 around 1am. E8's progress note stated "resident wanted to be changed but was not that wet, resident told to wait two hours for scheduled change."The resident requested for assistance a second time around 3:30 am and was assisted by E8. 3. A review of E8's personnel record revealed that the employee was put on suspension pending an internal investigation on March 16, 2025. The employee was terminated for violation of facility policy on April1, 2025. 4. A review of the facility's Policies and Procedures titled, "Resident Rights" stated, "Residents will be treated with dignity, respect, and consideration." 5. In an interview, E1 revealed that when the manager learned of the behavior that E8 exhibited towards R8, the employee was suspended pending an investigation. The employee was terminated for violating policy. 6. In an interview, E1 acknowledged that the manager failed to ensure that a resident was treated with dignity, respect, or consideration.

Temporary Solution:

SOD Sent: 2024-08-29

Summary:

An on-site investigation of complaint AZ00214294 was conducted on August 9, 2024, and the following deficiency was cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview,the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided.

Findings include:

1. R9-10-808.A(3)(d) states "For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner."

2. 4. In record review, the medical record for R1 (received personal care and medication administration services), did not include documentation the resident's service plan was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner for the service plans dated December 12, 2023 and June 16, 2024.

3. During an interview, E1 and E2 both reported the system for obtaining signatures on the service plan changed and there was no further documentation available for review. E1 and E2 acknowledged the service plans were not signed and dated by the resident or resident's representative, the manager, and signed and dated as reviewed by the nurse or medical practitioner, as required.

This is an uncorrected deficiency from the compliance survey conducted on July 31, 2024.

INSP-0064443

Complete

Date: 8/7/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-09-03

Summary:

An on-site investigation of complaint AZ00214162 and AZ00214166 was conducted on August 07, 2024 and the following deficiencies were cited :

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
1. Established, documented, and implemented to protect the health and safety of a resident that:
g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident covering 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. The deficient practice posed a health and safety risk to residents, if the facility failed to have established policies and procedures, and employees were not instructed on managing a resident's aggressive behaviors, to ensure the safety of residents and others.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "Behavioral Problem-Solving Process and Procedure," that stated "1. Once a behavioral expression has been identified, the community team should meet to explore and clarify the symptoms that are associated with the resident's distress." "8. In the event a resident's behavioral expression poses immediate danger to the resident or others, please ensure the safety of the residents first and eliminate the immediate danger."

2. A review of R1's medical record revealed the following document titled "Charting Note" dated July 31, 2024;
- at 02:07pm that stated "R1 was very upset this afternoon, R1 was yelling at everyone care staff, Med-Tech and activities director. R1 said R1 was the head of every one and had to speak for all other residents, very hard to redirect, did not want to listen to anyone, R1 set off a couple of residents ... After a while R1 was able to be re-directed to take nap."
- at 08:05pm that stated " ... R1 kept screaming ... yelling in the hallways agitating other residents. ..."
- at 10:50pm that stated "Came out of R1's room, yelling at R2, calling R2 names, then E5 witnesses R1 punching R2 in the face then hit R2 with the walker in R2's right arm. E5 intervene separated R1 and R2. About 10 mins later E5 came out from assisting another resident, found R1 on the floors and R2's shirt is off and ripped, a witness told E5 that R1 grabbed R2 by the shirt and it ripped so R2 pushed R1. R1 has a skin tear on left hand, refused vitals."

3. A review of facility documentation revealed no evidence provided to the Compliance Officer that the facility had implemented measures as outlined in the "Behavioral Problem-Solving Process and Procedure" policy. The Compliance Officer was unable to determine what specific actions the facility had taken to separate the residents during the incident, and prevent similar incidents from occurring in the future.

4. In an interview, E2 and E3 acknowledged that the caregiver did not take immediate action to separate the residents during the incident on July 31, 2024 and acknowledged the facility policy covering how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual had not been implemented.

Deficiency #2

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on documentation review, record review, observation and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803(J). The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported as required.

Findings include:

1. A.R.S. \'a7 46-454. stated, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures."

2. A review of R1's medical record revealed a document titled "Charting Note" dated July 31, 2024 at 10:50pm that stated "Came out of R1's room, yelling at R2, calling R2 names, then E5 witnesses R1 punching R2 in the face then hit R2 with the walker in R2's right arm. E5 intervene separated R1 and R2. About 10 mins later E5 came out from assisting another resident, found R1 on the floors and R2's shirt is off and ripped, a witness told E5 that R1 grabbed R2 by the shirt and it ripped so R2 pushed R1. R1 has a skin tear on left hand, refused vitals."

3. R1's medical record revealed no documentation that the facility took immediate action to stop the suspected abuse and no documentation of reporting the incident to Adult Protective Services (APS) or a Peace Officer (police). Additionally, no documentation was available to show an investigation was conducted by the facility of the suspected abuse.

4. In an interview, R1 reported that R2 pushed R1, causing R1 to fall. As a result of the fall, R1 suffered a skin tear and hit R1's head, though no head injury was mentioned.

5. A review of R2's medical record revealed a document titled "Charting Notes" dated July 31, 2024 at 10:41pm that stated "Was physically attacked by two residents, One in the middle of R2's back and the other in the face. R2's skin tear on the right upper arm open up. No signs of bruising on the back and face.

6. R2's medical record revealed no documentation that the facility took immediate action to stop the suspected abuse and no documentation of reporting the incident to Adult Protective Services (APS) or a Peace Officer (police). Additionally, no documentation was available to show an investigation was conducted by the facility of the suspected abuse.

7. During an environmental tour, the Compliance Officer observed R2 wandering throughout the memory care unit, opening doors. The facility has identified R2 as a wanderer. However, the Compliance Officer was unable to determine what specific measures the facility had implemented to separate the residents and prevent similar incidents from occurring in the future.

8. In an interview, E2 and E3 acknowledged the facility did not take immediate action to stop the suspected abuse, report the abuse to Adult Protective Services (APS) or a Peace Officer (police), and no investigation was conducted by the facility of the suspected abuse.

9. E1 arrived around the time the Compliance Officer was about to leave the facility. In an interview, E1 acknowledged the facility did not take immediate action to stop the suspected abuse, report the abuse to Adult Protective Services (APS) or a Peace Officer (police), and no investigation was conducted by the facility of the suspected abuse. E1 reported that E1 was notified of the incident the day before (August 6, 2024) the Compliance Officer was at the facility.

INSP-0064442

Complete

Date: 7/29/2024 - 7/31/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-08-30

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints AZ00213809, AZ00213769, AZ00212955, AZ00212741 AZ00211631, AZ00210962, AZ00201232, and AZ00201117, conducted on July 29, 2024 and July 31, 2024:

Deficiencies Found: 30

Deficiency #5

Rule/Regulation Violated:

Based on observation, record review, documentation review, and interview, for one resident reviewed receiving opioid medication without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if a resident's pain was not identified, monitored, and documented, as required.

Findings include:

1. In observation, R2 was observed on the memory care unit in the common area during an activity. Observation of R2's medications revealed R2 had Morphine Sulfate ER Oral 15 mg medication and Morphine IR 5mg medication capsules on site, (a schedule II controlled substance).

2. In record review, R2's medical record (received directed care and medication administration services) included a medication order for "Morphine Sulfate ER oral Tablet extended release 15 mg, give 1 tablet by mouth three times a day for pain..." and "Morphine IR 5 mg caps, take 1 to 2 capsules by mouth every 4 hours as needed for pain." R2's medication administration record included documentation R2 received the Morphine Sulfate 15 mg daily, as ordered, and the Morphine IR 5 mg medication four times from June 20 - July 22, 2024. R2's medication administration record did not include documentation of an identification of the resident's need and the monitoring of the effect for the Morphine Sulfate 15mg medication administration. R2's record did not include an identification of the resident's need for the Morphine IR 5 mg medication administration, and did not indicate R2's level of pain; however, did include documentation of the monitoring of the effect of the opioid administered and was documented as "effective." R2's medical record did not include documentation R2 had an active malignancy or an end of life condition.

3. In documentation review, a facility policy, titled "... Medication and Treatment..., last revised "3/31/2022," documented, "...11. Administration of opioid medications requires assessment of resident pain with the use of the 0-10 verbal pain scale or faces scale as applicable... The assessment of pain is conducted prior to administration... Thirty minutes after administration the resident should be assessed for response and effectiveness of the opioid administration... Documentation of the resident's pain before administration of the opioid and the effect of the opioid administration should be documented on the MAR or eMAR..."

4. During an interview, E3 reported R2 received the Morphine medication, as ordered. R2 was not in the dying process, did not have an end of life condition, or an active malignancy. R2 had a prior car accident injury and received the opioid medication for back pain.

5. During an interview, the findings were reviewed with E1 and E5, who acknowledged the facility did not identify and document the resident's need for the opioid before the opioid was administered, and monitor and document the effect of the opioid administered, according to the facility's policies and procedures.

INSP-0064434

Complete

Date: 8/23/2023 - 8/24/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-10-04

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00188259, AZ00190508, AZ00191312, AZ00192889, and AZ00193010 conducted on August 23-24, 2023:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

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

Findings include:

1. A.R.S. \'a7 36-411 states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work...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. In an interview, E1 reported E1 was the manager, E6 worked as a caregiver, and E7 worked as a medication technician.

3. A review of E1's personnel record revealed E1 was hired in August 2022. E1's personnel record contained an application for a fingerprint clearance card dated November 7, 2022.

4. A review of the Department of Public Safety website revealed E1's fingerprint clearance card application was received on November 30, 2022.

5. A review of E6's personnel record revealed E6 was originally hired as an assistant caregiver in June 2022, then as a maintenance worker, then as an assistant caregiver again, and finally as a caregiver. E6's personnel record contained a fingerprint clearance card application receipt dated March 15, 2023, and a photocopy of the front and back of E6's fingerprint clearance card with a stamp reading "ENTERED."

6. Further review of E6's personnel record revealed an "Application for Employment." The application included information regarding E6's previous employment. However, the review revealed no documentation demonstrating the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E6's fitness to work in a residential care institution; or to verify the status of E6's fingerprint clearance card.

7. A review of the Department of Public Safety website revealed E6's fingerprint clearance card application was received on March 20, 2023. The website further revealed E6's fingerprint clearance card was valid.

8. A review of E7's personnel record revealed E7 was hired in August 2022. E7's personnel record contained a fingerprint clearance card application receipt dated March 9, 2023, and a photocopy of the front of E7's fingerprint clearance card with a stamp reading "ENTERED." However, E7's personnel record contained no documentation demonstrating the governing authority made documented, good faith efforts to verify the status of E7's fingerprint clearance card.

9. A review of the Department of Public Safety website revealed E7's application was received on March 13, 2023.

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Based on documentation review, record review, and interview, after having a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of facility documentation revealed a list of incidents. The list revealed R7 was involved in an incident on December 31, 2022. The document stated the "Nature of [the] Incident" to be "Alleged Aggressive Behavior, Abuse, Neglect or Exploitation."

2. A review of R7's medical record revealed documents titled "Progress Notes". The documents included information regarding the incident on December 31, 2022, and stated a caregiver found R9 sitting on R7's bed without R7's consent.

3. A review of R9's medical record revealed documents titled "Progress Notes". The documents included information regarding the incident on December 31, 2022, and stated a caregiver found R9 sitting on R7's bed "rubbing [R7's] back and body" without R7's consent.

4. In an interview, E1 reported the facility took immediate action to stop the suspected abuse, neglect, or exploitation; reported the incident according to A.R.S. \'a7 46-454; documented the incident; investigated the incident; and documented the investigation. However, E1 reported the facility did not have the police report required in R9-10-803(J)(2).

Deficiency #3

Rule/Regulation Violated:

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, for one of one applicable resident sampled. The deficient practice posed a risk as the resident's primary care provider was not notified of the incident in a timely manner in which the resident's primary care provider could participate in decisions concerning the resident's health and safety.

Findings include:

1. A review of R8's medical record revealed an incident report dated December 20, 2022. The incident report revealed R8 had an accident, emergency, or injury that resulted in 911 being called and R8 requiring medical services, stating, "Injury with Outside Treatment (e.g. urgent care, EMT, doctor's office)." The document stated the "Approx. Time of Incident [was] 12:30 PM." However, the document revealed R8's primary care provider was not notified until December 22, 2022, at 10:00 AM, nearly two days after the incident occurred.

2. In an interview, E1 acknowledged R8's primary care provider was not immediately notified.

Facility Information

Inspection History

INSP-0159758

Summary:

INSP-0136343

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0135643

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0064441

Summary:

INSP-0064440

Summary:

INSP-0064438

Summary:

INSP-0064437

Summary:

INSP-0064436

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064443

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064442

Summary:

Deficiencies Found: 30

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3