THE MANOR VILLAGE AT DESERT RIDGE

Assisted Living Center | Assisted Living

Facility Information

Address 5560 East Deer Valley Drive, Phoenix, AZ 85054
Phone 4802966151
License AL11856C (Active)
License Owner MANOR VILLAGE US HOLDINGS, LLC
Administrator Nicolle Blais
Capacity 129
License Effective 6/4/2025 - 6/3/2026
Services:
11
Total Inspections
30
Total Deficiencies
9
Complaint Inspections

Inspection History

INSP-0136155

POC
Date: 9/17/2025 - 9/18/2025
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2025-10-30

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00144288, 00143139, 00138218, 00105661, 00105373, 00104349, 00105088, 00105047, and 00104750 conducted on September 17, 2025, and September 18, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:
R9-10-807.B.1.a-b. Residency and Residency Agreements<br> B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: <br>1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: <br>a. Includes whether the individual requires: <br>i. Continuous medical services, <br>ii. Continuous or intermittent nursing services, or <br>iii. Restraints; and <br>b. Is dated and signed by a: <br>i. Physician, <br>ii. Registered nurse practitioner,<br>iii. Registered nurse, or <br>iv. Physician assistant; and
Evidence/Findings:
<p><span style="font-size: 10pt; font-family: Arial, sans-serif;">Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the assisted living facility accepted the individual, that included if the individual required continuous medical services; continuous or intermittent nursing services; or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant; for two out of seven sampled residents. </span></p><p><br></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;">Findings include:</span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><br></p><p><br></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> 1. A review of R6’s medical record contained a blank document titled “Determination for Admission", which did not include if R6 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.</span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;">2. A review of R7’s medical record contained a document titled “Determination for Admission” dated July 25, 2024, which reflected that R7 required continuous nursing services. </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><br></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> 3. In an interview, E1 reviewed R6’s and R7’s medical records and acknowledged that there was no documentation available to reflect that the above requirement had been met.</span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 10pt; font-family: Arial, sans-serif;"> </span></p>
Temporary Solution:
When the inspection was completed on September 18, 2025, and the deficient practice was discovered an immediate plan of action was put into place. Resident R-7 Determination of Admission record was updated to reflect resident does not require continuous nursing services. Resident R-6 Determination for Admission has been corrected indicating the appropriate services required. An audit was completed by the Wellness Team and there were no further inaccurate Determination of Admission documents.
Permanent Solution:
All Determination of Admission documents will be reviewed prior to acceptance and if there are discrepancies they will be corrected by the residents’ Medical Provider.
Person Responsible:
Leasing Team, Wellness Director, Wellness Coordinator, Memory Care Coordinator, Resident Administrator, Assisted Living Manager.

Deficiency #2

Rule/Regulation Violated:
R9-10-807.E.1-4. Residency and Residency Agreements<br> E. Before or within five working days after a resident’s acceptance by an assisted living facility, a manager shall obtain on the documented agreement, required in subsection (D), the signature of one of the following individuals: <br>1. The resident, <br>2. The resident’s representative, <br>3. The resident’s legal guardian, or <br>4. Another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual’s behalf.
Evidence/Findings:
<p>Based on record review and interview, before or within five working days after a resident's acceptance by an assisted living facility, the manager failed to obtain on the residency agreement, the signature of the resident, the resident's representative, the resident's legal guardian, or another individual who has been designated by the individual under A.R.S § 36-3221 to make health care decisions on the individual's behalf for one of seven residents sampled.   </p><p><br></p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p><br></p><p>1. A review of R3's medical record revealed a residency agreement; however, the residency agreement was not signed by R3 or R3's representative. Based on R3's date of acceptance, this documentation was required.  </p><p><br></p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 reviewed R3's medical record. E1 acknowledged that R3's documented residency agreement did not include the signature of the identified resident or their representative.  </p>
Temporary Solution:
When the inspection was completed on September 18, 2025, and the deficient practice was discovered, an immediate plan of action was put in place. The signed document was in fact in our Electronic Database/Resident system but there was an oversight of our Leasing Team accessing said document. The signed Lease Agreement was located on the evening of September 18th within the resident’s online profile in the database. The signed Resident Rights document was located on the evening of September 18th and emailed to the State Inspector. An audit was performed, and all residents were found to have signed residency agreements in place.
Permanent Solution:
The Leasing Team will provide the Resident Administrator with a copy of all signed leases prior to or on the day of residency at Manor Village. The resident administrator will ensure that the signed agreement has been uploaded to resident profile.
Person Responsible:
Leasing Team, Resident Administrator, Assisted Living Manager.

Deficiency #3

Rule/Regulation Violated:
R9-10-808.C.1.c. Service Plans<br> C. A manager shall ensure that: <br>1. A caregiver or an assistant caregiver: <br>c. Provides assistance with activities of daily living according to the resident’s service plan;
Evidence/Findings:
<p><span style="font-size: 18pt;">Based on record review and interview, the manager failed to ensure that a caregiver or assistant caregiver provided a resident with assistance with activities of daily living according to the resident's service plan for two of seven sampled residents. </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;">Findings include:</span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;">1.</span><span style="font-size: 7pt;">  </span><span style="font-size: 18pt;">A review of R1's medical record revealed a service plan dated June 2, 2025, for directed care. The service plan indicated R1 required the following assistance:</span></p><p><span style="font-size: 18pt;">- grooming personal hygiene twice daily;</span></p><p><span style="font-size: 18pt;">- dressing twice daily;</span></p><p><span style="font-size: 18pt;">- toileting assistance three times daily;</span></p><p><span style="font-size: 18pt;">- bathing twice weekly.</span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;">2.</span><span style="font-size: 7pt;">  </span><span style="font-size: 18pt;">A review of R1’s medical record contained a document titled “Monthly task log” dated September 2025, which reflected “INF (information only)” and did not reflect that R1 was provided assistance with activities of daily living according to R1’s service plan.</span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;">3.</span><span style="font-size: 7pt;">  </span><span style="font-size: 18pt;"> A review of R6's medical record revealed a service plan dated September 3, 2025, for directed care. The service plan indicated R6 required the following assistance:</span></p><p><span style="font-size: 18pt;">- transfer and escort assistance;</span></p><p><span style="font-size: 18pt;">- grooming twice daily;</span></p><p><span style="font-size: 18pt;">- dressing twice daily;</span></p><p><span style="font-size: 18pt;">- toileting three times daily;</span></p><p><span style="font-size: 18pt;">- bathing one time per day every week on Wednesday and Saturday.</span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;">4.</span><span style="font-size: 7pt;">  </span><span style="font-size: 18pt;">A review of R6’s medical record contained a document titled “Monthly task log” dated September 2025, which reflected the above services were not provided for various days, and did not reflect that R6 was provided assistance with activities of daily living according to R6’s service plan.</span></p><p><span style="font-size: 18pt;"> </span></p><p><br></p><p><span style="font-size: 18pt;"> </span></p><p><span style="font-size: 18pt;">5.</span><span style="font-size: 7pt;">  </span><span style="font-size: 18pt;">In an interview, E1 reviewed R1’s and R6’s medical records and acknowledged that the </span><span style="font-size: 24px;">medical records</span><span style="font-size: 18pt;"> did not reflect that the residents were provided assistance with activities of daily living according to the residents’ service plans.</span></p>
Temporary Solution:
A review of R-1 Medical Record revealed a service plan of directed care. Monthly task log dated September 2025 reflected INF (information only) and did not reflect that R-1 was provided assistance with activities of daily living according to service plan. The surveyor stated that she needed to meet with resident R-1. Upon the visit to the neighborhood and visualization of R-1, the surveyor stated that he was well groomed, clean, clean clothing, and appeared to be well taken care of. It was discovered after review of service plan that the tasks were not entered as show and chart but show only. R-1 receives assistance from care team staff for all his activities of daily living as he is directed care level. This was immediately corrected and education provided to all team members who complete service plans.
A review of R-6 Medical Record reflected missing ADLs charted. The deficient practice has been corrected. ADLs are reviewed daily by the Wellness Department.
Permanent Solution:
When the inspection was completed on September 18, 2025, and the deficient practice was discovered, an immediate plan of action was put in place. An audit was completed, and all tasks were entered correctly with show and chart. There was no further deficient practice discovered. All service plans completed will be reviewed by the Wellness Director, Wellness Coordinator, and Resident Administrator for a triple check process.
Person Responsible:
Wellness Director, Wellness Coordinator, Memory Care Coordinator, Resident Administrator, Assisted Living Manager.

Deficiency #4

Rule/Regulation Violated:
R9-10-810.A. Resident Rights<br> A. A manager shall ensure that, at the time of acceptance, a resident or the resident’s representative receives a written copy of the requirements in subsection (B) and the resident rights in subsection (C)
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a resident or the resident’s representative received a written copy of the resident rights.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of R3's medical record revealed no documentation to indicate R3 was given a written copy of the resident rights in subsection (C).</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E13 acknowledged there was no documentation to indicate R3 was given a written copy of the resident rights on R3's date of acceptance.</p>
Temporary Solution:
When the inspection was completed on September 18, 2025, and the deficient practice was discovered, an immediate plan of action was put in place. The signed document was in fact in our online resident records database but there was an oversight of our Leasing Team accessing said document. The signed Resident Rights document was located on the evening of September 18th and emailed to the State Inspector.
Permanent Solution:
An audit was carried out, and all residents were found to have signed copies that resident rights were given.
Person Responsible:
Leasing Team, Resident Administrator, Assisted Living Manager

INSP-0133847

Complete
Date: 6/11/2025
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2025-07-23

Summary:

The following deficiencies were found during the on-site investigation of complaint ID
00133076 and 00124401 conducted on June 11, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:
R9-10-808.C.1.g. Service Plans<br> C. A manager shall ensure that: <br>1. A caregiver or an assistant caregiver: <br>g. Documents the services provided in the resident’s medical record; and
Evidence/Findings:
<p><span style="font-size: 16px; font-family: Arial, sans-serif;">Based on record review, observation, documentation review, and interview, the manager failed to ensure that a caregiver documented assistance with activities of daily living according to the service plans for two of two sampled residents.</span></p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;">Findings include:</span></p><p><br></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;">1. A review of R1’s medical record revealed a service plan dated June 3, 2025, that reflected R1 required the following assistance: dressing twice daily and escorts twice daily. A review of R1’s June 2025 “Monthly task log did not reflect that R1 was assisted with escorts twice daily on June 1, 2025, and dressing assistance twice daily from June 1, 2025, through June 10, 2025.</span></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;"> </span></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;">2. A review of R2’s medical record revealed a service plan dated June 3, 2025, that reflected R2 required the following assistance: ambulation assistance three times daily, transferring assistance three times daily, grooming twice daily, dressing twice daily, and toileting three times daily. A review of R2’s June 2025 “Monthly Task Log” </span><span style="font-size: 16px; font-family: Arial, sans-serif; background-color: rgb(255, 255, 255);">did not reflect</span><span style="font-size: 16px; font-family: Arial, sans-serif;"> that R2 was assisted with ambulation twice daily on June 1, 2025, June 3, 2025 through June 8, 2025, and June 10, 2025, assisted with grooming/personal hygiene, dressing, and toileting on June 1, 2025, June 3, 2025 through June 8, 2025, and June 10, 2025.</span></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;"> </span></p><p><br></p><p><br></p><p><span style="font-size: 16px; font-family: Arial, sans-serif;">3. In an interview, E1 and E2 reviewed R1’s and R2’s service plans and documentation of services provided and acknowledged at the time of the survey, R1’s and R2’s documentation did not reflect that R1 and R2 were provided the above services. </span></p><p><br></p><p><br></p><p>This is a repeat deficiency from the complaint investigation conducted on September 30, 2024.</p>
Temporary Solution:
When the inspection was completed on June 11, 2025, and the deficient practice was discovered, an immediate plan of action was put into place. This includes one-on-one training with all care team staff to explain the process of signing off tasks and the importance of ensuring all care tasks are signed off daily each scheduled shift.
The Manor Licensed Nurses have been tasked to follow up at least one hour prior to the end of each shift to remind and review that care tasks have been signed off.
The Wellness Administration Team are checking daily to ensure all care tasks have been completed and recorded.
Permanent Solution:
One-on-one training with all care team staff to explain the process of signing off tasks and the importance of ensuring all care tasks are signed off daily each scheduled shift.
The Manor Licensed Nurses have been tasked to follow up at least one hour prior to the end of each shift to remind and review that care tasks have been signed off.
The Wellness Administration Team are checking daily to ensure all care tasks have been completed and recorded.
Person Responsible:
Wellness Director, Wellness Coordinator, Memory Care Coordinator, Resident Administrator, Assisted Living Manager

INSP-0090701

Complete
Date: 9/30/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-11-12

Summary:

The following deficiencies were found during the on-site investigation of complaints AZ00216167, AZ00214271, and AZ00214203 conducted on September 30, 2024 :

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of five sampled personnel. The deficient practice posed a risk if the individuals were a danger to a vulnerable population.

Findings include:

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

2. A review of E4's personnel record revealed an invalid fingerprint clearance card that expired September 19, 2024, and no documentation that E4 applied for a new fingerprint clearance card.

3. A review of R2's and R3's medical record revealed medication administration records dated August 2024 and September 2024 which reflected E4 provided medication administration services on various times and dates.

4. In an interview, E1 acknowledged E4's fingerprint clearance card was expired and reported being unaware of E4's fingerprint status.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;
Evidence/Findings:
Based on documentation review, record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of three caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents.

Findings include:

1. A review of E3's personnel records revealed no documented verification of E3's skills and knowledge.

2. A review of R2's and R3's medical record revealed a medication administration record dated August 2024 and September 2024, reflected E3 provided medication administration services on various dates.

3. In an interview, E1 reviewed and acknowledged E3's personnel file did not contain documented verification of E3's skills and knowledge.

This is a repeat deficiency from the complaint investigation conducted on February 1, 2024.

Deficiency #3

Rule/Regulation Violated:
A. A manager shall ensure that:
9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of four sampled caregivers and assistant caregivers.

Findings include:

1. A review of E1's personnel record revealed no documentation of completed orientation, based on E1's hire date orientation was required.

2. In an interview, E1 acknowledged E1's personnel record did not include documentation of orientation.

This is a repeat deficiency from the complaint investigation conducted on February 1, 2024.

Deficiency #4

Rule/Regulation Violated:
C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
g. Documents the services provided in the resident's medical record; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for three of three sampled residents reviewed.

Findings include:

1. A review of R1's medical record revealed a service plan August 23, 2024. R1's service plan reflected R1 would be provided assistance with bathing every Sunday, Wednesday and Saturday, grooming once daily, dressing two times daily, toileting every four hours daily. There was no documentation to show the above services were provided to R1.

2. A review of R2's medical record revealed a service plan dated December 14, 2023. R2's service plan reflected R2 would be provided assistance with bathing, grooming/personal hygiene three times daily, dressing three time daily, and toileting five times daily. A document titled "Monthly Task Log" dated August 2024 and September 2024 reflected "documented by exception". There was no documentation to show the above services were provided to R2.

3. A review of R3's medical record revealed a service plan dated August 23, 2024. R3's service plan reflected R3 would be provided assistance with bathing every Wednesday and Saturday, grooming/personal hygiene four times daily, dressing twice daily, toileting assistance every two hours daily. There was no documentation to show the above services were provided to R3.

4. In an interview, E1 reviewed R1's, R2's, and R3's medical records and reported the facility documents on exception and does not document the services provided to the residents.

Deficiency #5

Rule/Regulation Violated:
C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes:
1. The requirements in R9-10-814(F)(1) through (3);
Evidence/Findings:
Based on record review and interview, the manager failed to ensure the service plan for a resident who received directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for three of three residents.

Findings include:

1. A review of R1's medical record revealed a service plan August 23, 2024. R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

2. A review of R2's medical record revealed a service plan dated April 26, 2024. R2's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

3. A review of R3's medical record revealed a service plan dated August 23, 2024. R3's service plan R3's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

4. In an interview, E1 reviewed and acknowledged R1's, R2's, and R3's service plans did not include skin maintenance to prevent and treat bruises, injuries, pressure sores and infections.

Deficiency #6

Rule/Regulation Violated:
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
1. Immediately notifies the resident's emergency contact and primary care provider; and
Evidence/Findings:
Based on record 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 caregiver immediately notified the resident's primary care provider, for one of one residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

R9-10-101.110. "Immediate" means without delay.

1. A review of R2's medical record revealed an incident report dated August 6, 2024 in which 911 was contacted due to R2 feeling like lava was in R2's stomach and R2 was taken to the hospital by emergency medical services. However, R2's primary care physician (PCP) was not notified of the incident immediately.

2. In an interview, E1 acknowledged there was no documentation to reflected R2's physician was notified.

INSP-0090699

Complete
Date: 8/22/2024
Type: Change of Service
Worksheet: Assisted Living Center
SOD Sent: 2024-09-30

Summary:

No deficiencies were found during the on-site modification to increase occupancy from 50 Directed Care and 79 Personal Care to 50 Directed Care and 96 Personal Care completed on August 22, 2024.

✓ No deficiencies cited during this inspection.

INSP-0090698

Complete
Date: 7/19/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-08-27

Summary:

An on-site investigation of complaint AZ00212738 and AZ00213231 was conducted on July 19, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0090697

Complete
Date: 5/15/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-06-18

Summary:

An on-site investigation of complaints AZ00208650, AZ00210142, AZ00208498, AZ00210190, and AZ00209132, was conducted on May 15, 2024, and the following deficiencies were cited :

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:
36-420. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition
B. Each health care institution:
2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times.
Evidence/Findings:
Based on documentation review, record review, and interview, for two of six residents reviewed, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall.

Findings include:

1. In record review, the personnel records reviewed for E3, E4, E5, E6, E7, and E8, and E9 included documention the personnel received training on fall prevention and fall recovery.

2. In documentation review, the Department received a report from O1, which documented, "4/2/2024... 1:52 am...Staff failed to recover patient [R1] per ARS 36-420... Patient found supine on floor in bathroom in no distress... states... slipped of the toilet and needs help up... denies injury, 3 staff members on scene state they cannot lift [R1] up... they have no hoyer or other lift device. Patient lifted to wheelchair and transferred to recliner by LT52 without incident... has no additional needs."

3. In documentation review, the Department received a report from O1, which documented, "4/4/2024... 1:18 am... Staff failed to recover patient [R2] ... found patient laying in the prone position next to ... bed... Staff... states patient rolled out of bed... they need help lifting patient back into bed. Staff states patient is a hospice patient and hospice states they are on their way and will take care of the patient. Hospice nurse says they do not need patient transported... Pt is alert and oriented times three. Staff states this is a normal baseline for patient... facility had four staff members present... states that they need help lifting the patient into bed... did not assist the fire department in lifting the patient in the bed...".

4. During an interview, the findings were reviewed with E1, and E2, who reported all employees received fall prevention and fall recovery training, which included a video on fall recovery. E1 and E2 acknowledged, however, the night shift employees called for emergency services for R1 and R2 and reported they were unable to lift the residents from the floor.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;
Evidence/Findings:
Based on record review, documentation review, and interview, for one of seven caregivers reviewed, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and the Department was provided false and misleading information.

Findings include:

1. In record review, E6 was hired as a caregiver on November 23, 2022, and worked night shifts at the facility. E6's personnel record included a caregiver certificate from GSDM Healthcare Academy ALTP #0102, dated November 19, 2012.

2. In documentation review, a review of the website for caregiver certification verification, revealed the GSDM Healthcare Academy operated as an approved training program from September 13, 2004, through September 30, 2012, and was not in operation on November 19, 2012, (the date of E6's caregiver certificate).

3. During an interview, the findings were reviewed with E1 and E2, who acknowledged E6 did not provide documentation of completion of a caregiver training program approved by the Department or the NCIA Board as required.

INSP-0090696

Complete
Date: 4/2/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-04-16

Summary:

An on-site investigation of complaint AZ00208448 was conducted on April 2, 2024, and no deficiencies were cited .

✓ No deficiencies cited during this inspection.

INSP-0090694

Complete
Date: 3/21/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-04-02

Summary:

An on-site investigation of complaints AZ00207497, AZ00207423, AZ00207249, and AZ00207176 was conducted on March 21, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0090693

Complete
Date: 2/1/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-03-15

Summary:

An on-site investigation of complaint #AZ00205771 was conducted on February 1, 2024, and the following deficiencies were cited .

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
Based on record review and interview, for four of four employees reviewed, the governing authority failed to document an effort made to contact an employee's previous employer to obtain information or recommendations that may be relevant to a person's fitness to work in the facility.

A.R.S. \'a7 36-411(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..

Findings include:

1. In record review, the personnel records for E6 (hired September 25, 2023, as a caregiver), E7, (hired April 13, 2023, as a caregiver), E8, (hired September 13, 2023, as a caregiver), and E9, (hired on November 13, 2023, as a caregiver), did not include documentation the facility made a good faith effort to contact previous employers, to obtain information or recommendations relevant to the person's fitness to work in the facility.

2. During an interview, the findings were reviewed with E1, E2, E3, E4, and E5, who acknowledged the personnel records for E6, E7, E8, and E9 did not include documentation the facility made a good faith effort to contact the caregivers' previous employers.

Deficiency #2

Rule/Regulation Violated:
J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.
Evidence/Findings:
Based on record review, and interview, the administrator failed to report an alleged incident of abuse according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.

Findings include:

1. A.R.S. \'a7 46-454(A) states: " A. A health professional, emergency medical technician, home health provider, hospital intern or resident, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the department of economic security or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit. The guardian or conservator of a vulnerable adult shall immediately report or cause reports to be made of such reasonable basis to the superior court and the adult protective services central intake unit. All of the above reports shall be made immediately by telephone or online.."

2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay."

3. In record review, R1's medical record (received directed care services) included documentation of an "Incident Form," dated April 12, 2023, "Resident... continuously bothers resident R10 because of [R1's] condition and capabilities... believes [R10] is a small child who needs help... continues to physically bother... such as grabbing ... in different areas... while staff tries to separate the two [R1] gets physically and verbally aggressive towards staff and other residents around [R1]. Today...[R1] had... hands in between [R10]'s legs... I did try to stop it, [R1] got physically and verbally aggressive with me. [R1]'s intentions were unclear while trying to explain why [R1] had ... hands between [R10]'s legs but [R10] was clearly in distress and uncomfortable."

4. In record review, R1's medical record included documentation of an "Incident Form," dated January 13, 2024, at 6:34am, which documented, "At approximately 5:45am, during brief change, resident was very combative, hitting the caregiver, calling ... names and telling ... going to shoot ... between the eyes. As the resident was hitting the caregiver the caregiver touched residents arm ... to stop the hitting... the resident stated "I don't like that Bitch, get ... out of here."... We left. It was not until later, when I passed the meds to [R1] ... [R1] showed me the bruise on ... right arm... didn't complaint of pain at that time... let the caregiver know I have to report the injury and ... charted..."

5. R1's record included a "log entry," dated January 13, 2024, which documented, "At approximately 5:45am, this writer and caregiver was attempting to brief change resident, when [R1] began hitting the caregiver... caregiver defended .. self by grabbing the residents arm to stop the hitting, [R1's] arm was hurt during that process. There is a large bruise on resident's right arm. A log entry dated January 14, 2024, documented, "Visible bruising and swelling on resident's right arm noted, resident also stated, "it hurts", when asked. Offered Tylenol for pain, resident refused. A log note by E4, dated January 15, 2024, documented, "If [R1] becomes aggressive during cares, stop and reapproach."

6. During an interview, E3 reviewed the incident forms with the Compliance Officer. E3 reported the date of the April 12, 2023, incident was incorrect, and an interview with E10 revealed the incident actually occurred two - three months ago. E10 was a witness to the incident and documented the incident on the incident form. E3 reported the facility's policy is that caregiver's are to report incidents of suspected abuse to a manager, and document the notification on the Incident Form.

7. During an interview, the findings were reviewed with E1, E2, E3, and E4 who acknowledged the incidents were not reported, as required, per A.R.S. \'a7 46-454(A), and an investigation, including documentation of immediate action to stop the suspected abuse, and actions taken by the manager to prevent the suspected abuse from occurring in the future.

Deficiency #3

Rule/Regulation Violated:
A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;
Evidence/Findings:
Based on record review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, and according to policies and procedures. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident.

Findings include:

1. In record review, the personnel record for E6 (hired on September 25, 2023, as a caregiver) did not include documentation of the verification of E6's skills and knowledge.

2. During an interview, the findings were reviewed with E1, E2, E3, E4, and E5, who acknowledged the personnel record for E6 did not include documentation of the verification of E6's skills and knowledge.

Deficiency #4

Rule/Regulation Violated:
A. A manager shall ensure that:
9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
Evidence/Findings:
Based on record review, and interview, for three of four caregivers reviewed, the manager failed to ensure that before providing assisted living services, a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver did not receive the required orientation.

Findings include:

1. In record review, the personnel records for E6 (hired September 25, 2023, as a caregiver), E7, (hired April 13, 2023, as a caregiver), E8, (hired September 13, 2023, as a caregiver), and E9, (hired on November 13, 2023, as a caregiver), did not include documentation the caregivers received orientation.

2. During an interview, the findings were reviewed with E1, E2, E3, E4, and E5, who acknowledged the personnel records did not include documentation the caregivers received orientation.

INSP-0090691

Complete
Date: 1/2/2024
Type: Complaint
Worksheet: Assisted Living Center
SOD Sent: 2024-01-04

Summary:

An on-site investigation of complaints AZ00204662, AZ00204406, AZ00201249, and AZ00199552 was conducted on January 2, 2024, and the following deficiencies were cited .

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
Evidence/Findings:
Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Falls." The policy and procedure documented" ... team members will receive education on the fall policy and fall prevention. The training may include, but is not limited to: the [center] Fall Policy, Awareness of trip hazards within the community, Proper use of mobility aids, benefits of regular exercise and balance and mobility training, benefits of proper nutrition and hydration." The policy did not include training for staff on fall recovery.

2. In record review, the personnel records for E4, E5, E6, E7, E8, and E9 did not include documention the personnel received training on fall recovery.

3. During an interview, the findings were reviewed with E1, E2, and E3 who acknowledged the policy and procedures for training personnel on falls did not include training on fall recovery, and the personnel records did not include documentation the personnel received the training at the facility.

Deficiency #2

Rule/Regulation Violated:
J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
Evidence/Findings:
Based on record review, and interview, the manager failed to ensure if the manager had reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse or neglect had occurred on the premises or while a resident was receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager documented the report in subsection (J)(2). The deficient practice posed a risk as the Center failed to properly document the report of suspected abuse.

Findings include:

1. R9-10-803.J.2 requires: J. If a manager has a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. \'a7 46-454;

2. In record, R1's medical record included documentation of an "Incident Report," (IR), dated December 18, 2023, which indicated R1 was involved in a physical altercation with another resident, and had two skin tears; to the left hand and right forearm. A log note documented R2 entered R1's room and allegedly grabbed R1, and caused the skin tears. The record did not include documentation the alleged abuse was reported according to subsection (J)(2).

3. In observation, R1 was observed to have a bandage covering the left hand.

4. During an interview, E1 reported R2 caused the injury to R1, [E1] contacted the Department to request assistance, and then reported the alleged resident to resident abuse, as required. E1 acknowledged the resident's record did not include documentation of the report of the alleged abuse.

Deficiency #3

Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;
Evidence/Findings:
Based on observation, record review and interview, for one of four residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided.

Findings include:

"Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident.

1. In record review, R3's service plan, dated September 18, 2023, (received personal care services, and had diagnoses of Lewy Body Dementia, Transient Ischemic Attacks, Insomnia, and Degeneration of Lumbar) included documentation R3 had a fall with injury, requiring medical services on June 6, 2023, July 12, 2023, September 20, 2023, September 22, 2023, and December 7, 2023. R3's service plan section titled, "Fall Potential," documented "Resident will maintain and/or maximize current level of function with fall potential... Care staff to notify LPN on duty, Wellness Director/Coordinator and POA of any falls." The service plan did not include documentation of R3's falls, injuries, or services provided to ensure R3's safety.

2. During an interview, the findings were reviewed with E1, E2, and E3, who acknowledged R3's service plan did not include R3's falls and services provided.

Deficiency #4

Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.
Evidence/Findings:
Based on record review and interview, for two of four residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the resident's MP or nurse did not acknowledge the services that were to be provided.

Findings include:

1. In record review, R1's medical record (received directed care and medication administration services) included a service plan dated December 11, 2023, and a service plan dated September 13, 2023. The service plans were not signed and dated as reviewed by the resident or resident's representative, the manager, and the MP or nurse.

2. In record review, R3's medical record (received personal care and medication administration services) included service plans dated September 18, 2023, and April 4 2023. The service plans were not signed and dated as reviewed by the resident or resident's representative, the manager, and the MP or nurse.

3. During an interview, the findings were reviewed with E1, E2, and E3, who acknowledged the service plans were not signed and dated by the resident or resident's representative, the manager, and signed and dated as reviewed by the nurse or MP, as required.

Deficiency #5

Rule/Regulation Violated:
D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
2. Documents the following:
f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
Evidence/Findings:
Based on record review and interview, for one resident reviewed, who had injuries that resulted in the resident needing medical services, the manager failed to ensure a caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a health and safety risk to a resident if action to prevent an accident, emergency or injury was not identified, documented, and implemented, to ensure a resident's safety.

Findings include:

1. In record review, R3's medical record (received personal care services) included a document titled, "Incident Form," for the dates: June 6, 2023, July 12, 2023, September 20, 2023, September 22, 2023, and December 7, 2023. The documentation indicated R3 had a fall with injury resulting in the need for medical services. The documentation did not include action taken to prevent the accident, emergency, or injury from occurring in the future.

2. During an interview, the findings were reviewed with E1, E2, and E3, who acknowledged R3 had falls, with injuries resulting in the need for medical services, and the caregiver did not document action taken to prevent the accident, emergency, or injury from occurring in the future.

INSP-0090689

Complete
Date: 5/4/2023
Type: Compliance (Annual)
Worksheet: Assisted Living Center
SOD Sent: 2023-05-15

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on May 4, 2023:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:
A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;
Evidence/Findings:
Based on record review and interview, for one of 10 personnel records reviewed, the manager failed to ensure a personnel record included documentation of evidence of freedom from infectious tuberculosis (TB), which posed a potential health and safety risk of TB exposure, to residents and staff.

Findings include:

1. In record review, E4's personnel record (hired August 25, 2022), included a chest x-ray dated February 8, 2021, which documented a history of a positive PPD; however, included no further documentation of freedom from TB, as required.

2. In an interview, E1 and E12 acknowledged E4's personnel record did not include the required documentation of freedom from TB.

Deficiency #2

Rule/Regulation Violated:
A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.
Evidence/Findings:
Based on record review, observation, and interview, for two of 10 employees reviewed, the manager failed to ensure a caregiver and an assistant caregiver provided documentation of cardiopulmonary resuscitation training (CPR) certification specific to adults, which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR.

Findings include:

1. In record review, the personnel records for E3 (hired March 18, 2023, as an assistant caregiver) and E5 (hired April 1, 2023, as a caregiver) included documentation of completion of CPR certification provided by NationalCPRFoundation which is an online training program, and did not include a demonstration of an individual's ability to perform CPR.

2. In observation, E5 was observed working at the facility during the inspection.

3. In documentation review, E3 worked the night shift at the facility, and E5 worked both day and evening shifts at the facility.

4. During an interview, the findings were reviewed with E11 and E1, who reported being unaware the CPR training program was an online program, and acknowledged the CPR training received by the employees did not include the required demonstration of the employee's ability to perform CPR.

Deficiency #3

Rule/Regulation Violated:
A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis:
1. Before or within seven calendar days after the resident's date of occupancy, and
2. As specified in R9-10-113.
Evidence/Findings:
Based on record review and interview, for one of nine residents reviewed, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a potential health and safety risk, of TB exposure, to residents and staff.

Findings include:

1. In record review, R4's record (received personal care services) did not include documentation of freedom from TB. Based on R4's acceptance date, this documentation was required.

2. During an interview, the finding was reviewed with E12, who acknowledged R4's record did not include documentation of freedom from TB. No further documentation was provided.

Deficiency #4

Rule/Regulation Violated:
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and
Evidence/Findings:
Based on record review, and interview, for one of nine residents reviewed, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation which included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, which was signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant.

Findings include:

1. In record review, the medical record for R3 (received directed care services) did not include documentation, signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant, which included whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints.

2. In an interview, the findings were reviewed with E12, who acknowledged the required documentation was not in R3's medical record, and was not available for review.

Deficiency #5

Rule/Regulation Violated:
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or
Evidence/Findings:
Based on observation, record review, and interview, for two residents reviewed, who were unable to walk and receiving directed care services, the manager failed to ensure the resident's primary care provider (PCP) or other medical practitioner (MP) examined the resident at the onset of the condition and at least every six months throughout the duration of the resident's condition, reviewed the facility's scope of services, and signed and dated a determination stating the resident's needs were being met by the facility. The deficient practice posed a health risk to a resident if a resident's condition was not reviewed by a PCP or MP, to approve a resident's stay at the facility.

Findings include:

1. In observation, the surveyor observed R1 and R2 at the facility during the inspection.

2. In an interview, E1 and E12 reported R1 and R2 were unable to walk, even with assistance. E1 reported the residents were unable to walk when accepted at the facility.

3. In record review, the medical records for R1 and R2 did not include a signed and dated determination stating the resident's needs could be met by the facility. E12 provided the compliance officer with a physician's order that R1 was unable to walk; however, the order did not include the required documentation per R9-10-815.B.1. E12 provided the compliance officer a signed and dated determination for R2, dated February 14, 2023, which was faxed to the facility during the inspection, on May 3, 2023.

4. In an interview, the findings were reviewed with E1 and E12, who acknowledged the records for R1 and R2 did not include a signed and dated determination stating the resident's needs could be met by the facility.

Deficiency #6

Rule/Regulation Violated:
B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
c. Is documented in the resident's medical record.
Evidence/Findings:
Based on record review, and interview, for two of nine residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not know if a medication was administered.

Findings include:

1. In record review, R5's medical record included a medication order for Opium Tincture 10mg/ml, take 0.4ml by mouth four times daily. R5's MAR for May 2023, included documentation R5's medication times for the opioid were at 8:00am, 12:00pm, 4:00pm and 8:00pm. The MAR was reviewed by the compliance officer at approximately 11:00am on May 4, 2023. The MAR included documentation R5 received the medication three times on May 1, four times on May 2, one time on May 3, and 0 times on May 4, 2023. The MAR did not indicate R5 received the medication at 8:00am on May 1, at 12:00pm, 4:00pm, and 5:00pm on May 3, at 8:00am, on May 4, 2023.

2. In record review, R6's medical record included a medication order for Tramadol HCL 50 mg tab, take one tablet by mouth three times daily. R6's MAR for May, 2023, did not include documentation R6 received the medication on May 3, at 2:pm and 7:00pm, and on May 4, at 8:00am. The MAR was reviewed by the compliance officer during the afternoon of May 4, 2023.

3. In an interview, E1 reported the medications were administered to the residents as ordered; however, acknowledged the medication administration had not been documented, on the days noted above.

Deficiency #7

Rule/Regulation Violated:
A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Evidence/Findings:
Based on observation, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident who might access the materials.

Findings include:

1. During an environmental inspection with E1, the compliance officer observed an unsupervised unlocked laundry housekeeping in a hallway by resident units. The cart contained the following toxic materials: Stainless steel cleaner and polish, furniture polish, Lemon-Eze bathroom cleanser, an unlabeled bottle with a green liquid, Peroxide Multi Surface Cleaner/Disinfectant, and Zep Acidic toilet bowl cleaner.

2. A cabinet in an unlocked laundry room, on a residential unit hallway, contained a bottle of Ecolab StainBlaster Enzyme Boost.

3. In observation, the compliance officer observed residents were ambulatory and walking in the facility.

4. In an interview, E1 acknowledged the toxic materials were stored in a manner allowing access to residents.

Deficiency #8

Rule/Regulation Violated:
R9-10-120. Opioid Prescribing and Treatment
F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall:
4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid:
a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid;
b. Monitors the patient's response to the opioid; and
c. Documents in the patient's medical record:
i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and
ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided.
Evidence/Findings:
Based on documentation review, record review, observation, and interview, for two of two residents reviewed, and receiving an opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if the resident's level of pain was not documented, as required.

Findings include:

1. In documentation review, a facility policy titled, "Opioid Medication," on page "2/4" documented "Before administration of any opioid medication, the ... RN, LPN, and/or Med Tech must: Identify the resident's pain before the opioid is administered, Monitors the resident's response to the opioid, Document the resident's pain before and after administration of the opioid in the resident's medical record, Pain management will be evaluated on a daily basis using a pain scale for verbal and non verbal patients, The resident will be asked to identify what their pain level is using either a 0-1- Pain Scale or the FACES Pain Scale...The Wellness team member will document the Pain Scale information in the residents file via the QuickMar. The wellness team will recheck the resident's pain level utilizing the same scale 30 minutes to 1 hour after administration of the medication and redocument this in the QuickMar as a a follow-up."

2. In record review, R5's medical record included a medication order for Opium Tincture 10mg/ml, take 0.4ml by mouth four times daily. R5's MAR for May 2023, included documentation R5's medication times for the opioid were at 8:00am, 12:00pm, 4:00pm and 8:00pm. The resident's MAR was reviewed by the compliance officer at approximately 11:00am, on May 4, 2023, and included documentation R5 received the medication three times on May 1, four times on May 2, one time on May 3, and 0 times on May 4, 2023. The medical record did not include documentation of an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. R4's medical record did not include documentation of an active malignancy or end of life condition.

3. In observation, R5's medication was observed on site and available.

4. In record review, R6's medical record included a medication order dated March 2022, through April 18, 2023, for Tramadol HCL 50 mg tablet, take one tablet by mouth two times daily, and another order, dated April 18, 2023, for Tramadol HCL 50 mg tablet, take one tablet by mouth three daily. R6's MAR included documentation R6 received the medication, as ordered; however, each time of administration for days April 1, through April 30, 2023, (except as noted below) included documentation of one number (level of pain) and not two numbers (indicating an identification of the need for the opioid and the monitoring of the effect). On April 20, 21, 22, 24 and at 8:00am and 2:00pm on April 25, 2023, the record did not include documentation of any number (level of pain) and no identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. R6's medical record did not include documentation of an active malignancy or end of life condition.

5. In an interview, the findings were reviewed with E1 and E10. E10 reported the [MAR] system only allowed documentation of the effectiveness of the opioid. E1 and E2 acknowledged the medical records for R5 and R6 did not include documentation of both the identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered, as required, and per the facility's policy and procedures for Opioid administration.

This is a repeat deficiency from the compliance inspection conducted on May 5, 2022.