THE FORUM AT TUCSON

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of ten residents sampled. The deficient practice posed a risk as there was no timely service plan to direct services to be provided to a resident.

Findings include:

1. A review of R2's medical record revealed a service plan dated July 10, 2024. However, July 10, 2024 was more than 14 calendar days after R2's date of acceptance and a previous service plan was not available for review.

2. In an interview, E1 acknowledged a completed service plan, dated no later than 14 days after R2's date of acceptance, had not been provided for review.

Based on record review, and interview, the manager failed to ensure a resident had a written service plan which accurately included the level of service the resident was expected to receive, for two of ten residents sampled.

Findings include:

A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. A review of R1's medical record revealed a service plan, dated March 31, 2024, for personal care services. However, the service plan did not include any personal care services and had not been updated at least every once every six months.

2. In an interview, E8 reported R1 was receiving Supervisory care and the service plan was incorrect.

3. A review of R6's medical record revealed a service plan, dated October 9, 2024. However, the service plan did not include the level of care R6's was expected to receive.

4. In an interview, E1 acknowledged the service plan provided for R1 had not correctly identified the level of care R1 was expected to receive and R6's service plan did not include the level of care R6 was expected to receive.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medications, for two of ten residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan, dated July 10, 2024, for directed care services. The service plan stated, "Bathing.. I will maintain current level of function in bathing...I need physical assist with bathing, but i can participate in part of the bathing activity.. My Caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to the nurse and coordinator." However, the service plan did not include the amount, type, and frequency of the bathing service to be provided to R2.

2. A review of R3's medical record revealed a service plan, dated December 17, 2024, for personal care services. The service plan stated, "Bathing.. I will maintain current level of function in bathing-assist...I require staff standby supervision, set up, verbal cues and/or reminders to complete tasks...my caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to the nurse and coordinator...My caregivers will observe the skin for any redness, open areas, scratches, cuts, tears, bruises/discolorations and report any changes to the nurse." However, the service plan did not include the frequency of the bathing service to be provided to R3.

3. In an interview, E1 acknowledged R2's and R3's service plans did not include the type, amount, and frequency of the bathing service.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of ten residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan, dated July 10, 2024, for directed care services. The service plan did not include hospice services.

2. A review of R2's medical record revealed R2 enrolled with hospice services on September 25, 2024.

3. A review of R2's medical record revealed an updated service plan, dated on or before October 9, 2024, was not available for review.

4. In an interview, E1 acknowledged R2's service plan had not been updated within 14 calendar days after R2 had a significant change in condition requiring hospice services.

Based on record review, and interview, for one of seven residents sampled, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months.

Findings include:

1. A review of R5's medical record revealed a service plan, dated May 11, 2024, for personal care services. However, an updated service plan, dated on or before November 11, 2024, was not available for review.

2. In an interview, E1 acknowledged a current service plan had not been provided for R5.

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 three residents sampled receiving directed care services.

Findings include:

1. A review of R2's medical record revealed a written service plan for directed care services, dated July 10, 2024. However, a required service plan update, dated on or before October 10, 2024, was not available for review.

2. In an interview, E1 acknowledged R2's updated service plan had not been provided for review.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of ten residents sampled.

Findings include:

1. A review of R6's medical record revealed a service plan dated October 9, 2024. The service plan documented R6 required the following assisted living service: "I have altered cardiovascular status, I will be free from any s/sx of cardiovascular distress related to hypertension...My caregivers will monitor for any signs and symptoms of Hypertension with daily BPs."

2. A review of R6's medical record revealed R6's blood pressure had been documented on October 9, 2024 and on December 10, 2024.

3. In an interview, E1 acknowledged that a caregiver did not provide a resident with the assisted living services in the resident's service plan.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of ten residents sampled who received medication administration. 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 R3's medical record revealed a service plan, dated December 17, 2024, for personal care services including medication administration.

2. A review of R3's medical record revealed an order, dated August 30, 2024, which included the following:
- "Clobetasol 0.05% scalp solution, few drops once a day at bedtime to the open wound on the right parietal scalp for two weeks, take 1 week off, then restart the treatment for two weeks"; and
- "Hydrocortisone 2.5% topical cream, Apply to the rash in groins once a day in the morning for up to one month as needed."

3. A review of R3's medical record revealed an electronic Medication Administration Record (eMAR) dated January 2025. The MAR documented the following:
- "Clobetasol Propionate External Liquid 0.05%," was scheduled for administration at bedtime and had been administered on each day in January 2025; and
- "Hydrocortisone External Kit 2.5%," was scheduled for administration in the morning and had been administered on each day in January 2025.

4. A review of R3's January 2025 eMAR revealed R3 had been administered, "Triamcinolone Acetonide External Cream 0.1% Apply to arms, shoulders topically two times a day for itching," on each day at 09:00 and at 20:00.

5. A review of R3's medical record revealed an order for Triamcinolone was not available for review.

6. In an interview, E1 acknowledged R3's medical record did not document medication had been administered to R3 as ordered.

This is a repeat deficiency from the on-site compliance inspection conducted November 30, 2023.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of facility evacuation drills revealed an evacuation drill conducted on May 6, 2024. However a second evacuation drill conducted on or before November 6, 2024 was not provided for review.

2. A review of facility evacuation drills revealed a drill conducted on September 30, 2024. However, the evacuation drill did not include the time taken to evacuate, and did not include a list of residents needing assistance to evacuate or a list of residents who did not evacuate.

3. In an interview, E8 reported the facility did one full evacuation drill and one partial evacuation drill which did not involve residents.

4. In an interview, E1 acknowledged the facility's documentation of evacuation drills for employees and residents, conducted at least once every six months, had not been provided for review.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents included all individuals on the premises.

Findings include:

1. A review of facility evacuation drills revealed a drill conducted on September 30, 2024. However, the evacuation drill did not include the time taken to evacuate, and did not include a list of residents needing assistance to evacuate or a list of residents who did not evacuate.

3. In an interview, E8 reported the facility conducted one full evacuation drill in May 2024 and one partial evacuation drill in September 2024 which did not involve residents.

4. In an interview, E1 acknowledged the facility's evacuation drill conducted on September 30, 2024 had not included all individuals on the site.

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer an opioid in treating a patient documented in the resident's medical record the effect of the opioid administered, for one of one resident sampled who received medication administration of an opioid.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Opioid Administration and Assistance in the Self Administration of Prescribed Opioids." The policy stated "Following administration or taking an opioid medication by the resident, the licensed nurse or medication technician will record the effectiveness of the medication at relieving the pain..."

2. A review of R6's medical record revealed a service plan dated October 9, 2024, for personal care services including medication administration.

3. A review of R6's medical record revealed an electronic medication administration record (eMAR) dated January 2025. The eMAR documented "Hydrocodone-Acetaminophen Oral Tablet 7.5-325MG" had been administered at, "AM," "MD," "PM1," and "HS1," on each day between January 1, 2025, and the day of the on-site inspection. The eMAR documented an assessment of R6's need for the medication, however, documentation of the effectiveness of the medication was not available for review.

4. In an interview, E1 acknowledged the effect of the Hydrocodone administered to R6 during January 2025, had not been documented in R6's medical record.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for six of eight residents sampled.

Findings include:

1. A review of R1's, R3's, R4's, R5's, R6's, and R8's medical records revealed each resident had a current service plan which included the service, "I require safety checks by my caregivers every shift."

2. A review of R1's, R3's, R4's, R5's, R6's and R8's medical record revealed documentation of services provided to each resident on each shift. However, documentation of safety checks on each shift was inconsistent or unavailable.

3. In an interview, E1 acknowledged the services provided to each resident were not accurately documented in each resident's medical record.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan, and if a review was required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan, when initially developed and when updated, for four of nine residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated August 25, 2023. However, the service plan signature page was not provided for review.

2. A review of R3's medical record revealed a service plan dated November 25, 2023. However, the service plan signature page was not provided for review.

3. A review of R6's medical record revealed a service plan dated November 28, 2023. However, the service plan signature page was not provided for review.

4. A review of R7's medical record revealed a service plan dated August 30, 2023. However, the service plan signature page was not provided for review.

5. In an interview, E1, E2, and E3 acknowledged the service plan signature pages had not been provided for provided for R1, R3, R6, and R7.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for three of nine residents sampled.

Findings include:

1. A review of R4's medical record revealed a service plan, updated September 20, 2023, which included medication administration.

2. A review of R4's medical record revealed an order,signed November 3, 2023, which stated, "Acetaminophen (Tylenol) 325 MG Tablet, Take 2 tablets by mouth three times a day. May also take 1 tablet every six hours as needed for pain. OK to CRUSH. Start Date 09/29/2023."

3. A review of R4's medical record revealed a medication administration record (MAR) dated November 2023. The MAR documented the medications administered to R4 during the month of November 2023. However, the MAR indicated the following:
- "Acetaminophen ER Oral Tablet 650 MG, Give 1 tablet by mouth three times a day," had been administered three times per day on November 1, 2023 and November 2, 2023;
- No Acetaminophen had been administered on November 3, 2023 through November 10, 2023; and
- "Acetaminophen 325 MG, Give 2 tablets by mouth three times a day for pain," had started administration on November 11, 2023.

4. A review of R6's medical record revealed a service plan, updated November 28, 2023, which included medication administration.

5. A review of R6's medical record revealed current medication orders were not available for review.

6. A review of R6's medical record revealed a MAR dated November 2023. The MAR documented R6 had received administration of multiple medications during the month.

7. A review of R7's medical record revealed a service plan, updated August 30, 2023, which included medication administration

8. A review of R7's medical record revealed an order,signed October 15, 2023, which stated, "Amlodipine Besylate Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for Hypertension. Hold if SBP is less than 100, is DBP less than 50, if heart rate is less than 60."

9. A review of R7's medical record revealed a MAR dated November 2023. The MAR documented the medications administered to R7 during the month of November 2023. The MAR indicated R7 had been administered, "Amlodipine Besylate Oral Tablet 5 MG," on each day in November 2023. However, the MAR did not include documentation of R7's blood pressure or heart rate before each dose of the medication as required.

10. In an interview, E1, E2, and E3 acknowledged the provided orders and MARs for R4, R6, and R7 had included omissions or discrepancies and did not document all medications had been administered in compliance with a medication order for each resident.

Based on record review and interview, the manager failed to ensure a resident was provided a diet to meet the resident's nutritional needs as specified in the resident's service plan, for two of nine residents sampled.

Findings include:

1. A review of R1's medical record revealed a current service plan dated June 16, 2023. However, R1's diet was not specified in the service plan as required.

2. A review of R4's medical record revealed a current service plan dated September 20, 2023. However, R4's diet was not specified in the service plan as required.

3. In an interview, E1, E2, and E3 acknowledged the service plans provided for R1 and R4 did not specify each resident's nutritional needs.

Technical Assistance for this rule was provided during the on-site compliance inspection conducted on January 17, 2023.

Based on observation and interview, the manager failed to ensure the premises were free from a situation that may cause a resident to suffer physical injury.

Findings include:

1. During an environmental tour, the Compliance Officer inspected a resident's bedroom in the secured memory care unit. In an unlocked medicine cabinet in the resident's private bathroom, the Compliance Officer observed a bottle of nail polish remover, a poisonous material. Due to the acuity of the residents in the unit, unsecured poisons represented a hazard which could cause a resident to suffer physical injury.

2. In an interview, E1, E2, and E3 acknowledged the premises were not free from a situation that may cause a resident to suffer physical injury.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for three of eight sampled employees.

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.

B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.

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.

D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.

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

F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.

G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.

H. For the purposes of this section:

1. "Direct supportive services":

(a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:

(i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.

(ii) Assistance with self-administration of medication.

(iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.

(iv) Transportation services, including van services.

(b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.

2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.

3. "Home health services" has the same meaning prescribed in section 36-151."

2. A review of E8's personnel record revealed E8 was hired as a caregiver. E8's personnel record included a valid fingerprint clearance card.

3. A review of E8's personnel record revealed two forms titled, "Confidential Reference Check", however, both forms were not completely filled out and were attached to letters of recommendation from co-workers. E8's personnel record included no documented, good faith attempts to 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 per A.R.S. \'a7 36-411(C)(1).

4. A review of E8's personnel record revealed an employment record. However, the employment record was insufficient to determine whether there was a six-month or longer time frame during which E8 was not employed by any employer per A.R.S. \'a7 36-411(G). E8's personnel record included an employment record listing one previous employer. However, the employment record provided only the year during which E8's employment ended with the previous employer and did not include the month during which E8's employment ended with the previous employer. Depending on what month E8's employment ended with the previous employer, it was possible E8 had been unemployed for more than six months at the time of hire.

5. A review of E9's personnel record revealed E9 was hired as a caregiver. E9's personnel record included a valid fingerprint clearance card.

6. A review of E9's personnel record revealed three forms titled, "Confidential Reference Check", however, all three forms indicated the person contacted was a "co-worker." E9's personnel record included no documented, good faith attempts to 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 per A.R.S. \'a7 36-411(C)(1).

7. A review of E13's personnel record revealed E13 was hired as a caregiver. E13's personnel record included a valid fingerprint clearance card issued in 2020.

8. A review of E13's personnel record revealed an employment record. However, the employment record ended in 2014. Based on E13's hire date, when E13 was hired, more than six months had elapsed since E13's fingerprint clearance card was issued. E13's employment record included a six-month or longer time frame during which E13 was not documented to have been employed by any employer, however, no documentation of a completed application with a new set of fingerprints having been submitted to the department of public safety per A.R.S. \'a7 36-411(G) was available for review.

9. A review of E13's personnel record revealed a form titled, "Confidential Reference Check", for a second job which was not listed on

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of cardiopulmonary resuscitation training, including a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of five sampled caregivers.

Findings include:

1. A review of the facility's policies and procedures, reviewed by the facility on September 21, 2022, revealed a policy covering CPR training for applicable employees and volunteers was not available for review.

2. A review of E8's personnel record revealed E8 was hired as a caregiver.

3. A review of E8's personnel record revealed a CPR card from "NationalCPRFoundation", an online-only CPR provider.

4. In an interview, E1, E2, E3, and E4 acknowledged a policy covering CPR training for applicable employees and volunteers had not been provided for review and acknowledged E8's CPR training did not include a demonstration of E8's ability to perform CPR.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of six sampled personnel hired as caregivers.

Findings include:

1. A review of facility documentation, revealed a staff schedule for the week of January 12, 2023 through January 18, 2023. The staff schedule revealed the following:
-E13 was scheduled to work from 2:00 PM to 10:00 PM on Sunday, January 15, 2023; and
-E13 was also scheduled to work from 3:00 PM to 11:00 PM on Monday, January 16, 2023 and Tuesday, January 17, 2023.

2. A review of E13's personnel record revealed a resume which included one prior employer. The employer was in Kentucky and the employment dates were from 2012 through 2014. The resume also indicated E13 obtained a high school diploma in 2012 in Georgia.

3. A review of E13's personnel record revealed a form titled, "Confidential Reference Check." The form indicated E13's prior supervisor at the employer in Kentucky was contacted and confirmed E13 worked for the employer in Kentucky from 2012 to 2014.

4. A review of E13's personnel record revealed a caregiver certificate with a completed date of January 2, 2013 from "About Time Care Training Program, ALTP 0182."

5. In an interview, E1, E2, E3, and E4 acknowledged E13's personnel record indicated E13 was not a resident of Arizona at the time E13's caregiver certificate was issued, and E13's personnel file did not document any attempt to resolve the apparent contradiction between E13's verified work history and E13's alleged caregiver training date.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers and stored in a locked area inaccessible to residents.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked laundry room in the "Assisted Living Neighborhood" unit. In the unlocked laundry room, the Compliance Officer observed a tote containing cleaning chemicals on a counter next to a refrigerator. The Compliance Officer observed the tote contained a spray bottle of "Zep Streak-Free Glass Cleaner," and a spray bottle with an illegible, water damaged label and a handwritten label of "infestante" and a name, O1.

2. A review of facility documentation revealed the name, "O1" on the spray bottle was not the name of any current staff on the provided staff roster.

3. During the environmental inspection of the facility, the Compliance Officer observed a commercial kitchen adjacent to a resident dining area near the "Ambassador" unit. The door leading into the kitchen was unlocked. The Compliance Officer observed no personnel were present in the kitchen area. The Compliance Officer observed a spray bottle of "Oasis 146 Multi-Quat Sanitizer" on the lower section of a steel table in the kitchen.

4. During the environmental inspection of the facility, the Compliance Officer observed a room with a sign stating, "Utility Closet" on the first floor near the entrance to the "Ambassador" unit. The door to the room did not have a lock. Inside the room, the Compliance Officer observed a bag of, "Ecolab Peroxide Multi Surface Cleaner and Disinfectant."

5. During the environmental inspection of the facility, the Compliance Officer observed a laundry room on the south wing of the first floor of the "Ambassador" unit. The laundry room was for resident use and was not locked. On the floor next to a washing machine, the Compliance Officer observed two containers of "Harmony Detergent with Oxygen Bleach," which were not secured in the automatic detergent dispenser for the washing machines.

6. During the environmental inspection of the facility, the Compliance Officer observed an unlocked common area on the third floor of the "Ambassador" unit used for activities. In an unlocked cabinet in the activity room, the surveyor observed a bottle of "Bath and Beauty Nail Polish Remover."

7. In an interview, E1, E2, E3, and E4 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in labeled containers in a locked area, separate from food preparation and storage, dining areas, and medications, and inaccessible to residents.