BRIDGEWATER LA CHOLLA OPERATIONS, LLC

<p>Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, for three of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.</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 R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative.</p><p><br></p><p><br></p><p><br></p><p>2. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager.</p><p><br></p><p><br></p><p><br></p><p>3. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative.</p><p><br></p><p><br></p><p><br></p><p>4. In an interview, E1 and E2 acknowledged the service plans for R3, R5, and R7 were not signed as required by the resident or resident's representative. E2 took the unsigned service plans and met with each of the three resident’s and obtained resident signatures during the inspection. </p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record for seven of seven resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a 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 R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for September 2025. The document recorded the service provided and initials of the person who provided the service.  </p><p><br></p><p><br></p><p><br></p><p>2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; </p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and</p><p>- “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “AM/PM Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Bathing: Full Assistance”, on September 29, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025;</p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025;</p><p>- “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Dressing: Full Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Full Mobility Assistance (Every 3-6 Hours)”, on September 29, 2025, and October 1, 2025;</p><p>- “Grooming Moderate Assistance”, on September 29, 2025, and October 1, 2025; </p><p>- “Resident Laundry+Put Away”, on September 29, 2025; </p><p>- “Skin Evaluation”, on September 29, 2025; and </p><p>- “Toileting Assistance”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025;</p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and</p><p>- “Resident Laundry”, on September 29, 2025.</p><p><br></p><p><br></p><p><br></p><p>5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; </p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; </p><p>- “Resident Laundry+Put Away”, on October 1, 2025; and </p><p>- “Status Checks: 2 Hours”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>6. A review of R5's medical record revealed R5 received personal care level services. A review of R5's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “AM/PM Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Daily Housekeeping”, on September 29, 2025, and October 1, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; </p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025;</p><p>- “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Dressing: Limited Assistance”, on September 29, 2025, and October 1, 2025; and</p><p>- “Grooming Limited Assistance”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>7. A review of R6's medical record revealed R6 received personal care level services. A review of R6's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025;</p><p>- “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025;</p><p>- “Dressing: Limited Assistance”, on September 29, 2025, and October 1, 2025; and</p><p>- “Grooming Limited Assist”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>8. A review of R7's medical record revealed R7 received personal care level services. A review of R7's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025;</p><p>- “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; and</p><p>- “Toileting Assistance”, on September 29, 2025, and October 1, 2025.</p><p><br></p><p><br></p><p><br></p><p>9. In an interview, E1 and E2 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, and R7 did not contain accurate documentation of the services provided on September 29, 2025, and October 1, 2025, for seven of seven resident records reviewed.</p>

<p>Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of seven resident records reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.</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 R6's medical record revealed a service plan update, signed and dated November 1, 2024, for personal care services. A reviewed and updated service plan was required on or before May 31, 2025. However, no updated service plan was available for review.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged R6's service plan was not reviewed and updated at least once every six months. E2 further reported the system, that let them know when a service plan was due, in process, or completed, was not functioning properly and the facility was unaware it was unsigned.</p>

<p>Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, and the manager, for five of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.</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 an updated service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative.  </p><p><br></p><p><br></p><p><br></p><p>2. A review of R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative.</p><p><br></p><p><br></p><p><br></p><p>3. A review of R4's medical record revealed an initial service plan, for personal care level of services, dated July 6, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager.</p><p><br></p><p><br></p><p><br></p><p>4. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager.</p><p><br></p><p><br></p><p><br></p><p>5. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative.</p><p><br></p><p><br></p><p><br></p><p>6. In an interview, E1 and E2 acknowledged the service plans for R1, R3, R4, R5, and R7 were not signed as required by the resident or resident's representative and the manager. </p>

<p>Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for seven of seven resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a 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 R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for July 2025. The document recorded the service provided and initials of the person who provided the service.  </p><p><br></p><p><br></p><p><br></p><p>2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Bathing Limited Assistance”, on July 2 and 9, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on July 1, 2, 8, 9, 10, 11, 19, 22, and 24, 2025; </p><p>- “Daily Wellness Checks”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025;</p><p>- “Dining Moderate Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 24, and 25, 2025;</p><p>- “Dressing: Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025;</p><p>- “Grooming Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025;</p><p>- “Resident Laundry+Put Away”, on July 2 and 9, 2025;</p><p>- “Skin: Evaluation Assistance”, on July 9 and 19, 2025; and </p><p>- “Status Checks: 2 Hours”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025.</p><p><br></p><p><br></p><p><br></p><p>3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “AM/PM Assistance”, on July 19, 20, 26, and 27, 2025;</p><p>- “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Dining Limited Assistance”, on July 19, 20, 26, and 27, 2025;</p><p>- “Dressing: Full Assistance”, on July 19, 20, 26, and 27, 2025;</p><p>- “Full Mobility Assistance (Every 3-6 Hours)”, on July 19, 20, 26, and 27, 2025;</p><p>- “Grooming Moderate Assistance”, on July 19, 20, 26, and 27, 2025; and </p><p>- “Toileting Assistance”, on July 18, 19, 20, 23, 24, 25, 26, 27, and 28, 2025.</p><p><br></p><p><br></p><p><br></p><p>4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; and</p><p>- “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025.</p><p><br></p><p><br></p><p><br></p><p>5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; </p><p>- “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; and </p><p>- “Status Checks: 2 Hours”, on July 18, 19, 20, 23, 25, 26, and 27, 2025.</p><p><br></p><p><br></p><p><br></p><p>6. A review of R5's medical record revealed R5 received personal care level services. A review of R5's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “AM/PM Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Bathing Full Assistance”, on July 2 and 9, 2025;</p><p>- “Daily Housekeeping”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; </p><p>- “Daily Wellness Checks”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Dining Limited Assistance”, on July 12, 19, 20, 26, and 27, 2025;</p><p>- “Dressing: Moderate Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Grooming Limited Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; and</p><p>- “Resident Laundry+Put Away”, on July 20 and 27, 2025.</p><p><br></p><p><br></p><p><br></p><p>7. A review of R6's medical record revealed R6 received personal care level services. A review of R6's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Bathing Limited Assistance”, on July 19 and 26, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on July 19, 20, 26, and 27, 2025;</p><p>- “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Dining Limited Assistance”, on July 2, 19, 20, 26, and 27, 2025;</p><p>- “Dressing: Limited Assistance”, on July 2, 19, 20, 26, and 27, 2025; and</p><p>- “Grooming Limited Assist”, on July 2, 19, 20, 26, and 27, 2025.</p><p><br></p><p><br></p><p><br></p><p>8. A review of R7's medical record revealed R7 received personal care level services. A review of R7's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided:</p><p>- “Bathing Limited Assistance”, on July 20 and 27, 2025;</p><p>- “Daily Trash Removal and Bed Making”, on July 19, 20, 26, and 27, 2025;</p><p>- “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025;</p><p>- “Resident Laundry+Put Away”, on July 20 and 27, 2025; and</p><p>- “Toileting Assistance”, on July 18, 19, 20, 23, 24, 25, 26, 27, and 28, 2025.</p><p><br></p><p><br></p><p><br></p><p>9. In an interview, E1 and E2 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, and R7 did not contain accurate documentation of the services provided for seven of seven resident records reviewed.</p>

<p><span style="font-size: 10pt;">Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. </span><span style="font-size: 10pt; color: black;">The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">Findings include:</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">1. A review of R2’s medial record revealed a service plan which indicated R1 received directed care services, including medication administration. R2’s medical record contained a medication order for the following medications to be administered as indicated:</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">-“Brivact 50 MG TABLET, Take 2 tablets by mouth twice daily;” and</span></p><p><span style="font-size: 10pt;">-“Trihexyphenidyl 5 MG TABLET, Take one tablet by mouth every night at bedtime.”</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">2. Further review of R2’s medical record revealed a Medication Administration Record (MAR) which included sections for documenting the administration of Brivact and Trihexyphenidyl. The record reflected Brivact was administered as ordered during the month of January 2025; however, documentation revealed Brivact and Trihexyphenidyl were not administered during the following days and times:</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">Brivact:</span></p><p><span style="font-size: 10pt;">-January 12, 2025, at 5:00 p.m.;</span></p><p><span style="font-size: 10pt;">-January 13, 14 and 15, 2025, at 8:00 a.m., and 5:00 p.m.;</span></p><p><span style="font-size: 10pt;">-January 16, 2025, at 8:00 a.m.; and</span></p><p><span style="font-size: 10pt;">-January 17, 2025, at 8:00 a.m.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">Trihexyphenidyl:</span></p><p><span style="font-size: 10pt;">January 2, 3, 4, 5, and 6, 2025, at 8:00 p.m.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">3. R2’s medical record contained a document titled “Medication Exception Report,” for the month of January, 2025. The report documented “Medication not available” for the dates noted when Brivact, and Trihexyphenidyl were not administered.</span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;"> </span></p><p><span style="font-size: 10pt;">4. In an interview, E1 advised R2 had run out of Brivact and Trihexyphenidyl in January 2025, and the facility had been contacting the pharmacy attempting to obtain a refill of the medication. E1 reported documentation of efforts to contact R2’s pharmacy was unavailable for review. E1 advised documentation of efforts to contact R2’s physician to request a refill order or a discontinue order for R2’s Brivact and Trihexyphenidyl were unavailable for review. E1 agreed R1 had not been administered Brivact and Trihexyphenidyl in compliance with a medical order.</span></p><p><span style="font-size: 10pt;"><span class="ql-cursor"></span></span></p><p><br></p><p><span style="font-size: 10pt;">This is a repeat deficiency from the compliance/complaint inspection conducted October 4, 2024.</span></p>

Based on documentation review and interview, the manager failed to implement a policy and procedure to protect the health and safety of a resident that covered 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.

Findings include:

1. A review of facility policy and procedures, last reviewed November 4, 2024, revealed a policy titled "CL39 - Sudden, Intense, or Out of Control Behaviors." The policy outlined how care staff were to respond to a residents behaviors and stated all staff were to "...document the incident and notify all required parties and agencies."

2. A review of facility incident reports filed between October 1, 2024 and January 15, 2025 revealed six reports documenting the sudden, intense or out of control behavior of R1, R2, R3 or R4.

3. According to the report, dated October 18, 2024, one "case staff" observed R1 "hitting" "and scratching" another care staff member in the face. The report was authored by E3, but did not identify the second care staff member present during the incident.

4. A review of staff schedules revealed E3 and E4 were working together between 1:45 p.m. and 10:00 p.m., on October 18, 2024. A request was made to review the incident report documented by E4, however evidence of the report was unavailable for review.

5. A review of the incident report dated October 21, 2024, revealed R2 had been "having a heavy behaviors day...," and "...was being very verbally aggressive, combative, and argumentative with...staff." The report was submitted by E5, but did not identify any other care staff present.

6. A review of staff schedules revealed E5 and E6 were working together between 1:45 PM and 10:00 PM, on October 21, 2024. A request was made to review the incident report documented by E6, however evidence of the report was unavailable for review.

7. In an interview, E1 agreed staff did not document all incident reports as required, and the facility's policy had not been completely implemented.

Based on interview and document review, after the manager had 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 document the report made to a peace officer or to the adult protective services central intake unit. Furthermore, the manager failed to initiate and document an investigation of the suspected abuse, neglect, or exploitation within five working days. 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. In an interview, E1 reported Adult Protective Services (APS) had been to the facility at least twice between October 1, 2024 and January 17, 2025, to investigate allegations of abuse, neglect or exploitation. E1 indicated they had called APS in approximately November 2024 and reported suspected exploitation of R5. E1 added APS had responded to the facility in recent weeks to investigate an allegation of R5's missing property. E1 reported APS had been to the facility on an unknown day in January 2025 to investigate an incident of alleged abuse between R6 and R7.

2. A request was made to review documentation of the report to APS made by E1 as well as the documented investigation initiated by E1. However, evidence of such documentation was unavailable for review.

3. A review of facility incident reports filed between October 1, 2024 and January 15, 2025 did not reveal any incident reports involving suspected abuse, neglect, or exploitation of a resident.

4. According to O2, O1 had responded to the facility on December 17, 2024 to conduct an investigation involving R5.

5. A review of facility visitor sign in rosters revealed two representatives from Adult Protective Services (APS) responded to the facility on January 12, 2025.

6. A request was made to review the documented investigation initiated by E1 pertaining to the January 12, 2025 response by APS. E1 advised they had not initiated or documented any such investigation.

7. In an interview, E1 reported they had not documented their APS report in November as required by R9-10-803.J.3. E1 advised they had not initiated or documented any investigation of suspected abuse, neglect or exploitation as required by R9-10-803.J.5.

Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for six of six residents sampled for whom an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed six separate incident reports, filed between March and September 2024, in which emergency responders had been contacted, responded to the facility and then transported six separate residents to a hospital.

2. A request was made to view the documentation provided to the emergency responders as required by ARS 36-420.04. However, the documentation was unavailable for review.

3. In an interview, E1 advised required documentation was provided to emergency responders, but copies of documentation provided were maintained separately for each individual incident. E1 acknowledged a copy of the documentation given to the emergency responder for each resident was not available for review as required by ARS 36-420.04.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination influenza (flu) and pneumonia were offered every 12 months, for five of eight residents sampled. The deficient practice posed a health and safety risk of residents not having the knowledge of the availability of the vaccinations.

Findings include:

1. A review of R2's R5's, R6's and R7's (admitted 2022) medical records revealed evidence of documentation of the availability of the flu or pneumonia vaccine in 2023 was unavailable for review.

2. A review of R4's (admitted 2023) medical record revealed evidence of documentation of the availability of the flu or pneumonia vaccine in 2023 or 2024 was unavailable for review.

3. In an interview E1 acknowledged R2's, R4's, R5's, R6's and R7's medical record did not contain evidence of documentation of the availability of the flu or pneumonia vaccine being offered annually.

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 two of eight residents sampled. 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 R5's medical record revealed a current service plan which indicated R5 received personal care services and medication administration. Further review revealed a medication order, dated August 20, 2024, for "Diclofenac Sodium External Gel 1%, Apply 4g topically 4 times every day" In addition, R5's medical record contained a medication administration record (MAR) for September 2024. The document reflected Diclofenac was applied four times a day, at 7:00 AM, 11:30 AM, 4:30 PM and 8:30 PM, on September 1, 5 and 7. However, the medication was documented as not having been administered at 7:00 AM on September 3, 6, 8-10, and 29. In addition, the medication was documented as not having been administered at 11:30 AM on September 2, 3, 8, 9, 22, and 29. Furthermore, the medication was documented as not having been administered at 4:30 PM on September 2-4, 8, 9, 11-29, and 30. Lastly, the medication was documented as not having been administered at 8:30 PM on September 3, 4, 8, 9, and 11-30. R5's medical record also contained a medication order for "Allopurinol Oral Tablet 100 MG, take 1 tablet by mouth every day." R5's MAR reflected this medication was not administered as ordered on September 2-4, 6-10, 13-17, 20-30.

2. A review of progress notes for R5 revealed documentation on September 3, 17 and 22, 2024, indicating R5 was refusing application of Diclofenac. In addition, documentation on September 22, 2024 reflected "[R5] is still out of allopurinol waiting for the medication..." Documentation on September 25, 2024 indicated refills of R5's medications were requested from [Pharmacy 1], "specifically alopurinol (sic)." A second entry on September 25, 2024 read, "resident does not use [Pharmacy 1] despite what [R5's] profile says. MedTech says resident was using [Pharmacy 2]."

3. A review of R6's medical record revealed a current service plan which indicated R6 received personal care services and medication administration. Further review revealed a medication order, dated April 9, 2024, for "Bupropion HCL SR 40 MG Tablet, take 1 tablet by mouth once daily." In addition, R6's medical record contained a MAR for September 2024. The document indicated Bupropion HCL SR 100 MG tablet was not administered as ordered on September 4, 5, 8-12, 15-19, 23 or 24, 2024.

4. A review of R6's progress notes for the month of September revealed evidence of documentation describing why Bupropion HCL SR 100 MG tablet was not administered as ordered was unavailable for review.

5. In an interview E1 acknowledged R5 and R6 were not being administered medication as ordered.

Based on observation, record review, and interview, for one resident storing medications in their room, the manager failed to ensure the medication was stored according to the resident's service plan. The deficient practice posed a risk to the health and safety of the residents if the medications were accessible to other residents.

Findings include:

1. During a tour of the facility, the Compliance Officer observed the following medications being stored inside an unsecured medicine cabinet, in R14's residential unit:
"-over the counter Acetaminophen caplets 500 mg;"
"-Fluticasone 50MCG Nasal SP (120) RX;"
"-90 mcg Albuterol" rescue inhaler; and
"-Prednisolone Acetate ophthalmic suspension, USP 1%."

2. A review of R14's medical record revealed a current service plan which indicated R14 received personal care services, including medication administration. The service plan indicated "[R14] requires the assistance of one nurse or certified caregiver with the administration of medication..." However, the service plan did not include documentation to indicate medication was to be stored in R14's residential unit.

3. In an interview, E1 agreed R14's medications were stored in an unlocked manner and not stored according to R14's service plan.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency or injury and needed medical services, as required per R9-10-818.D.2.

Findings include:

1. A review of facility documentation from July 2024 through August 2024 revealed three incident reports documenting accidents, emergencies or injuries where 911 was contacted. A review of the incident report dated August 14, 2024 revealed the report involved a resident experiencing chest pain, and contained most documentation required required per R9-10-818.D.2. The report included a section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future, however the section was not completed. A review of the incident report dated August 25, 2024 revealed the report involved a resident having difficulty transferring themselves and complaining of "numb" legs. The report contained most documentation required required per R9-10-818.D.2, however, the section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future was not completed. A review of the incident report dated September 14, 2024 revealed the report involved R8 and described a head injury sustained after an unwitnessed fall. The section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future did not contain any evidence of documentation of action taken to prevent the incident from occurring in the future.

2. In an interview, E1 agreed the incident reports did not contain all documented required per R9-10-818.D.2.

Based on observation, document review and interview, the manager failed to ensure the premises was cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.

Findings include:

1. During a tour of the facility the Compliance Officer observed a kitchen area which contained a refrigerator used for storing food and snacks for residents. The bottom of the refrigerator was stained with spilled liquids which were dark in color. The Compliance Officer also observed a cabinet which contained a metal cooking sheet. The bottom of the cooking sheet was covered with food particles including rice and what appeared to be dried carrots, as well as an oily looking substance which had pooled in the corner of the pan. In a cabinet, under a kitchen sink, the Compliance Officer observed what appeared to be a dried piece of meat, possibly poultry.

2. A review of facility policy and procedures, last reviewed December 2023, revealed a policy titled, "Environmental Standards." The policy read, in part, "1. Staff will clean and if necessary, disinfect, equipment according to established policies or manufactures' recommendations in order to prevent, minimize, and control illness or infection..."

3. In an interview, E1 reported acknowledged the kitchen area, including the refrigerator and cabinets, was not being kept clean.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During a tour of the facility, the Compliance Officer observed no fewer than ten ambulatory residents, and the following:

A cabinet located under the kitchen sink accessible to visitors and residents, which was not equipped with any type of device to prevent unauthorized access. The Compliance Officer was able to open the cabinet with little effort and observed one spray bottle of "Zep Spirit II detergent Disinfectant," one can of "Comet," scouring powder, and an aerosol can of "ECOLAB Stainless Steel Cleaner & Polish." Each container was marked, "KEEP OUT OF REACH OF CHILDREN;" and

In a cabinet located under a second kitchen sink accessible to visitors and residents, which was equipped with a child safety locking mechanism. However, the locking mechanism was broken and the Compliance Officer was able to open the cabinet with little effort. Inside, the Compliance Officer observed a spray bottle of "Lysol Bleach Multi-Purpose Cleaner," a spray bottle of "Clorox Tilex Mold & Mildew" cleaner and a spray bottle of "Hillyard Non-Acid Restroom Disinfectant/Cleaner." All bottles were marked, "KEEP OUT OF REACH OF CHILDREN." In addition, another spray bottle was observed with no label indicating the contents of the bottle. The bottle contained an unidentified, purple/pink in color liquid.

An office door was observed to be closed and affixed with a handle which locked with a key. However, the lock was not engaged and the Compliance Officer was able to open the door with little effort. Inside the office, the Compliance Officer observed a bookshelf which held a can of "Raid Ant & Roach" insecticide. Also observed was a spray can of "Hydro Balance Zip Clean Evaporator Coil Cleaner." The cleaner label read, "DANGER: CAUSES SEVERE SKIN BURNS AND EYE DAMAGE."

A laundry room door was observed to be affixed with a locking handle which required a numerical code to open. However, the lock was not engaged and the Compliance Officer was able to open the door with little effort. The locking mechanism on the inside of the door was equipped with a thumb turn lock which had been disengaged, allowing the door to be opened without entering the code. The Compliance Officer observed a cabinet under the sink which was not equipped with a locking mechanism and the Compliance Officer was able to open the cabinet with little effort. Inside was a bottle of "Jazzle Liquid Laundry Bleach."

2. In an interview, E1 advised the office belonged to the facility's plant manager and should have been locked; E1 locked the office door upon leaving the room. E1 said the laundry room should have been locked as well. E1 agreed the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure a dog or cat allowed in the facility was vaccinated against rabies.

Findings include:

1. A review of facility's pet records revealed no documentation of current vaccination against rabies was available to review for the following:
- cats, C1 and C2, who were living at the facility with R9;
- cats C3 and C4 who were living at the facility with R10;
- cat C5 who was living at the facility with R11;
- cat C6 who was living at the facility with R12; and

2. A review of facility's pet records revealed documentation of rabies vaccination for dog, D1 had expired on June 7, 2023. No evidence of current vaccination against rabies was available for review. D1 was living at the facility with R13.

3. In an interview, E2 acknowledged there was no current documentation available to ensure C1, C2, C3, C4, C5, C6 and D1 were vaccinated against rabies.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On October 31, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- Documentation of E6's valid Cardiopulmonary resuscitation training and first aid certification;
- Documentation of E2 and E4's skills and knowledge;
- Documentation of E6's valid fingerprint clearance card or good cause exception;
- Documentation of R2, R4, R5, R6, R7, R8, R9, and R10's signed service plans;
- Documentation of disaster plan review; and
- Documentation of evacuation drills with employees and residents.

2. In an interview, E1, and E8 acknowledged this information was not provided to the Compliance Officer within two hours after a Department request .

This is a repeat citation from the complaint inspections conducted on January 26, 2023, and May 30, 2023.

Based on record review, documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for two of four caregivers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. The Compliance Officer requested the skills and knowledge checklist list for the following caregivers E2, E3, E4, and E5.

2. A review of E2 and E4's personal records revealed no documentation of skills and knowledge was available for review. E1 reported being unable to locate these documents.

3. In an interview, E1 acknowledged these documents were unavailable for review.

This is a repeat citation from the complaint survey conducted on on January 26, 2023.

Based on record review, documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four caregivers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. A review of E5's personnel record revealed that E5 was hired as a caregiver in March 2023.

2. A review of documentation revealed E5 had a first aid training and cardiopulmonary resuscitation training certification issued by Save A Life from Tucson Fire Department, however, the certification expired May 10, 2023. No other documentation was provided during the compliance inspection to show E5 had valid first aid training and cardiopulmonary resuscitation training certification.

3. A review of staffing schedules revealed that E5 was scheduled to work on the following days: October 2, 3, 4, 5, 8, 9, 10, 11, 14, 22, 23, 23, 25, 29, and 31, 2023.

4. In an interview, E1 reported calling E5, however, E5 never returned E1's call while the Compliance Officer was on-site.

This is a repeat citation from the complaint surveys conducted on January 26, 2023, and May 30, 2023.

Based on record review, documentation review, observation, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C), for three of three personnel sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. A.R.S. \'a7 36-411 states, "... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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.". And A.R.S. \'a7 36-411(C) states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card."

2. A review of documentation titled " Arizona Team Member Fingerprinting Policy & Procedures" revealed "All team members must employed in the state of Arizona will maintain a valid Fingerprint Clearance Card as conducted by the Arizona Department of Public Safety. .... Copies of all documents pertaining to background checks will be kept in the employee's personnel file in the Business Office. .... 4. If any employee's fingerprint clearance card is denied or suspended, they will notify the community immediately. 5. If the employee is to eligible to file a good cause exception, the employee will be terminated effective immediately. 6. If the employee is eligible to file for a good cause exception, the community will maintain documentation of the good cause exception paperwork and process. The employee will be permitted to continue to work under the direct supervision of an employee with a valid fingerprint clearance card, while the good cause exception paperwork is reviewed. Every 30 days the employee's performance and job capabilities will be reviewed by a member of the management team. An employee will be permitted to work for a maximum of 90 days while applying for a good cause exception".

3. A review of E6's personnel record revealed an application from the Arizona Department of Public Safety for a fingerprint clearance card. The application was dated June 20, 2023, which was within the twenty days of E6's employment, however, the Compliance Officer observed a handwritten note attached to the application "July 13 - notice of not valid [E6] did not receive - as of 10/9 [E6] is contacting to follow up". The Compliance Officer did not find a copy of a request for good cause exception in E6's personnel record. E1 reported E6 is still employed by the facility and is not working under the direct supervision of another employee with a valid fingerprint clearance card.

4. In an interview, E1 reported E6 was working on the good cause exception, however, E1 did not provide any documentation to show E6 had requested a good cause exception.

5. During an interview E1 reported E6 is a housekeeper. The Compliance Officer requested E6's schedule, E1 reported the facility has two housekeepers and they do not have a printed-out schedule they work Monday through Friday from 7:30 am until 5:00 pm. No other documentation was provided to the Compliance Officer while on-site to show that E6 had a valid fingerprint clearance card.

6. A review of E6's personnel record revealed a document titled "Employment Application" with a signed date of May 2023. The Compliance Officer observed a document titled "Reference Check Form, however, the document was blank no evidence of documentation of contact with E6's previous employers to obtain information or recommendations that may be relevant to E6's fitness to work in a residential care institution.

7. A review of E4's personnel record revealed a document titled "Employment Application" with a signed date of May 2023. The Compliance Officer observed a document titled "Reference Check Form, however, the document was blank no evidence of documentation of contact with E4's previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution.

8. A review of E5's personnel record revealed no documentation of an application of employment or documentation of contact with E5's previous employers to obtain information or recommendations that may be relevant to E5's fitness to work in a residential care institution.

9. In an interview E1, acknowledged E6 did not have a valid fingerprint clearance card, and reported being unaware the reference documentation was not in the personnel records for E4 and E5.

Based on record review, documentation review, and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated was signed and dated by the resident's representative, the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for seven of nine directed care residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. A review of R2's medical record revealed a service plan dated June 16, 2023, which indicated R2 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing:

- The resident's representative had not dated or signed this document.

2. A review of R4's medical record revealed a service plan dated August 1, 2023, which indicated R4 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing:

- The resident's representative; and
- The manager.

3. A review of R5's medical record revealed a service plan dated September 28, 2023, which indicated R5 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing:

- The resident's representative;
- The manager;
- If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
- If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

4. A review of R6's medical record revealed a service plan dated August 9, 2023, which indicated R6 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing:

- The resident or resident's representative;
- The manager;
- If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
- If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

5. A review of R7's medical record revealed a service plan dated July 19, 2023, which indicated R7 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing:

- The resident or resident's representative.

6. A review of R8's medical record revealed a service plan dated August 1, 2023, which indicated R8 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing:

- The manager;
- If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
- If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan

7. A review of R9's medical record revealed a service plan dated June 12, 2023, which indicated R9 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing:

- The resident or resident's representative.

8. In an interview, E1 acknowledged the service plans provided did not have the required signatures and date.

This is a repeat citation from the complaint inspection conducted on May 30, 2023.

Based on documentation review, and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

A.A.C. R9-10-818.A.3. states, "A manager shall ensure that documentation of the disaster plan review required in subsection (A)(2) includes:

a. The date and time of the disaster plan review;
b. The name of each employee or volunteer participating
in the disaster plan review;
c. A critique of the disaster plan review; and
d. If applicable, recommendations for improvement"

1. A review of facility documentation revealed no evidence of an annual disaster plan review.

2. In an interview, E1 acknowledged an annual disaster plan review was not available for review.

This is a repeat citation from the compliance survey conducted on October 3, 2022.

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. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. A review of facility documentation revealed no documention was available to review to show an evacuation drill for employees and residents was conducted at least once every six months.

2. In an interview, E1 acknowledged documentation of evacuation drills had not been provided to the Compliance Officer upon request.

Technical assistance was given on the last compliance inspection completed October 3, 2022.

Based on documentation review, record 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.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, "Fall Prevention." This policy contained information on fall prevention and fall recovery.

2. A review of E2, E3, E4's personnel records revealed no documentation indicating the employees had reviewed or received the fall prevention and fall recovery training.

3. In an interview, E1,acknowledged E2, E3, and E4 did not have documentation that they reviewed or received the fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On August 28, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- Skills and knowledge checklist for E2;
- Personnel record for E2; and
- Documentation of fall prevention and fall recovery training for E2, E3, and E4.

2. In an interview, E1, acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request.

Technical assistance was provided during the on-site compliance inspection conducted on May 30, 2023.

Based on observation, record review, and interview, the manager failed to ensure the facility caregivers demonstrated they had the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. For one of three caregivers sampled.

Findings include:

1. The Compliance Officer requested a copy of the staffing roster. The Compliance Officer observed that E2 had a hire date of May 20, 2023, and a title of "Care Specialist". E1 reported a Care Specialist is a caregiver.

2. The Compliance Officer requested the personnel records for E2, E3, and E4. The Compliance Officer received E3, and E4's, however, E1 was unable to locate a personnel record for E2.

3. The following documentation was unavailable for review:

- Qualifications, experience, skills, and knowledge checklist;
- A caregiver certification, from a school approved by the NCIA Board;
- CPR or First Aid certification which included a demonstration;
- Fingerprint clearance card; and
- TB documentation.

4. A review of staffing schedules revealed that E2 was scheduled to work on July 8, 15, 29, 2023, and August 5, 19, and 26 2023.

5. In an interview, E1 acknowledged that E2 did not have documentation of qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included the individual's name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education required by policies and procedures, the individual is a behavioral health technician, clinical oversight required in R9-10-115, cardiopulmonary resuscitation training, First aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) for one of three personnel members sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs.

A.A.C. R9-10-101(165) states a "Personnel member" means, "except as defined in specific Articles of this Chapter and excluding medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services."

Findings include:

1. The Compliance Officer requested a copy of the staffing roster. The Compliance Officer observed that E2 had a hire date of May 20, 2023, and a title of "Care Specialist". E1 reported a Care Specialist is a caregiver.

2. The Compliance Officer requested the personnel records for E2, E3, and E4. The Compliance Officer received E3, and E4's, however, E1 was unable to locate a personnel record for E2.

3. A review of staffing schedules revealed that E2 was scheduled to work on July 8, 15, 29, 2023, and August 5, 19, and 26 2023.

4. In an interview E1 acknowledged being unable to locate a personnel record for E2.

Based on documentation review, record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of six residents sampled.

Findings include:

1. A review of documentation provided by O1, a Registered Nurse (RN) for Mercy Care of Arizona revealed the following; "The member did not receive scheduled pain medication because it was not available at Bridgewater Assisted Living Facility. On the medication administration record from the facility, it shows that on July 19, 2023, and July 20, 2023, Morphine Sulfate 15 mg was not given to member due to refills not being processed per protocol".

2. A review of documentation revealed that R6 was receiving personal care services and medication management from the facility, and was a member receiving services from Mercy Care of Arizona.

3. A review of R6's medical record revealed a signed medication order dated June 1, 2023 - June 30, 2023. This medication order included:

- Morphine Sulfate ER 15 mg, Take 1 tablet by mouth every 8 hours for chronic pain.

4. A review of R6's medication administration record (MAR) revealed R6 was not given Morphine Sulfate ER 15 mg for pain as ordered by R6's physicians on the following dates:

- June 19, 2023, 4:00 PM, Exceptions: "waiting on doctor sent new order to the pharmacy";
- June 20, 2023, 12:00 AM, Exception: "not recorded"
- June 20, 2023, 8:00 AM, Exceptions: "waiting on pharmacy";
- June 20, 2023, 4:00 PM, Exceptions: "medication has not arrived yet"; and
- June 21, 2023, 12:00 AM, Exceptions; "resident got this med as soon as this came a little bit after 10 PM when it was delivered".

5. A review of documentation revealed a document titled "Medication Refills". It states "1. The Nurse/Med Tech on duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication unless medication is on a cycle refill with the pharmacy. .... 3. Nurses/Med Techs work to ensure medications are not allowed to run out, unless directed to do so by the physician. This is done by coordinating refills with the pharmacy and responsible party. .... 4. Each shift of Nurses/Med Techs is responsible to make any necessary reminder and follow up calls to assist with receipt of medications".

6. In an interview, E1 reported the medication was faxed to "Korman Pharmacy" to be filled on Friday before the medication ran out. The Compliance Officer observed that date to be June 16, 2023.

7. In an interview, E1 acknowledged the medications were not administered to R6 in compliance with a medication order.

Technical assistance was provided during the on-site compliance inspection conducted on May 30, 2023.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On May 30, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- Documentation of E2's first aid documentation;
- Documentation of E3's CPR documentation;
- Documentation of E2, and E3's qualifications, including skills and knowledge applicable to the individual's job duties;
- Documention of investigations and incident reports; and
- Documentation of exceptions for medication from the MAR report.

2. In an interview, E1, reported unable to locate this information and acknowledged it was not provided to the Compliance Officer within the two hours after a Department request.

This is a repeat citation from the compliance survey conducted on January 26, 2023.

Based on record review, documentation review and interview, after the manager had 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 document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse, and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Findings include:

1. A review of the facility's policy and procedures revealed "Abuse, Neglect, or Exploitation Prevention and Reporting" the document stated " .... If a manager has a reasonable basis to believe abuse, neglect, or exposition of a resident has occurred on the premises or while the resident is receiving services from Solterra'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 State rules and regulations;
3. Document the suspected abuse, neglect, or exploitation. Document the report made of the suspected behavior according to State rules and regulations. This document will be maintained for at least (12) months after the date of report.
4. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five (5) working days after the report that includes:
a. 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.
d. The actions taken by the manager to prevent the alleged or suspected abuse, neglect, or exploitation in the future.
e. Submit a copy of the investigation report required in subsection four to ADHS within ten (10) working days after submitting the report in subsection two.
f. Maintain a copy the documented information required in subsection four for twelve (12) months after the date of the investigation".

2. A review of documentation provided by Adult Protective Services (APS) revealed an incident involving R7 and caregiver E5 on March 10, 2023, and May 12, 2023. The facility was notified of the allegations of abuse by APS.

3. In a telephonic interview with O2 from APS the facility had reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises. O2 had been to the facility and completed an investigation on these allegations involving R7, and E5.

4. A review of documentation provided by Adult Protective Services (APS) revealed a report of abuse involving R13. According to the report APS notified the facility and interviewed R13 on May 17, 2023.

5. A review of documentation provided by E1 titled "Internal Incident Report" dated May 7, 2023, revealed an incident occurred between R13 and E3. The document included the following: The date of the incident, a description of the incident, a family member was notified, however no name of the family member, the RCC was notified and the ED. The following information was missing from the document: Initiate an investigation, times, any injury, any witnesses, the actions taken by the manager to prevent the suspected abuse from occurring in the future.

6. A review of documentation provided to the department by E1 with an incident date of May 16, 2023, revealed a self-report of an incident involving R13 and E3. The Compliance Officer requested a copy of the investigation of alleged abuse involving R13 and E3. E1 reported not having any documentation available to review.

7. A review of documentation provided by Adult Protective Services (APS) revealed on March 13, 2023, an incident involving R12 and an unknown caregiver. R12 reported being abuse by a caregiver. The Compliance Officer asked E1 for the documentation on this investigation. E1 reported not having any documentation available to review.

8. A review of documentation provided by The Adult Protective Services (APS) revealed on March 17, 2023, an incident involving R14 and E2. R14 reported being abused by E2. A review of Pima County Sheriff's Department documentation revealed an Officer came out to the facility to do a report. The Compliance Officer asked E1 for the documentation on this investigation. E1 reported not having any documentation available to review.

9. A review of documentation provided by Adult Protective Services (APS) revealed on March 31, 2023, an incident involving R14 and a caregiver. R14 reported being abused by unknown caregiver. The Compliance Officer asked E1 for the documentation on this investigation. E1 reported not having any documentation available to review.

10. In an interview, E1 reported APS had been out to investigate these allegations. E1 acknowledged no documentation was available to review on these investigations.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, and according to policies and procedures for two of six caregivers sampled.

Findings include:

1. A documentation review of the facility's policies and procedures revealed a policy titled, "Personnel Records". The policy stated, " ... 3. Documentation of the individual's qualifications, including skills and knowledge applicable to their job duties".

2. A review of E2's personnel record revealed no documentation of skills and knowledge applicable to their job duties.

3. A review of E3's personnel record revealed no documentation of skills and knowledge applicable to their job duties.

4. In an interview E1, acknowledged E2, and E3 did not have documentation of skills and knowledge applicable to their job duties in their personnel record and unavailable for review.

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation training certification for two of seven caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E2's documentation revealed E2 was hired as a caregiver from Preferred Staffing Agency.

2. A review of E2's documentation revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The course was taken on June 16, 2022.

3. An on-line search of National CPR Foundation revealed this is an on-line course. Current documentation of cardiopulmonary resuscitation training was unavailable for review at the time of the inspection.

4. A review of E3's documentation revealed E3 was hired as a caregiver from Nurse Corp Staffing Agency.

5. A review of E3's documentation revealed a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" dated July 30, 2022, with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection.

6. A review of a policy's and procedures revealed a policy titled "Certified Care Specialist" revealed "Qualifications .... current CPR and First Aid Certifications", and "Personnel Records" this document stated "When applicable, the personnel files for each team member or volunteer will contain the following:

- Cardiopulmonary resuscitation training, if required for the individual in this article or by policy and procedure; and
- First aid training, if required for the individual in this Article or policies and procedures.

7. In an interview, E1, reported being unaware E2 and E3 did not have the proper documentation of CPR and first aid training.

This is a repeat citation from the compliance survey conducted on January 26, 2023.

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 and the manager, when initially developed and when updated, for eight of eight residents sampled.

Findings include:

1. A review of R7's medical record revealed a service plan dated December 30, 2022, and one from May 9, 2023. The service plans revealed R7 was receiving directed care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident's representative, and
- was not signed and dated by the manager.

2. A review of R11's medical record revealed a service plan dated February 14, 2023, and one from May 8, 2023. The service plans revealed R11 was receiving directed care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident's representative, and
- was not signed and dated by the manager.

3. A review of R12's medical record revealed a service plan dated December 29, 2022, and one from March 9, 2023. The service plans revealed R12 was receiving directed care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident's representative, and
- was not signed and dated by the manager.

4. A review of R13's medical record revealed a service plan dated December 30, 2022. The service plan revealed R13 was receiving directed care services. However, the service plan was not signed and dated by the following:

- was not signed or dated by the resident's representative, and
- was not signed and dated by the manager.

5. A review of R15's medical record revealed a service plan dated March 31, 2023. The service plan revealed R12 was receiving directed care services. However, the service plan were not signed and dated by the following:

- was not signed or dated by the resident's representative, and
- was not signed and dated by the manager.

6. A review of R9's medical record revealed a service plan dated December 29, 2022, and one dated February 12, 2023. The service plans revealed R14 was receiving personal care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident or the resident's representative, and
- was not signed and dated by the manager.

7. A review of R10's medical record revealed a service plan dated January 10, 2023. The service plan revealed R10 was receiving personal care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident or the resident's representative, and
- was not signed and dated by the manager.

8. A review of R14's medical record revealed a service plan dated December 23, 2022, and one dated March 20, 2023. The service plans revealed R14 was receiving personal care services. However, the service plans were not signed and dated by the following:

- was not signed or dated by the resident or the resident's representative, and
- was not signed and dated by the manager.

9. In an interview, E1 acknowledged the service plans had not been signed or dated by the residents or resident's representative, and had not been signed and dated by the manager.

Based on observation, record review, and interview the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies for two out of two directed care residents sampled. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. In an interview, the Compliance Officer asked E1 how the resident alert employees to their needs or emergencies. E1 reported using wrist bands that when pushed alert the caregivers to their needs.

2. During a facility tour with E1, the Compliance Officer observed a group of residents sitting and talking in the dining room. The Compliance Officer asked R7 to push R7's wrist band. When pushed it did not alert a caregiver. When E1 called the caregiver on the walk-ie talk-ie the caregiver came to check the wrist band. The battery was low and did not alert the caregiver.

3. The Compliance Officer asked R9 to push R9's wrist band. R9's wrist band was working it alerted the caregiver.

4. The Compliance Officer asked R13 to push R13's wrist band. R13's wrist band did not alert the caregiver.
The battery was low and did not alert the caregivers.

5. The Compliance Officer observed R3 in R3's room. The Compliance Officer asked R3 to push R3's wrist band to alert the caregivers. R3 lifted up R3's arm and stated I don't know where it is I can't find it. E1 looked around R3's room and was unable to locate the wrist band. E1 called a caregiver to ask if they knew where R3's wrist band was, the caregiver reported unable to locate the wrist band. R3 did not have bell, intercom, or other means to alert employees to needs or emergencies.

6. In an interview, E1 acknowledged the wrist bands for R7, R13 had a low battery and were not working, and R3 did not have a bell, intercom, or other means to alert employees to needs or emergencies.

Based on documentation review, record review, observation and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for five of seven residents sampled.

Findings include:

1. A review of documentation provided by O3, a Registered Nurse (RN) for Mercy Care of Arizona revealed R1 was not given medications as ordered by R1's physicians on the following dates:

- Gabapentin 300 mg TID, on February 7, 2023;
- Nystatin ointment BID, on February 2, 2023; and
- Zinc Oxide 20 % ointment BID, on February 4, 2023.

2. A review of documentation revealed R1 was receiving personal care services and medication management from the facility.

3. A review of R1's medical record revealed a signed medication order dated February 1, 2023 - February 31, 2023. This medication order included:

- Amlodipine Besylate 10 MG tablet, take one tablet once a day;
- Aripiprazole 30 MG tablet, take 1 tablet once a day;
- Carvedilol 25 MG Tablet, Take 1 tablet twice daily with food;
- Chlorhexidine 0.12% Rinse with 1/2 ounces by mouth daily for 14 days;
- Duloxetine HCL DR 60 MG Cap; take 2 capsules once daily
- Gabapentin 300 MG TID, Take 1 capsule three times daily;
- Lisinopril 10 MG Tablet, Take 1 tablet once daily;
- Loratadine 10 MG tablet, take 1 tablet once daily;
- Nystatin ointment BID; Apply topically to affected area twice daily for 30 days;
- Oxybutynin 5 MG tablet; Take 1 tablet three times daily;
- Pantoprazole DR 40 MG tablet, Take 1 tablet once daily:
- Stool Softener 100 MG table, Take 1 tablet twice daily; and
- Zinc Oxide 20 % ointment BID, apply topically to affected area twice daily.

3. A review of R1's medication administration record (MAR) dated February 2023, revealed the following medications were shaded darker in a box marked "Key"/ "Exception". The Compliance Officer asked E1 what "Key/Exception" meant. E1 reported the medications were not given when scheduled, which is the documented time on the MAR, one hour before the medication is schedule or one hour after the medication is scheduled. The shaded box meant the medication was not given at the prescribed time. E1 reported at the end of the MAR there is a page with the exceptions where it explains why the medications were not given when schedules. A review of the last pages of the MAR revealed no documentation on the explanation why these medications were not administered in compliance with the physician's order. The following medications were not given as ordered:

- Amlodipine Besylate 10 MG tablet, on February 21, and 28, 2023 at 8:00 AM;
- Aripiprazole 30 MG tablet, on February 21, and 28, 2023 at 8:00 AM;
- Carvedilol 25 MG Tablet, on February 21, and 28, 2023, at 8:00 AM;
- Chlorhexidine 0.12% Rinse, February 21, and 28, 2023, at 8:00 AM;
- Duloxetine HCL DR 60 MG Cap; February 21, and 28, 2023, at 8:00 AM;
- Gabapentin 300 MG TID, February 21, and 28, 2023, at 8:00 AM, and February 7 2023, at 5:00 PM;
- Lisinopril 10 MG Tablet, February 21, and 28, 2023, at 8:00 AM;
- Loratadine 10 MG tablet, February 21, and 28, 2023, at 8:00 AM;
- Nystatin ointment BID; February 12, 21,24, and 26 at 8:00 AM, and February 2, and 12, 2023 at 5:00 PM;
- Oxybutynin 5 MG tablet; February 21, and 28 2023, at 8:00 AM;
- Pantoprazole DR 40 MG tablet, February 21, and 28, 2023;
- Stool Softener 100 MG table, February 19, 21, 23, 25, 26, 28, 2023 at 8:00 AM, and February 2,17,19, and 26, 2023 at 5:00 PM; and
- Zinc Oxide 20 % ointment BID, February 4, 6, 17, 21, 24, 28, 2023.

No documentation on MAR exceptions were available for review.

4. A review of documentation provided by O3, a Registered Nurse (RN) for Mercy Care of Arizona revealed R2 was not given medications as ordered by R2's physician on the following dates:

- Desvenlafaxine Succinate ER 25 MG, on February 9, 2023;
- Nystatin 100, 00-unit powder, on February 7, 8,9, 14 19, 2023;
- Levemir 50 units BID AM, February 7, 8, 9, 2023;
- Sertraline HCL 25 MG tablet, February 6, 7, 9, 2023; and
- Clonazepam 1 MG tablet, February 3, 2023, marked not given.

5. A review of documentation revealed R2 was receiving personal care services and medication management from the facility.

6. A review of R2's medical record revealed a signed medication order dated February 1, 2023 - February 31, 2023. This medication order included:

- Desvenlafaxine Succinate ER 25 MG, Take 1 tablet daily for 14 days;
- Nystatin 100, 00-unit powder, apply topically to affected area twice daily;
- Sertraline HCL 25 MG tablet, Take 1 tablet once daily;
- Clonazepam 1 MG tablet, Take 1 tablet once daily;
-Levothyroxine 100 MCG tablet, Take 1 tablet once daily on empty stomach;
- Levemir 50 units BID AM, Inject 50 units subcutaneously twice daily morning and bedtime; and
- Furosemide 40 MG tablet, Take 1 tablet once daily for seven days (February 3 -9).

6. A review of R2's medication administration record (MAR) dated February 2023, revealed the following medications were shaded darker in a box marked "Key"/ "Exception", and were not administered in compliance with the physician order. The following medications were not given as ordered:

- Desvenlafaxine Succinate ER 25 MG, on February 9, 2023;
- Nystatin 100, 00-unit powder, on February 9, 2023;
- Sertraline HCL 25 MG tablet, February 7, 8, 9, 14, 2023;
- Clonazepam 1 MG tablet, February 3, 2023, was marked not given;
- Levothyroxine 100 MCG tablet, February 17, 20, 2023;
- Levemir 50 units BID AM, and PM, February 7, 8, 9, 2023; and
- Furosemide 40 MG tablet, February 9, 2023.

No documentation on MAR exceptions were available for review.

7. A review of documentation provided by O3, a Registered Nurse (RN) for Mercy Care of Arizona revealed R3 was not given medications as ordered by R3's physician on the following dates:

- Mupirocin 2% ointment BID, February 6, 7, 2023;

8. A review of documentation revealed R3 was receiving personal care services and medication management from the facility.

9. A review of R3's medical record revealed a signed medication order dated February 1, 2023 - February 31, 2023. This medication order included:

- Mupirocin 2% ointment BID, apply topically to affected area twice a daily; and
The following medications were never recorded as given:
- Atorvastatin 40 MG tablet, take 1 tablet once daily;
- Bupropion HCL XL 150 MG tablet, take 1 tablet once daily;
- Aspirin 81 MG Chewable tablet, February 15, 2023, at 8:00 AM
- Citalopram HBR 40 MG tablet AM, take 1 tablet once daily;
- Divalproex SOD DR 500 MG tablet AM, take 1 tablet every 12 hours;
- Lisinopril 20 MG tablet AM, take 1 tablet once daily; and
- Mupirocin 2% ointment, apply topically to affected area twice daily.

10. A review of R3's medication administration record (MAR) dated February 2023, revealed the following medications were shaded darker in a box marked "Key"/ "Exception", and were not administered in compliance with the physician order.

- Mupirocin 2% ointment BID, February 6, 21 2023, at 8:00 AM, and February 6, 7, 2023, at 5:00 PM; and
The following medications were never recorded as given:
- Mupirocin 2% ointment BID, February 15, 2023 at 8:00 AM;
- Atorvastatin 40 MG tablet, February 15, 2023 AM;
- Bupropion HCL XL 150 MG tablet, February 15, 2023, at 8:00 AM;
- Aspirin 81 MG Chewable tablet, February 15, 2023, at 8:00 AM;
- Citalopram HBR 40 MG tablet AM, February 15, 2023, at 8:00 AM;
- Divalproex SOD DR 500 MG tablet AM, February 15, 2023, at 8:00 AM; and
- Lisinopril 20 MG tablet AM, February 15, 2023, at 8:00 AM.

No documentation on MAR exceptions were available for review.

11. A review of documentation provided by O3, a Registered Nurse (RN) for Mercy Care of Arizona revealed R4 w

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency or injury resulting in the resident needing medical services a manager shall ensure a caregiver or assistant caregiver documents the date and time of the accident, emergency, or injury, a description of the accident, emergency, or injury, the names of individuals who observed the accident, emergency, or injury, the actions taken by the caregiver or assistant caregiver, the individuals notified by the caregiver or assistant caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future.

Findings include:

1. A review of documentation provided to the Department by the Adult Protective Services (APS) dated March 23, 2023, revealed R9 had bruises and a skin tear on the right arm. It was undetermined how the skin tear happened however, R9 needed medical services. The Compliance Officer asked E1 for a copy of the incident report for R9. E1 reported unable to locate the documentation.

2. In an interview, E1 acknowledged an incident report for R9 was unavailable for review.

Based on documentation review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On January 19, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- documented skills and knowledge verified for E3 and E5.

However, this documentation was not provided.

2. In an interview, E1 acknowledged this information was not provided to the compliance officer within the two hours requested.

Based on documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for two of three caregivers reviewed.

Findings include:

1. The Compliance Officer requested the skills and knowledge checklist list for the following caregivers E3, E4, and E5. O1 reported not having access to these files due to the Resident Care Coordinator (RCC) was out of the building.

2. A little while later the Compliance Officer received a document titled "Assistant Caregiver Skills Checklist". This document had E4's name on it and was dated one day after E4's hire date. E3 and E5's skills and knowledge check list were not provided to the Compliance Officer to review while onsite.

3. In an interview, E1 acknowledged these documents were unavailable for review.

Based on documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E6's personnel record revealed E6 worked as a caregiver from a caregiver agency. The Compliance Officer observed the following: "CPR/AED/First Aid card ... National CPR Foundation (CPR). Valid for 2 years" This CPR/first aid certification was dated November 19, 2020. This would make this certification expired on November 19, 2022.

2. An on-line search of the National CPR Foundation revealed this is an on-line course only.

No other documentation was provided while Compliance Officer was on-site.

3. In an interview, E2 reported being unaware that E6's first aid training and CPR card certification had expired, and that the National CPR Foundation is an on-line course.

Based on documentation review, observation, and interview the manager failed to ensure the heating systems maintained the assisted living facility at a temperature between 70\'b0 F and 84\'b0 F at all times, unless individually controlled by a resident.

Findings include:

1. A review of documentation provided to the department revealed the heater was not working in building five of this community.

2. During a tour of building five the Compliance Officer observed this building to be cooler than building two the Compliance Officer had just been in. The Compliance Officer asked two caregivers in the hallway if the facility was having heating issues and the caregiver replied yes, especially in room #509.

3. The Compliance Officer used the department-issued infrared thermometer in several areas and rooms in this building. The Compliance Officer observed the following temperatures in building five:
- In room #509 which is on the right side of the building had a temperature reading of 67.5\'b0 in the living area, at 5:00 pm;
- In the bathroom area the temperature reading was 63.7\'b0; and
- Over the resident's bed the temperature readying was 63.7\'b0.

4. E2 reported to Compliance Officer these rooms have a central control system which is located in the hallway. The Compliance Officer observed the thermostat had a locked clear box over the thermostat, and the temperature reading was set at 74\'b0.

5. The Compliance Officer asked E2 if E2 could adjust the temperature, and E2 reported they did not have the keys to unlock the thermostat boxes, and a regional maintenance person from Phoenix was scheduled to come and fix the heating issue the next day. The facility had just lost their maintenance person.

6. In an interview, E1, and E2 acknowledged the heating system on the right side of the building failed to maintain the assisted living facility at a temperature between 70\'b0 F and 84\'b0 F at all times.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During a facility tour, the surveyor observed the following:

2. The Compliance Officer used the department-issued infrared thermometer in several areas and rooms in this building. The Compliance Officer observed the following temperatures in building five:

- In room #509 which is on the right side of the building had a temperature reading of 67.5\'b0 in the living area, at 5:00 pm;
- In the bathroom area the temperature reading was 63.7\'b0; and
- Over the resident's bed the temperature readying was 63.7\'b0.

3. In the central hallway off the living room the Compliance Officer observed a thermostat that was not reading the rooms temperature. E2 reported not having a key to open the box, and stated it might need a new battery.

4. In an interview, E1 reported a regional maintenance person was scheduled to come and fix the heating issue the next day and acknowledged the heating system in room #509 was not in working order, and the thermostat may need a new battery.