CAREFREE ASSISTED LIVING CENTER

<p>Based on observation and interview, the manager failed to ensure the assisted living facility's license was conspicuously posted.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . During an inspection at the facility, the Compliance Officers observed the assisted living facility's license was not conspicuously posted.</p><p><br></p><p><br></p><p><br></p><p>2 . In an interview, E1 reported the license was moved because of remodeling happening at the home. E1 acknowledged the facility's license was not conspicuously posted at the time of the inspection.</p>

<p>Based on record review and interview, the manager failed to ensure <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility, includes if the resident is expected to receive supervisory care, personal care, or directed care services, and includes whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints. </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">1 . A review of R3's medical record revealed documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility, includes if the resident is expected to receive supervisory care, personal care, or directed care services, and includes whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints was not available for review at the time of inspection. </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">2 . In an interview, E1 acknowledged R3's file did not include the aforementioned documentation. </span></p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure caregivers documented the services provided to residents listed in their service plan.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . A review of R1's medical record revealed a service plan. The service plan reported the resident was encouraged to drink fluids of choice. Further review of R1's medical record revealed an Activities of Daily Living (ADL) sheet for April 2025. However, documentation of caregivers encouraging residents to drink fluids of choice was not available for review at the time of inspection.</p><p><br></p><p><br></p><p><br></p><p>2 . A review of R2's medical record revealed a service plan. The service plan reported the resident was encouraged to drink fluids of choice, and R2 would receive physical assistance with bathing twice weekly. Further review of R2's medical record revealed an ADL sheet with no month listed. E1 confirmed the ADL sheet was for the month of April 2025. However, the documentation of caregivers encouraging residents to drink fluids of choice was not available for review at the time of inspection. Further review of the ADL sheet revealed R2 had only one documentation of physical assistance with bathing from April 13, 2025, to April 19, 2025.</p><p><br></p><p><br></p><p><br></p><p>3 . In an interview, E1 acknowledged R1's and R2's ADL sheets were missing documentation of services provided.</p>

<p>Based on observation, the manager failed to ensure medication stored by an assisted living facility is kept in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. </p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . When the Compliance Officers arrived at the facility at approximately 2 PM, they observed the office door was left open. Inside the office, there was a bag with medication sitting on the desk, and a medication pack lying on the floor next to the desk. </p><p><br></p><p><br></p><p><br></p><p>2 . In an interview, E1 acknowledged medication was not kept in a locked area.</p>

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S.36-420.01.

Findings include:
1. Review of the record for E1 (hired March 27, 2023), failed to reveal documentation of fall prevention and fall recovery training.
2. Review of the record for E3 (hired October 3, 2021), failed to reveal documentation of fall prevention and fall recovery training.
3. During an interview, E1 indicated that the required training documentation for fall prevention and recovery was not available for review.

Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years.

Findings include:
1. Review of the facility policy and procedure manual revealed documentation indicating that the manual had been reviewed on July 1, 2019. No additional documentation indicating that the policies and procedures had been reviewed at least once every three years was available for review.
2. During an interview, E1 acknowledged the documentation failed to indicate that the policies and procedures were reviewed at least once every three years.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority "every three months".
2. No reports were available for review.
3. During an interview, E1 stated, "I don't have that."

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of a service plan that when updated, was signed and dated by the nurse or medical practitioner who reviewed the service plan.

Findings include:
1. The record for R1 (directed care, receiving medication administration), contained a service plan dated April 11, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan.
2. The record for R2, (directed care, receiving medication administration services), contained a service plan dated March 9, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan.
3. During an interview, E1 acknowledged that the service plans did not reflect the dated signature of the nurse or medical professional.

Based on record review and interview, the manager failed to ensure that one of two sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia.

Findings include:
1. The record belonging to R2 contained documentation indicating that the resident was last notified of the availability of the influenza and pneumonia vaccinations on September 16, 2020. No additional documentation indicating when the resident had been offered, refused, or received either vaccination was available for review. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E1 acknowledged that the vaccinations had been made available to the resident on a yearly basis however the record did not contain the required documentation.

This is a repeat deficiency from the compliance inspection conducted on December 16, 2021.

Based on documentation review, observation and interview the manager failed to ensure that a food menu includes the food to be served each day.

Findings include:
1. Review of the posted facility menu dated May 2, 2023 revealed the following notation for the dinner meal, "Chef Surprise". No additional information identifying the food served was available for review.
2. Sixty days of menus were requested. Review of the following menus revealed no record of the food served: March 5, March 10-12, March 17-18, March 26, March 31, April 1-2, April 7-8, April 14-15, April 21-22 and April 27-29.
3. During an interview, E1 acknowledged that the menus did not include the food to be served each day.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months.

Findings include:
1. Review of facility disaster plan review documentation indicated that the last review was conducted on June 11, 2020.
2. During an interview, E1 acknowledged that the documentation failed to reflect that a review had been conducted at least once every 12 months.

This is a repeat deficiency from the compliance inspection conducted on December 16, 2021.

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

Findings include:
1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that the last evacuation drill was conducted on October 1, 2022. No other evacuation drill documentation was available for review.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that documentation of the current fire inspection was maintained.

Findings include:
1. Facility fire inspection documentation indicated that the last fire inspection was conducted on May 14, 2019.
2. During a telephone interview with the local fire department it was determined that fire inspections are required annually.
3. During an interview, E1 acknowledged that the facility did not have documentation of a current fire inspection.
4. This is a repeat deficiency from the compliance inspection conducted on December 15, 2021.