ACOYA MESA

INSP-0132796

Complete

Date: 5/30/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-07-14

Summary:

The following deficiencies were found during the on-site investigation of Case IDs 00121881 and 00132145 conducted on May 30, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-808.C.1.a-g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident's service plan; b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; c. Provides assistance with activities of daily living according to the resident's service plan; d. If applicable, suggests techniques a resident may use to maintain or improve the resident's independence in performing activities of daily living; e. Provides assistance with, supervises, or directs a resident's personal hygiene according to the resident's service plan; f. Encourages a resident to participate in activities planned according to subsection (E); and g. Documents the services provided in the resident's medical record;

Evidence/Findings:

Based on a record review and interview, the manager failed to ensure that a caregiver provided assisted living services in accordance with the resident's service plan for one of three sampled residents. Findings include: 1. A review of R2’s service plan dated January 23, 2025 reflected R2 would be assisted with the following services: Bathing reminders and stand-by assist two times per every Sunday and Wednesday of every week, dressing, skin monitoring performed twice weekly with showers and dressing assistance daily. 2. A review of R2’s medical record revealed a document titled “Monthly Task Log” that reflected that R2 was not assisted with bathing twice daily on Wednesday, May 7, 2025, Sunday, May 11, 2025, and Wednesday, May 14, 2025. R2’s “Monthly Task Log” reflected that R2 was not assisted with dressing on May 7, 2025, May 14, 2025, and May 24, 2025. R2’s “Monthly Task Log” reflected that R2 was not assisted with skin maintenance on May 6, 2025, May 11, 2025, May 14, 2025, and May 24, 2025. 3. In an interview, E1 reviewed R2’s May 2025 Monthly task log and acknowledged that there was no documentation that the above assistance was provided to R2.

Temporary Solution:

For immediate correction in order to ensure that ADLs are completed and documentation is reflective of such, paper documentation will be provided for staff to document in the event that the electronic documentation is not available at any time for any reason.

Permanent Solution:

Resident Services Director with support from Executive Director will ensure that ADLs are completed and documented through a daily review of Task Not Completed Report. Should this report show any outstanding ADLs, RSD and/or ED will communicate with care provider to ensure that task was completed and documentation is appropriately completed either in the electronic or paper format.

Person Responsible:

Melissa Cecil, Executive Director Sheree Wilson, Resident Services Director

Deficiency #2

Rule/Regulation Violated:

R9-10-816.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of three sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a service plan dated February 13, 2025, which reflects that R1 receives medication administration services. 2. A review of R1’s medical record revealed the following medication orders dated January 29, 2025: Donepezil 10mg one tablet at bedtime; Quetiapine Fumarate 25mg one tablet three times daily with additional 50 mg dose; Quetiapine Fumarate 50 mg one tablet three times daily with an additional 25 mg dose. 3. A review of R1’s medication administration record (MAR) dated March 2025 reflected that R1 was not administered the following medications according to R1’s medication orders:· Donepezil 10mg on March 3, 2025; · Quetiapine Fumarate 25mg with 50 mg tablet on May 2, 2025, 1:30 pm dose, May 2, 2025 at 1:30pm dose, May 2, 2025 at 1:30 pm dose, May 3, 2025 8 pm dose, and May 28, 2025 1:30 pm dose.· Quetiapine fumarate 50mg with 25mg tablet on March 2, 2025, 1:30 pm dose, May 28, 2025, 1:30 pm dose, and May 3, 2025, 8:30 pm dose. 4. In an interview, E1 reviewed R1’s May 2025 MAR and acknowledged there was no documentation that the above medications were administered to R1.

Temporary Solution:

For immediate correction in order to ensure that Medication Administration is completed according to doctor’s orders and documentation is reflective of such, paper documentation will be provided for staff to document in the event that the electronic documentation is not available at any time for any reason. In addition, staff will be required to add a progress note explaining any missed/delayed medication documentation in the event that it should occur.

Permanent Solution:

Resident Services Director with support from Executive Director will ensure that MARs are completed and documented through a daily review of Missed Medication Report. Should this report show any outstanding medications, RSD and/or ED will communicate with care provider to ensure that medication was provided and documentation is appropriately completed either in the electronic or paper format.

Person Responsible:

Melissa Cecil, Executive Director Sheree Wilson, Resident Services Director, Brooklyn Harris, Compliance Officer

INSP-0055790

Complete

Date: 2/5/2025 - 2/6/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-03-21

Summary:

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 if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently.

Findings include:

1. A review of E1's, E2's, E3's, and E4's personnel records revealed no documentation of fall prevention and fall recovery training.

2. In an interview, E1 acknowledged there was no documentation to reflect E1, E2, E3, and E4 received training in fall prevention and fall recovery.

Deficiency #2

Rule/Regulation Violated:

K. A manager shall provide written notification to the Department of a resident's:
1. Death, if the resident's death is required to be reported according to A.R.S. § 11-593, within one working day after the resident's death; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident's unexpected death within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner.

Findings include:

1. A review of R1's medical record revealed a document titled "Human Remain Release Form" which reflected R1's date of death was June 24, 2023.

2. A review of R1's medical record revealed a document titled "Incident Report" June 24, 2023 which reflected R1 was found on the floor unresponsive. A review of R1's medical record revealed R1 was not on hospice.

3. A review of the facility's documentation revealed an email submitted to the Department on June 28, 2023 notifying the Department of R1's death.

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

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:
3. Includes the following:
c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type and frequency of assisted living services to be provided to the resident, for one of five sampled residents. The deficient practice posed a risk if a resident did not receive sufficient services as necessary.

Findings include:

1. A review of R2's medical record revealed a service plan dated December 17, 2024 for directed care services. The service plan indicated R2 required cues and reminders for grooming, hygiene, and dressing. However, the service plan did not indicate the amount or frequency at which the services would be provided.

2. In an interview, E1 reviewed R2's service plan and acknowledged R2's service plan did not reflect the amount or frequency of reminders or cues
for grooming, hygiene, and dressing that would be provided to R2.

Deficiency #5

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 to a resident in the residents' medical record, for one of five sampled residents.

Findings include:

1. A review of R3's medical record revealed a service plan on December 2, 2024 which reflected R3 require extensive physical assistance with toileting three times per day and weight monitoring once a month. A review of documented services provided to R3 reflected R3 was not provided toileting assistance from January 1, 2025 through February 4, 2025 and was not provided weight monitoring.

2. In an interview, E1 reviewed and acknowledged there was no documentation of R3 being assisted with toileting.

INSP-0055788

Complete

Date: 3/28/2023 - 3/29/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-04-27

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints #AZ00180422, #AZ00180532, #AZ00181566, and #AZ00187614 conducted on March 28, 2023 and March 29, 2022:

Deficiencies Found: 4

Deficiency #1

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 documentation review, record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for three of nine individuals sampled who were hired as a caregiver. The deficient practice posed a risk if E5, E7, and E8 were not qualified to provide the required services.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "Licensing of Nursing Personnel," dated June 8, 2021. Under the title, "Procedure," the document stated: "1. At the time of employment, nursing personnel who require a license or registration present verification of such license to the Resident Services Director and/or to Human Resources. 2. A copy of the current license and registration number is filed in the nurse's personnel record...4. If the validity or standing of a license is in question, the Resident Services Director and/or Human Resources will contact the appropriate board for verification. 5. Until the license is verified, the nurse will not perform any duties requiring licensure."

2. A review of E5's personnel record (hired as a caregiver) revealed a document titled, "Community Living Services, Inc. Part I Training Transcript for [E5]" located in Wayne, Michigan. The document indicated, "Training Complete for Part I Group Home Training Program. Date Completed: August 13, 2002."

3. A review of E5's personnel record revealed a training transcript from Macomb-Oakland Regional Center, Inc., indicating training dates of November 26, 2007 and December 11, 2007. An Internet search revealed the Macomb-Oakland Regional Center was located in Michigan.

4. Further review of E5's personnel record revealed no evidence that indicated E5 completed a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

5. A review of the NCIA verification of caregiver training portal (https://az.tmuniverse.com/) revealed E5 had not completed a caregiver training program after August 3, 2013 in Arizona.

6. A review of E7's personnel record (hired as a medication technician/caregiver) revealed a caregiver training certificate from Red Mountain Senior Services, ALTP 00049, dated February 27, 2006. A review of the certificate revealed the ALTP number on the certificate was five digits, rather than the typical four digits. Further review revealed a misspelling of the word Completion in the title, (spelled "COMPLEATION") and mistakes in documentation of the certificate number and the "Restricted Use for only RMSH only till" date. Two numbers appeared altered as evidenced by two hand-written numbers being written over existing documentation and not initialed or dated to indicate the mistake.

7. A review of the NCIA verification of caregiver training portal (https://az.tmuniverse.com/) revealed E7 had not completed a caregiver training program after August 3, 2013.

8. A review of E8's personnel record (hired as a caregiver) revealed a caregiver training certificate from Adult Caregiver Training Institute, ALTP 0136, dated October 11, 2012. Further review of the certificate revealed the certificate did not indicate the correct number of training hours required for each level of care.

9. A review of the NCIA verification of caregiver training portal (https://az.tmuniverse.com/) revealed E8 had not completed a caregiver training program after August 3, 2013.

10. In an interview, E1 acknowledged the aforementioned personnel members appeared to have invalid caregiver certificates. E1 reported E5, E7, and E8 did not work alone at the facility.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2), for five of twelve employees sampled. The deficient practice posed a risk if E3, E5, E9, E10, and E11 were a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(2) states: "Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card."

2. A review of E3's, E5's, E9's, E10's, and E11's personnel records revealed no documentation of good faith efforts to verify the current status of a person's fingerprint clearance card.

3. In an interview, E1 acknowledged E3's, E5's, E9's, E10's, and E11's personnel records did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2).

Deficiency #3

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 one of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R1's medical record revealed a service plan dated February 18, 2023. The service plan indicated R1 required medication administration, extensive assistance with bathing, total assistance with dressing, total assistance with grooming, extensive assistance with ambulation, minimal assistance with toileting, and moderate assistance with transferring.

2. A review of R1's medical record revealed documentation of the aforementioned activities of daily living was not included in R1's medical record.

3. The compliance officer requested R1's documentation of activities of daily living for review. E2 reported E2 was unable to find the documentation.

4. In an interview, E1 and E2 acknowledged the aforementioned services for R1 were not documented as required.

Deficiency #4

Rule/Regulation Violated:

F. A manager of an assisted living facility authorized to provide directed care services shall ensure that:
2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following:
a. Provides access to an outside area that:
i. Allows the resident to be at least 30 feet away from the facility, and
ii. Controls or alerts employees of the egress of a resident from the facility;

Evidence/Findings:

Based on documentation review, observation, and interview, the manager of an assisted living facility authorized to provide directed care services failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During a tour of the memory care area, the surveyor observed two doors leading to an outside patio area. Upon exiting the facility to the patio, the compliance officer did not hear an alert that would indicate egress of a resident. E1 reported the doors are equipped with alerts. However, E1 reported the alerts are only activated at night.

3. In an interview, E1 acknowledged the two doors in the memory care area did not alert employees of egress of a resident. E1 instructed an employee to activate the alert and indicated it needed to remain activated at all times.

Facility Information

Inspection History

INSP-0132796

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0055790

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

INSP-0055788

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings: