BROOKDALE NORTH GILBERT

<p>Based on documentation review and interview, the assisted living center that contacted an emergency responder on behalf of a resident failed to provide the emergency responder a written document that included all requirements in Subsection A.1-9. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:</p><p>1. The reason or reasons the emergency responder was requested on behalf of the resident.</p><p>2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.</p><p>3. The name, address and telephone number of the resident's current pharmacy.</p><p>4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.</p><p>5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.</p><p>6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.</p><p>7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.</p><p>8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization.</p><p>9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives."</p><p><br></p><p><br></p><p>2. A review of the facility’s emergency responder documentation from April 3, 2025, did not include the following required elements for R1: </p><ul><li>The reason or reasons the emergency responder was requested on behalf of the resident; and </li><li>A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. </li></ul><p><br></p><p><br></p><p>3. A review of the facility’s emergency responder documentation from March 21, 2025, did not include the following required elements for R6: </p><ul><li>The reason or reasons the emergency responder was requested on behalf of the resident; and </li><li>A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. </li></ul><p><br></p><p><br></p><p>4. In an interview, E1 acknowledged that the facility failed to provide emergency responders with all required documents for R1 and R6. </p>

<p>Based on record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of R4’s medical record revealed a progress note dated May 19, 2025. The documentation indicated care staff discovered bruising on R4's body. However, the report required in <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">A.R.S. § 46-454 was not submitted until May 21, 2025.</span></p><p><br></p><p><br></p><p>2. In an interview, E1 reported the facility did not notify Adult Protective Services of the incident until May 21, 2025, as that is when E1 became aware of the incident. E1 acknowledged that after E1 had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, E1 failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454.</p>

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for six of nine personnel records sampled. The deficient practice posed a risk if the employees were unable to meet residents' needs.

Findings include:

1. A review of the staff schedule revealed E4, E5, E6, E7, E8, and E9 worked at the facility during the month of October 2024.

2. A review of E4, E5, E6, E7, E8, and E9's personnel records revealed no documentation of the individual's completed orientation.

3. In an interview, E1 acknowledged E4, E5, E6, E7, E8, and E9's personnel records did not include documentation of the required orientation.

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

Findings include:

1. Review of the facility's documentation revealed E1's, E3's, E4's, E5's, and E6's personnel records did not contain any documented evidence the fall prevention and fall recovery training program had been implemented for these sampled staff.

2. In an interview, E1 and E2 acknowledged there was no documentation that the facility had completed the required fall prevention and fall recovery training for all staff.

This is a repeat deficiency from the complaint investigation conducted on July 18, 2022.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training; for one of three sampled employees personnel records which posed a health and safety risk.

Findings include:

1. Review of E6's personnel record revealed no documentation of first aid training. E6's record contained documentation that E6 was a trained caregiver and was hired on January 10, 2023.

2. In an interview, E1 and E7 acknowledged there was no documentation that E6, who was working as a caregiver, had current first aid training.

This is a repeat deficiency from the compliance inspection conducted on March 17-18, 2022.

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

Findings include:

1. During a facility tour of randomly selected residents' units, E1 and the compliance officer observed in R5's unit there was a pungent urine odor which gave the impression that R5's unit was not kept clean. R5 was not in the unit at the time of the observation.

2. In an interview, E1 acknowledged R5's unit had a urine odor which gave the impression the unit was not kept clean.

This is a repeat deficiency from the compliance inspection conducted on March 17-18, 2022.

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

Findings include:

1. During a facility tour of randomly selected residents' units, E1 and the compliance officer observed in R4's unit the lower part of the wall from the resident's living room to the resident's bathroom had broken through the dry wall and the bare frame of the wall was exposed. This broken wall was not kept in good repair which could cause the resident or other individual to suffer physical injury should equipment get caught in this broken area.

2. In an interview, E1 acknowledged some of R4's unit walls were not in good repair.

This is a repeat deficiency from the compliance inspection conducted on March 17-18, 2022.

Based on observation and interview, the manager failed to ensure soiled linen and soiled clothing stored by the facility were stored in closed containers.

Findings include:

1. During a tour of the facility's central laundry area, E1 and the compliance officer observed an uncover tall basket full of soiled linen and clothing with a bundle of soiled linen and clothing sitting on top of this uncovered basket. In an interview the employee working in the laundry room reported this basket was soiled linen and clothing waiting to be washed.

2. In an interview, E1 acknowledged the facility was not storing soiled linen and clothing in closed containers.

Technical assistance was provided during the compliance inspection conducted on March 17-18, 2022.