THE CITADEL ASSISTED LIVING FACILITY

<p>Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of ten personnel sampled. The deficient practice posed a potential TB exposure risk to residents.</p><p> </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p> </p><p>1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."</p><p><br></p><p><br></p><p><br></p><p> </p><p>2. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative..."</p><p><br></p><p><br></p><p><br></p><p> </p><p>3. A review of E8's personnel records revealed a negative TB skin test that was less than 12 months old; however, no documentation of a second negative TB skin test was available for review. Based on E8's hire date, this documentation was required.</p><p> </p><p> </p><p> </p><p>4. In an exit interview, the findings were reviewed with E1, E11, E12, and E13, and no additional information was provided.</p><p><br></p><p>  </p>

<p>Based on record review and interview, the manager failed to ensure that a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training for three of ten employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of E6’s, E7’s, and E9’s personnel records, who were hired as caregivers, revealed no documentation of current CPR training cards.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, the Compliance Officers requested the current CPR certifications, and the facility staff were unsure if E6, E7, and E9 had valid CPR training. E12 went online using their phone to locate the current CPR records for E6, E7, and E9. E12 acknowledged that the CPR was not documented in the personnel record at the time of the inspection.</p><p><br></p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, E11, E12, and E13, and no additional information was provided.</p>

<p>Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of ten residents sampled. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."</p><p> </p><p><br></p><p><br></p><p>2. A review of R3's and R5's medical records revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination of whether these residents had signs or symptoms of TB, signed by a registered nurse, medical practitioner, or local health department. Based on R3's and R5's admission dates, this documentation was required.</p><p><br></p><p><br></p><p> </p><p>3. In an interview, E11 reported that the documentation had been completed; however, it could not be found at the time of the inspection because the facility maintained all electronic records, and the requested document might not have been scanned in. E11 acknowledged that <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">R3's and R5's</span> medical records did not contain complete documentation of TB requirements at the time of the inspection.</p><p> </p><p><br></p><p><br></p><p>4. <span style="font-size: 14px;">In an exit interview, the findings were reviewed with E1, E11, E12, and E13, and no additional information was provided.</span></p>

<p>Based on record review, and interview, for one resident who stored medication in their residential unit, the manager failed to ensure the service plan included how the medication was stored and controlled. The deficient practice posed a health and safety risk if medications were not stored in a safe manner, as indicated on the resident's service plan. </p><p> </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R6's record revealed a written service plan dated March 26, 2025. This service plan stated R6 was receiving "personal care services and self-medication administration." However, this service plan did not indicate how the medication would be stored and controlled.</p><p><br></p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E6 reported that R6 had stored medications in the bedroom, the facility had not provided medication to R6, and the service plan was inaccurate.</p><p><br></p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, E11, E12, and E13, and no additional information was provided.</p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); font-size: 14px;">This is a repeat deficiency from the complaint inspection conducted on August 30, 2023.</span></p>

<p><span style="font-size: 10.5pt;">Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident.</span></p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 10.5pt;">1. A review of facility incident reports revealed an incident report for R1, dated September 7, 2025. and the report type was "Allegation of sexual abuse." The report stated, "On 09/07/25 it was reported by family that had informed daughter that [R1] had stated that a caregiver [E3] had tried to have sex with her."</span></p><p><span style="font-size: 10.5pt;"> </span></p><p><br></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">2. In an interview, R1 reported E6 had gone to R1’s room during the night, which is when E6 worked. R1 was able to describe who the caregiver was. R1 also reported E6 had touched R1’s breast and tried to put their hand down R1’s pants. R1 reported E6 had done this more than once. </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><br></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">3. </span><span style="font-size: 14px;">In an exit interview, the findings were reviewed with E1, E11, E12, E13, and no additional information was provided.</span></p><p><br></p><p><span style="font-size: 14px;"></span></p>

<p>Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning for four of four residents reviewed, receiving directed care services. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R1's, R5's, R8's, and R9's medical records revealed a current service plan for directed care service. The service plans stated "Activities and Socialization: Provide Activity Calendar Monthly; Provide Reminders and Assist to Activities of Choice; Encourage resident to participate in activities; Cognitive stimulation and activities to maximize functioning." The service plan did not include documentation of any specific details specifying what cognitive stimulation or activities to maximize functioning would be provided.</p><p><br></p><p><br></p><p><br></p><p>2. During an interview, E11 acknowledged that R1's, R5's, R8's, and R9's service plans did not include documentation of any specific details specifying what cognitive stimulation or activities to maximize functioning would be provided.</p><p><br></p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, E11, E12, E13, and no additional information was provided.</p><p><br></p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of ten residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.</p><p> </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p> </p><p>1. A review of R3's record revealed a current service plan for personal care services dated April 2025. This service plan indicated R3 received medication administration. </p><p><br></p><p><br></p><p><br></p><p>2. A review of R3's medical record revealed a signed medication order. This order stated "Metoprolol Tartrate Tablet 100 MG Give 0.5 tablet by mouth two times a day for HTN [hypertension]. HOLD FOR SBP [systolic blood pressure] LOWER THAN 100 OR PULSE LOWER THAN 55."</p><p><br></p><p><br></p><p> </p><p>3. A review of R3's <span style="color: rgb(68, 68, 68);">electronic </span>medication administration record (eMAR) revealed "Metoprolol Tartrate Tablet 100 MG Give 0.5 tablet by mouth two times a day for HTN. HOLD FOR SBP LOWER THAN 100 OR PULSE LOWER THAN 55" was administered July 1st - present. However, R3’s MAR did not include documentation of the resident’s systolic blood pressure (SBP) reading before each administration of the medication.</p><p><br></p><p><br></p><p><br></p><p>4. A review of R5's record revealed a current service plan for directed care services dated August 2025. This service plan indicated R5 received medication administration. </p><p><br></p><p><br></p><p><br></p><p>5. A review of R5's medical record revealed a signed medication order. This order stated "Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day HTN HOLD FOR SBP <110."</p><p><br></p><p><br></p><p> </p><p>6. A review of R5's eMAR revealed "Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day, related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD FOR SBP <110" was administered July 1st - present. However, the SBP reading was only documented on the following days;</p><p>-09/01/2025 17:07 117/78 mmHg (Sitting r/arm)</p><p>-08/01/2025 17:06 123/73 mmHg (Sitting r/arm)</p><p>-07/29/2025 11:37 106/65 mmHg</p><p>-06/30/2025 15:59 106/65 mmHg (Sitting r/arm)</p><p>However, R5’s eMAR did not include documentation of the resident’s SBP reading before each administration of the medication. The <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">Losartan Potassium should not have been administered on June 30, or on July 29, since the resident's SBP was below 110.</span></p><p><br></p><p><br></p><p><br></p><p>7. In an interview, E11 reported that R3’s and R5’s SBP readings were not obtained before each administration of the medication, and that the Losartan Potassium should not have been administered to R5 on June 30, or on July 29, since the resident's SBP was below 110.</p><p><br></p><p><br></p><p><br></p><p><br></p><p>8. <span style="font-size: 14px; background-color: rgb(255, 255, 255);">In an exit interview, the findings were reviewed with E1, E11, E12, and E13, and no additional information was provided.</span></p><p><br></p><p><br></p><p><br></p><p>This is a repeat deficiency from the inspections conducted on October 7, 2022, August 7, 2023, August 30, 2023, October 21, 2024, <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">and </span>December 18, 2024.</p>

<p>Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record for one of ten residents sampled. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p> </p><p><br></p><p>1. A review of R2's medical record revealed a current service plan that included personal care services and medication administration.</p><p><br></p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed documentation of a signed medication order dated September 02, 2025, for "Rosuvastatin Calcium Oral Tablet 40 MG Give 1 tablet by mouth at bedtime."</p><p><br></p><p><br></p><p><br></p><p>3. A review of R2's medical record revealed a September 2025 electronic medication administration record (eMAR). The eMAR had documented the following medications as administered;</p><p>-Rosuvastatin Calcium Oral Tablet 40 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime for cholesterol. Order Date: 09/07/2025. Administered September 7th to present.</p><p>-Rosuvastatin Calcium Oral Tablet 40 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime related to HYPERLIPIDEMIA, UNSPECIFIED. Order Date: 05/29/2025. Administered September 1st to present.</p><p>A further review of R2’s eMARs from July and August 2025 revealed that ‘Rosuvastatin Calcium Oral Tablet 40 MG’ was ordered to be administered once daily; however, the September 2025 eMAR incorrectly documented the medication as given twice a day at the same time.</p><p><br></p><p><br></p><p><br></p><p><br></p><p>4. In an interview, E11 reported that the above-mentioned medication was administered to R2 according to the medication order; however, the administrations were not properly documented.</p><p> </p><p> </p><p><br></p><p>5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p><br></p><p><br></p><p>This is a repeat deficiency from the inspections conducted on October 07, 2022, August 7, 2023, and May 05, 2023.</p>

<p><span style="font-size: 10.5pt;">Based on observation and interview, the manager failed to ensure the resident's bathroom provided privacy when in use. The deficient practice posed a risk to a resident's right to privacy, per R9-10-810.C.3.a.</span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">Findings include:</span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">1. The Compliance Officers observed a shared living space for R9 and R11 in Room 204A and 204B (Residential Unit). R9 resided in the actual bedroom, which was separated by a door from the living area, while R11 resided in the living area itself. If R9 needed to access the bathroom, R11 would pass through R9’s bedroom. The shared bathroom included a toilet, a shower, and a sink; however, there was no door or curtain at the bathroom entrance to ensure privacy while using the shower or toilet. </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">2. A review of Department documentation revealed the facility had provided a plan of correction (POC) with a correction date of June 6, 2025. The POC stated, “Long-Term: Privacy curtains will be installed in all shared units no later than 06/06/25. Monitoring System Going Forward: The Manager or designee will continue to have members of the Maintenance Department complete regular random quarterly audits of the facility going forward to ensure curtains are in place, clean and in in good condition. The facility’s compliance with this rule will be tracked by the Quality Management Program on an ongoing basis.” However, during the inspection, the Compliance Officers observed that no privacy curtain was in place at the time of the inspection. </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;"> </span></p><p><span style="font-size: 10.5pt;">This is a repeat citation from the complaint inspection conducted on April 21, 2025.</span></p>

<p>Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk.</p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed an incident report dated July 09, 2025. This incident report stated, “I was paged to resident room when I got to the resident [R1] was pale, and stated that [R1] had been throwing up for 3 days. residents throw up was black. I advised resident that [R1] was going to be sent out.... 911 came and transported resident to the hospital banner baywood.” However, documentation was not available that showed R1's emergency contact and primary care provider were notified <span style="color: rgb(68, 68, 68);"> Immediately.</span></p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 and E2 acknowledged that R1’s medical record did not contain documentation showing the caregiver had immediately notified the resident’s emergency contact and primary care provider.</p><p><br></p>

<p><span style="font-size: 14px;">Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for two of four residents sampled who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk.</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 14px;">1. A review of R1's medical record revealed an incident </span><span style="font-size: 14px; background-color: rgb(255, 255, 255);">report</span><span style="font-size: 14px;"> dated July 09, 2025. This incident </span><span style="font-size: 14px; background-color: rgb(255, 255, 255);">report</span><span style="font-size: 14px;"> stated, “I was paged to resident room when I got to the resident [R1] was pale, and stated that [R1] had been throwing up for 3 days. residents throw up was black. I advised resident that [R1] was going to be sent out.... 911 came and transported resident to the hospital banner baywood.” However, the documentation did not include any action taken to prevent the incident from occurring in the future.</span></p><p><br></p><p><br></p><p><br></p><p>2. <span style="background-color: rgb(255, 255, 255); font-size: 14px;">A review of R2's medical record revealed an incident report dated May 11, 2025. This incident report stated, “caregiver found resident on floor. with bleeding from head. took vitals contacted 911. applied pressure on wound to stop bleeding... sent to banner gateway.” However, the documentation did not include any action taken to prevent the incident from occurring in the future.</span></p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 14px;">3. In an interview, E1 and E2 reported that R1 and R2 were sent out to the hospital and acknowledged that </span><span style="font-size: 14px; background-color: rgb(255, 255, 255);">R1's and R2's</span><span style="font-size: 14px;"> medical records did not include documentation of any action taken to prevent the incident from occurring in the future.</span></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255); font-size: 14px;">This is a repeat deficiency from the inspection conducted on October 7, 2022, May 5, 2023 and </span><span style="background-color: rgb(255, 255, 255); font-size: 14px;">April 21, 2025.</span></p>

<p>Based on observation and interview, the manager failed to ensure the facility premises were cleaned and disinfected for two of four residents' rooms observed. The deficient practice posed a health risk to residents if the environment was not kept clean.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">Compliance Officers arrived at the facility around 11:00 AM.</span></p><p><br></p><p><br></p><p>2. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">During the environmental inspection, the Compliance Officers observed feces in the bathroom of R2 (Room 149). The bathroom had a strong feces odor, and dried feces were present on the rim of the toilet seat.</span></p><p><br></p><p><br></p><p><br></p><p>3<span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">. During the environmental inspection, the Compliance Officers observed an odor of urine in the hallway, which led the Compliance Officers to R5’s (room 157). The compliance officers observed a sticky floor with dried urine. </span></p><p><br></p><p><br></p><p>4. During the environmental inspection, E1 contacted housekeeping, and the rooms were cleaned immediately.</p><p><br></p><p><br></p><p>5. In an interview, E1 reported that R5 urinates on the floor and acknowledged that the facility was not maintained in a clean manner.</p>

<p>Based on documentation review, record review, and interview, 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 effect of the opioid administered, for two of two resident sampled who received an opioid.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure titled "Opioid Medication Administration, Policy Number: 7A.2." The Policy stated "5. Prior to administering the opioid medication, the Caregiver or Licensed Nurse will request the resident identify the pain they are experiencing. This will be entered into the eMAR as the resident described. 6. One to two hours after receiving the opioid medication, staff will return to the resident and ask them to identify their current pain. This will be entered into the eMAR as the resident described."</p><p><br></p><p><br></p><p>2. A review of R1's medical record revealed a medication order dated April 2025 for "Tramadol HCl Oral Tab 100 mg, three times a day." The April 2025 medication administration record (MAR) documented Tramadol as administered three times daily. However, documentation identifying R1’s need for the opioid prior to administration was only recorded on some days, and there was no documentation available showing the effectiveness of the opioid after administration.</p><p><br></p><p><br></p><p>3. A review of R4’s medical record revealed a medication order dated March 2025 for “Oxycodone HCl Oral Tab 15 mg.” The March 2025 MAR documented the administration of Oxycodone. However, documentation identifying R4’s need for the opioid prior to administration, as well as the effectiveness of the medication afterward, was not available for review.</p><p><br></p><p><br></p><p>4. A review of R1's and R4's medical records revealed no documentation stating either resident had an end-of-life condition or an active malignancy.  </p><p><br></p><p><br></p><p>5. In an interview, E1 acknowledged R1's and R4's medical records did not contain documentation of identification of the need for the opioid before the opioid was administered, and the effectiveness of the opioid administered. </p>

<p>Based on interview and documentation review, after having a reasonable basis to believe exploitation occurred on the premises, the manager failed to initiate an investigation of the suspected exploitation within five working days and documented the information. The deficient practice posed a risk to the resident’s financial well-being.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, E1 reported believing that exploitation occurred on the premises and stated that R3's daughter was exploiting R3 by not making any payments toward rent. E1 also reported that the concern was reported to Adult Protective Services (APS) around August 2024.</p><p><br></p><p> </p><p>2. The Compliance Officer requested the investigation related to the suspected exploitation; however, no documentation was available for review.</p><p><br></p><p><br></p><p>3. This is a repeat deficiency from the inspection conducted on October 3, 2023. </p>

<p>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 being provided to the resident, for two of two residents sampled who were nonambulatory. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to a resident.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of R1's medical record revealed a service plan dated March 01, 2025. The service plan stated, "Requires assist of 2 for transfer via Hoyer lift." However, there was no documentation of the need for repositioning.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed a service plan dated February 08, 2025. The service plan stated, "Requires assist of 1 or 2 for transfers. Requires assistance to propel wheelchair." However, there was no documentation of the need for repositioning.</p><p><br></p><p><br></p><p>3. In an interview, E2 reported that the staff repositioned R1 and R2 every 2 hours and as needed. E1 and E2 acknowledged R1's and R2's written service plans did not include the amount, type, and frequency of the services provided to the residents. </p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">4. This is a repeat deficiency from the inspection conducted on January 19, 2024. </span></p>

<p>Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p> </p><p><br></p><p>2. The Compliance Officer observed multiple ambulatory residents.</p><p> </p><p><br></p><p>3. During the environmental tour with E1, the Compliance Officer observed multiple unsecured exit doors that led directly to unprotected exterior areas, including the front parking lot, side roads, and main roads. The Compliance Officer opened each door and waited to see if any employees would respond to the potential elopement risk; however, no employees responded or approached to investigate. Some of the doors had alert systems that were not functioning. As a result, any resident could exit the facility without triggering an alert or notifying employees of the egress.</p><p> </p><p><br></p><p>4. In an interview, E1 acknowledged that there were ways to exit the facility to an outside area that did not control or alert employees of a resident's egress.</p>

<p>Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance, conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food subsitution no later than the morning of the day of meal service with a food subsitution. The deficient practice posed a risk of not meeting a resident's dietary needs.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental tour of the secured memory care unit, the Compliance Officer did not observe a conspicuously posted food menu. </p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged that the current food menu was not conspicuously posted the secured memory care unit.  </p>

<p>Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for two of two residents sampled who had an incident that resulted in the resident needing medical services. The deficient practice posed a risk if the facility did not take action to prevent an accident, emergency, or injury from occurring in the future to ensure the health and safety of residents.</p><p><br></p><p> </p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of R2's medical record revealed an incident report dated February 24, 2025. This incident report stated, "R2 states that R2 has been in pain since Saturday, and it has increased over the last few days. R2 says R2 is in a terrible amount of pain and wants it to stop and wants to be checked out at the ER. " However, the documentation did not include any action taken to prevent the incident from occurring in the future.</p><p> </p><p><br></p><p>2. In an interview, E1 and E2 reported R2 was sent out to the hospital. E1 and E2 acknowledged R2's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.</p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">3. This is a repeat deficiency from the inspection conducted on October 7, 2022 and May 5, 2023. </span></p>

<p>Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled, and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p> </p><p> </p><p>2. During the environmental tour, the Compliance Officer observed the following poisonous and toxic materials unlocked in the secured memory care unit:</p><p>- Gallon jug Cloralen Splash Bleach</p><p>- Gallon jug Great Value Lavender Scent Multi-Purpose Cleaner</p><p>- Spray bottle Bright Solutions Tropical Mist</p><p> </p><p><br></p><p>3. In an interview, E1 and E2 acknowledged that poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.</p>

<p>Based on observation and interview, the manager failed to ensure the resident's bathroom provided privacy when in use. The deficient practice posed a risk to a resident's right to privacy, per R9-10-810.C.3.a.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed a shared living space for R2 and R5 in Room 112 (Residential Unit). R5 resided in the actual bedroom, which was separated by a door from the living area, while R2 resided in the living area itself. If R2 needed to access the bathroom, R2 would pass through R5’s bedroom. The shared bathroom included a toilet, a shower, and a sink; however, there was no door or curtain at the bathroom entrance to ensure privacy while using the shower or toilet. Upon further investigation, the Compliance Officer identified that multiple residents resided in shared units with similar privacy concerns.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported that privacy concerns had not been raised during previous inspections and stated that the facility was originally licensed with that layout. E1 and E2 acknowledged that the shared bathroom used by R2 and R5 did not provide privacy when in use, and that multiple other residents resided in shared units with similar privacy concerns.</p>

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for four of seven residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R2's, R3's, R5's and R6's medical records revealed R2, R3, R5, and R6 received medication administration.

2. A review of R2's medical record revealed a signed medication list, dated November 19, 2024, which included Lantus SoloStar 100 unit/milliliter (mL), inject 35 units subcutaneously (sq) one time a day (qd).

3. A review of R2's medical record revealed a discontinue (d/c) order, dated November 19, 2024, for Triamcinolone Acetonide Cream 0.1%, apply to affected areas topically bid.

4. A review of R2's medication administration record (MAR), for December 2023, revealed the administration of the following medications:
- Lantus SoloStar 100 unit/mL, inject 25 units sq qd; and indicated 25 units were administered qd December 1, 2024 - December 10, 2024; and
- Triamcinolone Acetonide Cream 0.1% , apply to the affected areas topically bid, and indicated it was applied topically bid December 1, 2024 - December 10, 2024.

5. A review of R3's medical record revealed a signed medication list which included a d/c order, dated November 20, 2024, for Diclofenac Sodium External Gel 1%, apply to affected areas four times a day.

6. A review of R3's MAR, for December 2024, revealed the administration of Diclofenac Sodium External Gel 1%, apply to affected areas four times a day and indicated it was applied topically four times a day December 1, 2024 - December 13, 2024.

7. A review of R5's medical record revealed a signed medication list, dated November 27, 2024, which included the following medications:
- Trulicity 1.5 milligrams (mg)/0.5 mL, inject 1.5 mg sq once a week (q1w);
- Claritin 10 mg, 1 tablet by mouth (po) qd; and
- Escitalopram 10 mg, 1 tablet po qd.

8. A review of R5's medical record did not include a signed order for Erythromycin Ophthalmic Ointment 5 mg/gram (gm), 1 application in the left eye three times a day (tid).

9. A review of R5's MAR, for December 2024, revealed the administration of the following medications:
- Trulicity 0.75 mg/0.5 mL, inject 0.75 mg sq q1w and indicated 0.75 mg was injected on December 6, 2024 and December 13, 2024; and
- Erythromycin Ophthalmic Ointment 5 mg/gm, 1 application in left eye tid and indicated it was administered December 1, 2024 - current.

10. A review of R5's MAR, for December 2024, did not include documentation of administration of the following medications:
- Claritin 10 mg, 1 tablet po qd; and
- Escitalopram 10 mg, 1 tablet po qd.
However, documentation of d/c orders were not available for review.

11. A review of R6's medical record revealed signed orders, dated May 8, 2024, for the following medications:
- Insulin Lispro 100 units/mL, administered per sliding scale;
- Senna 8.6 mg, 2 tablets po bid; and
- Hydrochlorothiazide 25 mg, 0.5 tablet po qd.

12. A review of R6's medical record revealed a signed medication list, dated November 22, 2024, which included the following medications:
- Farxiga 10 mg, 1 tablet po qd;
- Pantoprazole Sodium 40 mg, 1 tablet po 30 minutes - 1 hour before morning meal qd;
- Tradjenta 5 mg, 1 tablet po qd;
- Admelog SoloStar 100 unit/mL, inject 4 units sq tid; and
- Furosemide 20 mg, 1 tablet po qd.

13. A review of R6's medical record did not include signed orders for the following medications:
- Clotrimozole Cream 1%, apply to affected areas topically qd;
- Dapaglifozin Propanediol 10 mg, 1 tablet po qd; and
- Ketoconazole External Cream 2%, apply to skin qd.

14. A review of R6's MAR, for December 2024, revealed the administration of the following medications:
- Clotrimozole Cream 1%, apply to affected areas topically qd and indicated it was applied topically qd December 1, 2024 - present;
- Dapaglifozin Propanediol 10 mg, 1 tablet po qd and indicated 1 tablet was administered qd December 1, 2024 - present; and
- Ketoconazole External Cream 2%, apply to skin qd and indicated it was applied qd December 1, 2024 - present.

15. A review of R6's MAR, for December 2024, did not include documentation of the administration of the following medications:
- Insulin Lispro 100 units/mL, administered per sliding scale;
- Senna 8.6 mg, 2 tablets po bid;
- Hydrochlorothiazide 25 mg, 0.5 tablet po qd;
- Farxiga 10 mg, 1 tablet po qd;
- Pantoprazole Sodium 40 mg, 1 tablet po 30 minutes - 1 hour before morning meal qd;
- Tradjenta 5 mg, 1 tablet po qd;
- Admelog SoloStar 100 unit/mL, inject 4 units sq tid; and
- Furosemide 20 mg, 1 tablet po qd.
However, documentation of d/c orders were not available for review.

16. In an interview, E1 acknowledged medications administered to R2, R3, R5, and R6 were not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual requires 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 three of ten residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R3's medical record revealed documentation of R3's need for continuous medical services, continuous or intermttent nursing services, or restraints signed by a medical practitioner. However, the document was not dated.

2. A review of R4's and R5's medical records revealed no documentation to indicate whether R4 and R5 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

3. In an interview E1 acknowledged the medical records for R3, R4, and R5 did not include the required documentation dated within 90 calendar days before the individuals were accepted by the assisted living facility.

This is a repeat deficiency from the copliance inspection conducted on May 4, 2023 - May 5, 2023.

Based on record review and interview the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident ' s medical record. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R4 ' s medical record revealed a current written service plan, for personal care services, dated April 30, 2024, which reported R4 would receive the following services:
- Encouragement to drink fluids of choice;
- Meals provided three times daily;
- Escorting to and from meals;
- Allowable assistance with indwelling catheter;
- Bowel incontinence care;
- Monitor skin for redness, openings, or abnormalities;
- Bathing two times per week;
- Encouragement with oral, skin, and daily grooming;
- Assistance with dressing;
- Medication administration
- Bed safety checks one time per night; and
- Housekeeping and laundry services weekly and as needed.

2. A review of R4 ' s ADL documentation for the month of October 2024, revealed R4 was provided assistance with the following services:
- Meal attendance; and
- Encouragement to drink fluids of choice.
However, no other documentation of additional services provided was available.

3. A review of R7 ' s service plan, dated August 8, 2024, revealed R7 would receive assistance with the following ADLs:
- Encouragement to drink fluids of choice;
- Meals provided three times daily;
- Escort to and from meals;
- Assistance with a mechanical soft diet;
- Assistance to propel the wheelchair;
- Medication administration
- Assistance with prompting to verbalize toileting needs and with incontinence care;
- Ensuring skin is clean and dried after incontinence;
- Assistance with bathing daily;
- Application of lotion after bathing;
- Monitor skin for redness, openings, or abnormalities;
- Assistance with all dressing including zippers, buttons, and laying out clothing;
- Frequent incontinence checks throughout the night; and
- Housekeeping and laundry services weekly.

4. A review of R7 ' s ADL documentation for the month of October 2024, revealed R7 was provided assistance with the following services:
- Encouragement for fluids of R7 ' s choice
- Meal attendance
However, no other documentation of additional services provided was available.

5. A review of R10 ' s medical record revealed a current written service plan, for personal care services, dated April 15, 2024, which reported R10 would receive the following services:
- Encourage R10 to drink fluids of choice;
- Meals provided three times daily;
- One time bed safety check / assistance per night;
- Medication Administration
- Assistance with R10 ' s glasses;
- Providing housekeeping and laundry service weekly and as needed; and
- Assist with skin maintenance by offering a cup of water with each medication pass and minimum one glass of fluid is offered with each meal.

6. A review of R10 ' s ADL documentation for the month of October 2024, revealed R10 was provided with assistance for meal attendance three times per day. However, no other documentation of additional services provided was available.

7. During an interview E1 reported that R4, R7, and R10 received assistance with all ADLs during October 2024. E1 acknowledged a caregiver or an assistant caregiver did not document the services provided in the resident's medical record.

This is a repeat deficiency from the complaint inspections conducted on January 18, 2024, August 7, 2023, and the compliance inspection conducted on May 4, 2023- May 5, 2023.

Based on record review and interview, the manager failed to ensure that if an assisted living facility provides medication administration, a medication administered to a resident is administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R7's and R10's medical records revealed R7 and R10 received medication administration.

2. A review of R7's medical record revealed documentation of a verbal order dated October 1, 2024, for Levaquin Oral Tablet 750 milligrams (mg). This order was documented by a Licensed Practical Nurse (LPN); however, the medication order was not verified by a medical practitioner as required. No other orders for Levaquin Oral Tablet 750 milligrams (mg) were available for review.

3. A review of R7's medication administration record (MAR) revealed Levaquin Oral Tablet 750mg was administered once daily October 3 - October 21, 2024.

4. A review of R10's medical record revealed an unsigned medication list, titled "Order Summary Report", however, this list was not a signed medication order.

5. A review of R10's medication administration record (MAR) for October, 2024 revealed R10 was administered the following medications:
- Acetaminophen Tablet 325 milligram (MG), two tablets three times per day administered in the morning, afternoon, and evening October 1 - October 21, 2024;
-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 12 unit subcutaneously two times a day in the morning, and in the evening October 1 - October 21, 2024;
- Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 UNIT/ML, twenty unit two times a day in the morning, and evening October 1 - October 21, 2024;
- CycloSPORINE Emulsion 0.05%, instill one drop in both eyes two times a day in the morning, and evening October 1 - October 21, 2024;
- MetFORMIN HCl Tablet 1000 MG, one tablet two times a day in the morning, and evening October 1 - October 21, 2024;
- Metoprolol Tartrate Tablet 25 MG, one tablet two times a day in the morning, and evening October 1 - October 21, 2024;
- Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5 ML, 0.75 mg one time a day every Friday administered on October 4, October 11, and October 18;
- Vitamin D3 Tablet 25 MCG, one tablet one time a day at 8:00AM October 1 - October 21, 2024;
- CloNIDine HCl Tablet 0.1 MG, one tablet two times a day in the morning, and evening October 1 - October 21, 2024;
- Clotrimazole Vaginal Cream 2% (Clotrimazole Vaginai), apply to folds and vaginal area topically two time a day documented as self administered October 1 - October 21, 2024;
- Losartan Potassium Tablet 100 MG, one tablet one time a day at 8:00AM October 1 - October 21, 2024;
- Multivitamin Tablet (Multiple Vitamin), one tablet one time a day at 8:00AM October 1 - October 21, 2024;
- Solifenacin Succinate Tablet 10 MG, one tablet one time a day in the morning October 1 - October 21, 2024;
- Tradjenta Tablet 5 MG, one tablet one time a day at 8:00AM October 1 - October 21, 2024;
- Ferrous Sulfate Oral Tablet 325 (65Fe) MG (Ferrous Sulfate), one tablet one time a day in the morning October 1 - October 21, 2024;
- Fluticasone Propionate Suspension 50 MCG/ACT, two spray in both nostrils one time a day at 8:00AM October 1 - October 21, 2024t;
- Glimepiride Tablet 4mg, one tablet one time a day at 8:00AM October 1 - October 21, 2024t;
- Levothyroxine Sodium Tablet 125MCG, one tablet in the morning at 5:00AM October 1 - October 21, 2024t;
- amlodipine Besylate Oral Tablet 2.5 MG (Amlodipine Besylate), one tablet one time a day in the morning October 1 - October 21, 2024; and
- Atorvastatin Calcium Tablet 20 MG, give one tablet at bedtime at 8:00PM October 1 - October 20, 2024.

6. During an interview E1 acknowledged R7's and R10's medication was not administered in compliance with a medication order.

This is a repeat deficiency from the compliant inspection conducted on August 7, 2023.

Based on record review and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of R2's medical record revealed a document dated February 2, 2024. This document stated "...HWD [Health and Wellness Director] received a call from (R2's family) stating (R2) called (HWD) around 1am stating (R2) had been sitting on the toilet for 3 hours and no one came to check on (R2). Resident stated, "I pushed my pendant and sat for hours."

2. In an interview, E1 reported the call pendant system went down in the afternoon of February 1, 2024 and returned to functioning the morning of February 2, 2024.

3. In an interview E2 reported staff was instructed to conduct safety checks every two hours.

4. Review of facility documents revealed R2 received safety/room checks at 6:24pm and 8:12pm February 1, 2024 and at 12:09am and 6:42am February 2, 2024.

5. Review of R2's medical record revealed a current written service plan for personal care services dated February 2, 2024. This service plan indicated R2 required assistance of one of two for transfers and was incontinent of bladder/bowel and required assistance from staff.

6. In an interview, E1 and E2 acknowledge R2's bedroom did not contain a bell, intercom, or other mechanical means available to alert employees to R2's needs February 1-2nd, 2024.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the frequency of assisted living services being provided to the resident, for three of seven residents sampled.

Findings include

1. A review of R1's medical record revealed a service plan for directed care services dated January 15, 2024. The service plan indicated R1 required "Routine Planned Frequent Checks for Safety" at night. However, the service plan did not include the frequency of safety checks to be provided.

2. A review of R4's medical record revealed a service plan for directed care services dated November 21, 2023. The service plan stated, "Resident is visually checked on frequently through the day and night to promote safety and to encourage participation in activities." However, the service plan did not include the frequency of visual checks to be provided.

3. A review of R6's medical record revealed a service plan for personal care services dated September 18, 2023. The service plan indicated R6 required "Routine Planned Frequent Checks for Safety" at night. However, the service plan did not include the frequency of safety checks to be provided..

4. In an interview, E1 and E2 acknowledged the service plans did not include the frequency of safety checks provided to R1, R4, and R6.

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 seven 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 R2's medical record revealed a service plan dated October 24, 2023 for personal care services. The service plan indicated R2 required a "one time bed safety check/assistance per night."

2. A review of R2's activities of daily living documentation revealed an "X" from December 1, 2023-December 31, 2023, indicating the safety checks were not provided.

3. A review of R3's medical record revealed a service plan dated October 24, 2023 for personal care services. The service plan indicated R3 required a "one time bed safety check/assistance per night."

4. A review of R3's activities of daily living documentation revealed an "X" from December 1, 2023-December 31, 2023 and January 1, 2024-January 31, 2024, indicating the safety checks were not provided.

5. A review of R7's medical record revealed a service plan dated September 24, 2023 for personal care services. The service plan indicated R7 required a "one time bed safety check/assistance per night."

6. A review of R7's activities of daily living documentation revealed the safety checks were not documented as performed on the following nights:
-December 9, 2023-December 13, 2023; and
-December 19, 2023.

7. In an interview, E1 and E2 acknowledged the services were not documented as required.

This is an uncorrected deficiency from the complaint inspection conducted on August 7, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of facility documentation revealed an incident report dated January 16, 2024. The incident report revealed R1 could not be located in the memory care area and a room search of memory care was conducted. While conducting the room search, a family member (visiting another resident) asked the resident care coordinator (RCC) if the RCC was looking for someone. The RCC confirmed, and the family member stated, "Tall male was leaving out the door as we were coming in."

2. In an on-site complaint investigation, the Compliance Officer observed the memory care area of the facility. On the door leading into the memory care area, the Compliance Officer observed a red sign that stated, "Dear visitors, your kindness is appreciated. Our secured unit ensures resident safety. We kindly ask that you avoid letting anyone out without notifying staff. Thank you for your understanding and cooperation."

3. The Compliance Officer observed there was no control or alert on the door leading into the memory care area. E2 and the Compliance Officer were able to walk freely into the memory care area. When exiting the memory care area, the Compliance Officer observed a keypad combination was necessary to open the door from the inside.

4. In an interview, E1 and E2 reported it was believed R1 left the memory care area as other visitors were coming in from outside the memory care area. Security camera footage was reviewed and R1 was seen outside the locked memory care area and also walking out the front door of the facility.

5. In an interview, E1 and E2 acknowledged the memory care door was not controlled on both sides, resulting in R1 eloping and potentially causing R1 to suffer physical injury.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags.

Findings include:

1. During a facility tour, the Compliance Officer observed the garbage containers were not covered in R4 and R8's rooms.

2. In an interview, E1 and E2 acknowledged the garbage containers were uncovered.

This is an uncorrected deficiency from the complaint inspection conducted on August 30, 2023.

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 to include initial training in 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 policies and procedures revealed a policy titled "Fall Prevention and Fall Recovery" dated October 2021. The procedure stated "... 1. Staff training: All staff will receive their initial training immediately... 2. Ongoing (continued competency training) will be provided and mandatory annually as part of the facility's ongoing training policy requirements..."

2. A review of E5's personnel record revealed initial training in fall prevention and fall recovery was not available for review.

3. A review of E6's personnel record revealed initial training in fall prevention and fall recovery was not available for review.

4. A review of facility documentation revealed a fall prevention/recovery in-service training (dated August 15, 2023). However, the training documentation revealed E5 and E6 had not completed fall prevention and recovery training.

5. In a joint interview, E1, E2, and E3, acknowledged the health care institution failed to administer the initial fall prevention and fall recovery training to E5 and E6.

This Rule was cited on August 7, 2023. A letter sent to the facility, dated August 23, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Based on documentation review, record review, and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards.

Findings include:

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

2. A review of facility policies and procedures revealed a policy titled "Subject: Secured Unit; Policy: 6H.1" (reviewed April 2023). However, the policy did not include any procedures covering methods by which the assisted living facility was aware of the general or specific whereabouts of a residents based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

3. A review of facility documentation revealed a three page document titled "Location of resident" dated August 28, 2023. The documentation consisted of multiple rows and thirteen columns. The first column was assigned for resident room numbers starting at 131-A to 154. The remaining twelve columns were titled "6am; 8am; 10am; 12pm; 2pm; 4pm; 6pm; 8pm; 10pm; 12am; 2am; and 4am". The document indicated employees were to monitor residents daily within the secured unit (memory care unit). However, there was no documented procedure identifying the implemented operational control associated with the "Location of a resident" document presented to the Compliance Officers.

4. In an interview, E3 reported all residents, regardless of level of care, who are provided services in the assisted living facility, are monitored for any changes in conditions, based on incident reporting and service plan updates. The monitoring is documented within the electronic medical record system (EMR) to ensure residents residing in units outside of the secured unit (memory care unit) are appropriately cared for or placed in the appropriate unit based on the needs of the resident. However, E3 acknowledged the identified procedure has not been officially documented in and established and documented policy and procedure.

5. In a joint interview, E1, E2, and E3 acknowledged policies and procedures were not established or documented to cover the methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

Based on observation, record review and interview, the manager failed to ensure a resident had a written service plan included medication administration, for two of three residents sampled who received personal care services; and included, for a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled, for one of three residents sampled who received personal care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A.R.S. \'a7 36-401(A)(39) "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

2. The Compliance Officers observed the door to R6's and R7's shared residential unit propped open by a Swiffer sweeper/mop. The Compliance Officers observed a multi-dose medication blister pack prescribed to R6, on top of the dining room table of R6's and R7's shared residential unit. The medication blister pack was "Tramadol HCL 50 MG Tablet; Take 1/2 Tablet by mouth twice daily as needed for pain."

3. A review of R6's medical record revealed a service plan for personal care services dated in July 2023. In the section titled "Focus: Medication/Pharmacy" it stated "Able to Self Medicate." However, the service plan did not include administration of medications for a resident receiving personal care services, and the service plan did not include how the medication would be stored and controlled.

4. A review of R7's medical record revealed a service plan for personnel care services dated in August 2023. In the section titled "Focus: Medication/Pharmacy" it stated "Able to Self Medicate ... Self administration medications are stored and controlled in locked cabinet in residents room." However, the service plan did not include administration of medication for a resident receiving personal care services.

5. In a joint interview, E6, E7, and E3 acknowledged R6's and R7's service plans, did not include the required documentation.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for two of three current resident sampled who received directed care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A review of R1's medical record revealed a written service plan for directed care services dated in March 2023. However, a reviewed and updated service plan completed at least once every three months was not available for review.

2. A review of R2's medical record revealed a written service plan for directed care services dated in May 2023. However, a reviewed and updated service plan completed at least once every three months was not available for review.

3. In a joint interview, E1, E2, and E3 acknowledged the manager failed to ensure R1 and R2 had a written service plan reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure when a resident's written service plan was initially developed and when updated, the service plan was signed and dated by the resident or resident's representative, the manager, and if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plans, for two of four current residents sampled who received medication administration. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.

Findings include:

1. A review of R2's medical record revealed a service plan dated in May 2023. The service plan was seven pages and consisted of various rows and columns identifying R2's needs. In the row titled "Focus: Medication/Pharmacy" it stated "Staff performs medication administration. This includes ... administering medication to final destination." However, the service plan was not signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

2. A review of R5's medical record revealed a six-page document titled "Physicians Report" dated June 13, 2023 and signed by a medical practitioner. Under the section titled "Consents" it stated "Do you consent for trained caregivers to administer medications including DM injections and blood glucose monitoring ... Yes."

3. A review of R5's medical record revealed a service plan dated in August 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

4. In a joint interview, E1, E2, and E3 acknowledged R2's and R5's service plans were not signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

Based on documentation review, record review, and interview, the manager failed to establish and document policies and procedures to ensure the safety of a resident who may wander. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident, and posed a risk as policies and procedures reinforce and clarify the health care institution's standards.

Findings include:

1. A review of facility policies and procedures revealed a policy titled "Subject: Secured Unit; Policy: 6H.1" (reviewed April 2023). However, the policy did not include an procedures on how to ensure the safety of a resident who may wander.

2. A review of facility documentation revealed a three page document titled "Location of resident" dated August 28, 2023. The documentation consisted of multiple rows and thirteen columns. The first column was assigned for resident room numbers starting at 131-A to 154. The remaining twelve columns were titled "6am; 8am; 10am; 12pm; 2pm; 4pm; 6pm; 8pm; 10pm; 12am; 2am; and 4am". The document indicated employees were to monitor residents daily within the secured unit (memory care unit). However, there was no documented procedure identifying the implemented operational control associated with the "Location of a resident" document presented to the Compliance Officers.

3. In joint interview, E1, E2, and E3 acknowledged policies and procedures were not established and documented to ensure the safety of a resident who may wander.

Based on documentation review, 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 four current residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of facility policies and procedures revealed a policy titled "Subject: Administration of Medications; Policy: 7A" (reviewed April 2023). The procedure stated, "... 2. Medications must be given in accordance with the resident's service plan ... 3. Medications must be administered in accordance with the with the written orders of the attending physician ... 10. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation".

2. A review of R5's medical record revealed a six-page document titled "Physicians Report" dated June 13, 2023 and signed by a medical practitioner. Under the section titled "Consents" it stated, "Do you consent for trained caregivers to administer medications including DM injections and blood glucose monitoring ... Yes". Under the section titled "Current Medications" the following medications were listed:
- "Insulin Glargine Solution 100 UNIT/ML; Directions: Inject 25 Unit subcutaneously at bedtime for DM;
- "Omeprazole Oral Tablet Delayed Release 20 MG; Directions: Give 1 tablet by mouth in the morning for GERD";
- "Amlodipine Besylate Oral Tablet 10 MG. Directions: Give 1 tablet by mouth one time a day for HTN";
- "Atorvastatin Calcium Oral Tablet 80 MG: Directions: Give 1 tablet orally at bedtime for HYPERLIPIDEMIA";
- "Donepezil HCI Oral Tablet 10 MG; Directions: Give 1 tablet by mouth every 12 hours for DEMENTIA";
- "Metoprolol Tartate Oral Tablet 50 MG; Directions: Give 1 tablet by mouth every 12 hours for HYPERTENSION"; and
- "MetFORMIN HCI Oral Tablet 1000 MG; Directions: Give 1 tablet by mouth two times a day for DM".
No subsequent medication orders were provided for review at the time of the inspection.

3. A review of R5's medication administration record (MAR) dated June 1, 2023 to June 31, 2023, revealed a section titled "Chart Codes." The chart codes section stated "2=Hold/See Nurse Notes...7=Other/See Nurse Notes ...". A section titled "Chart Codes/Follow Up Codes" indicated a "check mark" indicated the medication had been administered.
However, medication administration was not documented as provided with and "X" on R2's MAR for the following medications on the following dates:
- From July 21 to July 22, "Omeprazole Oral Tablet Delayed Release 20 MG..."
- From 19 to July 21, "MetFORMIN HCI Oral Tablet 1000 MG ..."
- From July 19 to July 20, "MetFORMIN HCI Oral Tablet 1000 MG..." (afternoon).
Additionally, following medications were documented with a chart code "2" or "7", indicating the medication was not administered, and "nurse notes" were not provided during the time of the inspection:
- From July 19 to July 20, July 23 to July 25, and from July 27 to July 28 "Insulin Glargine Solution 100 UNIT/ML Inject 25 unit..." was not documented as administered
- From July 19 to July 21, and from July 24 -July 28, "Atorvastatin Calcium Oral Tablet 80 MG..." was not documented as administered;
- From July 19 to July 20, "Donepezil HCI Oral Tablet 10 MG..." was not administered in the morning;
- On July 19, "Donepezil HCI Oral Tablet 10 MG..." was not administered in the evening;
- From July 19 to July 20 "Metoprolol Tartate Oral Tablet 50 MG..." was not administered in the morning; and
- On July 19, "Metoprolol Tartate Oral Tablet 50 MG..." was not administered in evening.

4. A review of R5's medication administration record (MAR) dated August 1, 2023 to August 31, 2023, revealed a section titled "Chart Codes". The chart codes section stated "2=Hold/See Nurse Notes...7=Other/See Nurse Notes ...14=No Insulin Required". A section titled "Chart Codes/Follow Up Codes" indicated a "check mark" indicated the medication had been administered. Under the sections titled "Accucheck at bedtime for diabetis [sic]" R5's blood sugar was not documented between August 1 to August 17, and August 27. Under the section titled"Accucheck in the morning for diabetis [sic]" R6's blood sugar was not documented between August 1 to August 18, and August 27.
However, medication administration was not documented as administered with an "X" on R2's MAR for the following medications on the following dates:
- From August 15 to August 28, "Insulin Glargine Solution 100 UNIT/ML Inject 25 unit..."
- From August 3 to August 28, "Omeprazole Oral Tablet Delayed Release 20 MG..."
- From August 22 to August 28, "Atorvastatin Calcium Oral Tablet 80 MG..."
- From August 3 to August 28, "MetFORMIN HCI Oral Tablet 1000 MG..."
Additionally, the following medications were documented with a chart code "2","7" or "14", indicating the medication was not administered, and "nurse notes" were not provided during the time of the inspection:
- From August 1 to August 2, August 6 to August 10, and August 12, "Insulin Glargine Solution 100 UNIT/ML Inject 25 unit..." was not administered;
- From August 3 to August 4, "Amlodipine Besylate Oral Tablet 10..." was not administered; and
- From August 3 to August 4, and August 17 to August 19 "Atorvastatin Calcium Oral Tablet 80 MG..." was not administered.

5. In a joint interview E1, E2 and E3 acknowledged R5 received medication administration and R5's medication was not administered in compliance with an order.

Rule R9-10-816.B.3.a.b.c. was cited on August 7, 2023. A letter sent to the facility, dated August 23, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."

Based on observation, record review, and interview, the manager failed to ensure the premises used at the assisted living facility were cleaned and disinfected to prevent, minimize, and control illness or infection. The deficient practice posed a health and safety risk to residents.

Findings include:

1. The Compliance Officers observed R6's and R7's residential unit door propped open with a Swiffer sweeper/mop at the bottom of the door. The following was observered in a R6's and R7's shared unit:
- An open can of Pringles on R6's bed with Pringles chip crumbs all over R6's bed and floor surrounding R6's bed;
- A styrofoam cup filled with coins and what appeared to be pills, a clothing item, a package of water bottles, a bottle of hand sanitizer, picture frames and documents stacked on the dining room table; and
- Three bottles of All purpose concentrated cleaner, and an open can of cleaning powder were on top of the kitchen counter near an ice cube tray and plastic containers used for food storage.

2. A review of R6's medical record revealed a service plan for personal care services dated in July 2023. The service plan was six pages, five pages consisted of various rows and columns identifying R6's needs. In the row titled "Housekeeping" with revision date "03/24/2023" stated "Intervention: Provide Housekeeping and Laundry Service weekly and PRN; Pick Up Trash Daily; and Daily Bed Making."

3. A review of R7's medical record revealed a service plan for personnel care services dated in August 2023. The service plan was seven pages, six pages consisted of various rows and columns identifying R7's needs. In the row titled "Mobility" with revision date "04/18/2023" stated "Intervention: ... At Risk for Falls - Wears Emergency Pendant." In the row titled "Housekeeping" with revision date "04/18/2023" stated "Provide Housekeeping and Laundry Service Weekly and PRN." In the row titled "Falls" with revision date "04/18/2023" stated "Intervention: At Risk for Falls - Wears Emergency Pendant."

4. In an interview E1 acknowledged R6's and R7's shared residential unit was not in a condition to be able to prevent, minimize and control illness or infection. E1 acknowledged R6's bed sheets were soiled, the bedside table and dining table were not free of clutter to appropriately use and disinfect, and the cleaning supplies were stored near food containers.

5. In a joint interview, E1, E2, and E3 acknowledged R6's and R7's residential unit was not cleaned to prevent, minimize, and control illness or infection.

This is a repeat deficiency from the compliance inspection conducted on May 5, 2023, and the correction date was indicated as June 30, 2023.

Based on observation, record review, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Findings include:

1. The Compliance Officers observed R6's and R7's residential unit door propped open with a Swiffer sweeper/mop at the bottom of the door. The following was observered in a R6's and R7's shared unit:
- Three empty plastic containers, and two reaching aids on R6's bed;
- Two water bottles, a bottle of beer, baby oil, Listerine, deodorant, a flash light, no more than ten prescription ointments, and no more than ten over the counter medications, on the bedside tray table near R6's bed;
- An empty wine bottle, a flash light, an unlined trash can, and a cane on the floor near R6's bed;
- A bedside commode with a cardboard box, blankets and clothing items stacked on top of it, near R6's bed;
- Five exposed electrical cords plugged into an exposed power strip, two baskets with a cardboard box stacked on top, a package of adult diapers, a vacuum, a slipper, and a wheelchair on the floor in front of R6's dresser;
- Four pillows, blankets, a towel, boxes, a package of bed pads, and a red bucket with various textiles stuffed inside, on the floor surrounding the dining room table; and
- A multi-dose medication blister pack of "Tramadol HCL 50 MG Tablet; Take 1/2 Tablet by mouth twice daily as needed for pain." The blister pack was on top of the dining room table.

2. A review of R6's medical record revealed a service plan for personal care services dated in July 2023. The service plan was six pages, five pages consisted of various rows and columns identifying R6's needs. In the row titled "Housekeeping" with revision date "03/24/2023" stated "Intervention: Provide Housekeeping and Laundry Service weekly and PRN; Pick Up Trash Daily; and Daily Bed Making."

3. A review of R7's medical record revealed a service plan for personnel care services dated in August 2023. The service plan was seven pages, six pages consisted of various rows and columns identifying R7's needs. In the row titled "Mobility" with revision date "04/18/2023" stated "Intervention: ... At Risk for Falls - Wears Emergency Pendant." In the row titled "Housekeeping" with revision date "04/18/2023" stated "Provide Housekeeping and Laundry Service Weekly and PRN." In the row titled "Falls" with revision date "04/18/2023" stated "Intervention: At Risk for Falls - Wears Emergency Pendant."

4. In an interview E1 acknowledged R6's and R7's shared residential unit had various items on the floor near the R6's bed, the dining table, and in front of R6's dresser that may cause a resident or other individual to suffer physical injury. E1 acknowledged the controlled opioid medication (Tramadol) on the dining room table was accessible to any resident or other individual walking by the open room and could cause an individual to suffer physical injury.

5. In a joint interview, E1, E2, and E3 acknowledged R6's and R7's residential unit was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers.

Findings include:

1. The Compliance Officers observed an uncovered can, not lined with a plastic bag, in R6's and R7's shared residential unit.

2. In an interview, E1 acknowledged the uncovered garbage and refuse container was not lined with a plastic bag in R6's and R7's shared residential unit.

Based on documentation review, 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 suspected abuse or neglect; any action taken according to subsection (J)(1); and the report in subsection (J)(2). The deficient practice posed a risk as the Center failed to properly investigate and document suspected abuse or neglect.

Findings include:

1. A review of facility documentation revealed an incident report dated August 8, 2023. The incident report revealed R1 had a fall.

2. A review of facility documentation revealed an incident report for falls dated August 8, 2023, August 13, 2023, and August 14, 2023. The incident report revealed R1 had a fall on all of the above mentioned dated, emergency medical services was activated, and R1 was sent to the hospital for further evaluation and treatment.

3. In an interview, E1 reported E1 was aware the Mesa Fire Department referred the aforementioned incident to the Mesa Police Department for abuse and neglect.

4. A review of R1's medical record revealed documentation to indicate the manager documented the suspected abuse or neglect; any action taken according to subsection (J)(1); and reported in subsection (J)(2) was not available for review.

5. In a joint interview, E1, E2, E3, E7, and O1 acknowledged the manager failed to document the suspected abuse or neglect; any action taken according to subsection (J)(1); and report in subsection (J)(2).

6. In a telephonic interview, conducted on October 3, 2023, O2 reported O2 was assigned to investigate the suspected abuse and/or neglect of R1.

7. A review of documentation, received by the Department on October 3, 2023, revealed a "CRIME SCENE UNIT FIELD PROCESSING REPORT" (dated August 14, 2023). The report stated "...OFFENSE...ELDER ABUSE..."

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 to include initial training in fall prevention and fall recovery.

Findings include:

1. A review of facility policies and procedures revealed a policy titled " Fall Prevention and Fall Recovery" dated October 2021. The procedure stated "... 1. Staff training: All staff will receive their initial training immediately... 2. Ongoing (continued competency training) will be provided and mandatory annually as part of the facility's ongoing training policy requirements..."

2. A review of E5's personnel record revealed initial training in fall prevention and fall recovery was not available for review.

3. A review of facility documentation revealed a fall prevention/recovery in-service training (dated June 6, 2023). The training documentation revealed E5 had not completed fall prevention and recovery training.

4. In a joint interview, E1, E2, and E3 acknowledged the health care institution failed to administer the fall prevention and fall recovery intial training and continued competency training for all staff.

Based on record review and interview, the manager failed to ensure a resident had a written service plan updated based on changes in the requirements in subsections (A)(3)(a)(b)(c) no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for two of twelve residents sampled.

Findings include:

1. In an interview, E2 reported R5 was placed in the memory care unit in October 2022.

2. A review of R5's medical record revealed a service plan for personal care services dated in December 2021. However, a service plan dated 14 calendar days after R5's reported change in condition was not available for review.

3. In an interview, E2 reported R8 had a change in condition and was moved to the memory care unit on July 1, 2023.

4. A review of R8's medical record revealed a service plan for personal care services dated in July 2023. However, a service plan dated 14 calendar days after R8's reported change of condition was not available for review.

5. In a joint interview, E1, E2, and E3 acknowledged R5 and R8 had a change in condition and R5's and R8's service plans were not updated within 14 calendar days after the change.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of six current 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 R2's (admitted in 2022) medical record revealed a service plan for personal care services dated in March 2023. R2's service plan revealed R2 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R2 on the following dates and shifts were not available for review:
-June 2-3, 2023 (Night Shift);
-June 16, 2023 (Night Shift);
-June 24, 2023 (Night Shift); and
-June 30, 2023 (Night Shift).

2. A review of R7's (admitted in 2022) medical record revealed a service plan for personal care services dated in May 2023. R7's service plan revealed R7 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R7 on the following dates and shifts were not available for review:
-June 3, 10, 17, 2023 (Day Shift);
-June 11, 15, 16, 19-24, 26-30, 2023 (Evening Shift); and
-June 1-30, 2023 (Night Shift).

3. A review of R9's (admitted in 2022) medical record revealed a service plan for personal care services dated in May 2023. R9's service plan revealed R9 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R9 on the following dates and shifts were not available for review:
-June 3, 10, 17, 2023 (Day Shift);
-June 11, 15, 16, 19-24, 26-30, 2023 (Evening Shift); and
-June 1-30, 2023 (Night Shift).

4. A review of R10's (admitted in 2019) medical record revealed a service plan for directed care services dated in February 2023. R10's service plan revealed R10 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R10 on the following dates and shifts were not available for review:
-July 1, 2, 2023 (Day Shift);
-July 1, 2, 22-24, 27-31, 2023 (Evening Shift); and
-July 2-10, 11-22, 24-31, 2023 (Night Shift).

5. A review of R11's (admitted in 2023) medical record revealed a service plan for personal care services dated in January 2023. R11's service plan revealed R11 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R11 on the following dates and shifts were not available for review:
-August 1-3, 2023 (Day Shift);
-August 3-6, 2023 (Evening Shift); and
-August 1-6, 2023 (Night Shift).

6. In a joint interview, E1, E2, and E3 acknowledged documentation to indicate services were provided to R2, R7, R8, R9, R10, and R11 were not documented.

This is a repeat deficiency from the onsite compliance inspection and complaint investigation completed on May 4, 2023 and May 5, 2023.

Based on observation, record review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner, for one of six current residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration.

Findings include:

1. The Compliance Officers observed the following pharmacy provided medication bubble pack belonging to R10:
-Oxycodone Tab 5 mg, take 1 tablet by mouth two times a day.

2. A review of R10's medical record revealed a medication order for Oxycodone Tab 5 mg, take 1 tablet by mouth two times a day was not available for review.

3. A review of R10's medical record revealed a medication administration record dated in July 2023. The MAR revealed R10 received medication administration of the above mentioned medication on the following dates and times:
-July 1, 2023 at 8AM and 8PM;
-July 2, 2023 at 8AM;
-July 3-5, 2023 at 8AM and 8PM;
-July 6, 2023 at 8AM;
-July 7-8, 2023 at 8PM;
-July 9-10, 2023 at 8AM and 8PM;
-July 11, 2023 at 8PM;
-July 12-24, 2023 and 8AM and 8PM;
-July 25, 2023 at 8PM;
-July 27, 2023 at 8PM; and
-July 28-30, 2023 at 8AM and 8PM.

4. In a joint interview, E1, E2, and E3 acknowledged a medication order for the observed medication belonging to R10 was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for four of six current residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information regarding R7.

Findings include:

1. A review of R2's medical record revealed a service plan dated in March 2023 for personal care services. The service plan revealed R2 received medication administration.

2. A review of R2's medical record revealed a medication order dated in April 2023 and signed by a medical practitioner for the following:
-Nuplazid Oral Tablet 10 mg, give 1 tablet by mouth one time a day for Parkinsons; and
-Rytary Oral Capsule Extended Release 36.25-145 mg, give 2 capsules by mouth five times a day for Parkinsons.

3. A review of R2's medical record revealed a medication administration record (MAR) dated July 2023. The MAR revealed medication administration was not documented as administered on R2's MAR for the following medications on the following dates:
-Nuplazid Oral Tablet 10 mg, give 1 tablet by mouth one time a day for Parkinsons: July 12-30, 2023; and
-Rytary Oral Capsule Extended Release 36.25-145 mg, give 2 capsules by mouth five times a day for Parkinsons: July 13-14, 2023.

4. A further review of R2's MAR dated July 2023 revealed Nuplazid Oral Tablet 10 mg, give 1 tablet by mouth one time a day for Parkinsons was discontinued effective July 11, 2023. However, a discontinue order was not provided for review.

5. A review of R7's medical record revealed a service plan dated in May 2023 for personal care services. The service plan revealed R7 received medication administration.

6. A review of R7's medical record revealed a medication order dated in April 2023 and signed by a medical practitioner for the following:
-Atorvastatin Calcium Tablet 20 mg, give 1 tablet by mouth at bedtime for HLP;
-Gabapentin Oral Capsule 300 mg, give 2 capsule by mouth at bedtime for nerve pain;
-Ropinirole HCI Tablet 0.5 mg, give 1 tablet by mouth at bedtime for Tremors;
-Zonisamide Capsule 100 mg, give 3 capsule by mouth at bedtime for Seizures;
-Aspercreme Lidocaine Cream 4%, apply to left hand, neck topically two times a day for pain;
-Carvedilol Oral Tablet 3.125 mg, give 1 tablet by mouth two times a day for HTN;
-Corlanor Tablet 5 mg, give 1 tablet by mouth two times a day for chest pain;
-Gabapentin Capsule 400 mg, give 1 capsule by mouth two times a day for Neuropathy;
-Lamotrigine Tablet 150 mg, give 2 tablet by mouth two times a day related to Generalized Idiopathic Epilepsy and Epileptic Syndromes;
-Wixela Inhub Aerosol Powder Breath Activated 250-50 mcg/act, 1 puff inhale orally two times a day for COPD; and
-Pentoxifylline ER Tablet 400 mg, give 1 tablet by mouth three times a day for PVD.

7. A review of R7's medical record revealed a MAR dated July 2023. The MAR revealed medication administration was not documented as administered on R7's MAR for the following medications on the following dates and times:
-Atorvastatin Calcium Tablet 20 mg, give 1 tablet by mouth at bedtime for HLP on July 9-10, 2023;
-Gabapentin Oral Capsule 300 mg, give 2 capsule by mouth at bedtime for nerve pain on July 9-10, 2023;
-Ropinirole HCI Tablet 0.5 mg, give 1 tablet by mouth at bedtime for Tremors on July 1, 9-10, 2023;
-Zonisamide Capsule 100 mg, give 3 capsule by mouth at bedtime for Seizures on July 1, 9-10, 2023;
-Aspercreme Lidocaine Cream 4%, apply to left hand, neck topically two times a day for pain on July 9, 2023;
-Carvedilol Oral Tablet 3.125 mg, give 1 tablet by mouth two times a day for HTN on July 9, 2023 at 8PM;
-Corlanor Tablet 5 mg, give 1 tablet by mouth two times a day for chest pain on July 9, 2023 at 8PM;
-Gabapentin Capsule 400 mg, give 1 capsule by mouth two times a day for Neuropathy on July 9, 2023 at 8PM;
-Lamotrigine Tablet 150 mg, give 2 tablet by mouth two times a day related to Generalized Idiopathic Epilepsy and Epileptic Syndromes on July 9, 2023 at 8PM;
-Wixela Inhub Aerosol Powder Breath Activated 250-50 mcg/act, 1 puff inhale orally two times a day for COPD on July 9, 2023 at 8PM; and
-Pentoxifylline ER Tablet 400 mg, give 1 tablet by mouth three times a day for PVD on July 9, 2023 at 8PM.

8. The Compliance Officers observed a screenshot from E1's cell phone stated "Shift Notes 7-20-23 EMS called for 220AL" (R7) transported to [hospital]."

9. A review of R7's medical records revealed a progress note dated August 6, 2023. The progress note stated "hospital."

10. A further review of R7's MAR dated July 2023 revealed E5 initialed the following medications as being administered to R7 on July 20, 2023 at 8PM:
-Atorvastatin Calcium Tablet 20 mg, give 1 tablet by mouth at bedtime for HLP:
-Gabapentin Oral Capsule 300 mg, give 2 capsule by mouth at bedtime for nerve pain;
-Ropinirole HCI Tablet 0.5 mg, give 1 tablet by mouth at bedtime for Tremors;
-Zonisamide Capsule 100 mg, give 3 capsule by mouth at bedtime for Seizures;
-Aspercreme Lidocaine Cream 4%, apply to left hand, neck topically two times a day for pain;
-Carvedilol Oral Tablet 3.125 mg, give 1 tablet by mouth two times a day for HTN;
-Corlanor Tablet 5 mg, give 1 tablet by mouth two times a day for chest pain;
-Gabapentin Capsule 400 mg, give 1 capsule by mouth two times a day for Neuropathy;
-Lamotrigine Tablet 150 mg, give 2 tablet by mouth two times a day related to Generalized Idiopathic Epilepsy and Epileptic Syndromes;
-Wixela Inhub Aerosol Powder Breath Activated 250-50 mcg/act, 1 puff inhale orally two times a day for COPD; and
-Pentoxifylline ER Tablet 400 mg, give 1 tablet by mouth three times a day for PVD.
However, E4 reported R7 was in the hospital during the above mentioned time.

11. A review of R9's medical record revealed a service plan dated in May 2023 for personal care services. The service plan revealed R9 received medication administration.

12. A review of R9's medical record revealed a medication order dated in January 2023 and signed by a medical practitioner for the following:
-Atorvastatin Calcium Tablet 20 mg, give 1 tablet by mouth at bedtime for HLD;
-Donepezil HCI Tablet 5 mg, give 1 tablet by mouth at bedtime for Dementia; and
-Potassium Chloride ER Tablet 20 meq, give 1 tablet by mouth at bedtime.

13. A review of R9's medical record revealed a MAR dated July 2023. The MAR revealed medication administration was not documented as administered on R9's MAR for the following medications on July 9, 2023 at 8PM:
-Atorvastatin Calcium Tablet 20 mg, give 1 tablet by mouth at bedtime for HLD;
-Donepezil HCI Tablet 5 mg, give 1 tablet by mouth at bedtime for Dementia; and
-Potassium Chloride ER Tablet 20 meq, give 1 tablet by mouth at bedtime.

14. A review of R10's medical record revealed a service plan dated in February 2023 for directed care services. The service plan revealed R10 received medication administration.

15. A review of R10's medical record revealed a MAR dated in July 2023. The MAR revealed R10 received medication administration of Oxycodone HCI Oral Tablet 5 mg, give 1 tablet by mouth two times a day for pain on the following dates and times:
-July 1, 2023 at 8AM and 8PM;
-July 2, 2023 at 8AM;
-July 3-5, 2023 at 8AM and 8PM;
-July 6, 2023 at 8AM;
-July 7-8, 2023 at 8PM;
-July 9-10, 2023 at 8AM and 8PM;
-July 11, 2023 at 8PM;
-July 12-24, 2023 at 8AM and 8PM;
-July 25, 2023 at 8PM;
-July 27, 2023 at 8PM; and
-July 28-30, 2023 at 8AM and 8PM.
However, a medication order was not available for review.

16. In a joint interview, E1, E2, and E3 acknowledged medication administered to residents were not administered in compliance with a medication

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C)(1), for twelve of twelve employees sampled. The deficient practice posed a risk if employees were a danger to a vulnerable population, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

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.

1. A review of E1's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

2. A review of E2's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

3. A review of E3's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

5. A review of E4's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

6. A review of E5's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

7. A review of E6's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

8. A review of E7's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

9. A review of E8's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

10. A review of E9's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

11. A review of E10's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

12. A review of E11's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

13. A review of E12's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

14. In a joint interview, E1 and E2 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C)(1) for the above mentioned personnel members.

Based on record review, documentation review, and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings Include:

1. A review of E1's, E2's, E3's, E4's, E5's, E6's, E7's, E8's, E9's, E10's, E11's, and E12's personnel records revealed documentation of valid fingerprint clearance cards. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

2. A review of E8's personnel record revealed documentation of "TB Skin Test Consent Form" dated March 3, 2023. However, the documentation revealed E8's name, signature, date given and date read were filled in with wet ink, and E1's signature, site, lot number, and expiration date were phot copied.

3. A review of E10's personnel record revealed documentation of "TB Skin Test Consent Form" dated December 15, 2022. However, the documentation revealed E10's name and signature were filled in with wet ink and E1's signature was a photo copy.

4. A review of E12's personnel record revealed documentation of freedom from infectious tuberculosis was not available for review.

5. A review of E1's (hired in 2022) personnel record revealed a document titled "Job Description; Wellness Director" signed by E1 and dated on May 16, 2022. The section titled "Certificates and Licenses:"stated "Must possess an active Registered Nurse license valid in this state...". However, documentation to include evidence E1 was a registed nurse was not available for review.

5. A review of E3's, E5's, E6's, and E7's personnel records revealed initial training in fall prevention and fall recovery was not available for review.

6. A review of R8's medical record revealed documentation to include whether R8 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. However, the document was not dated and the word "Yes" was circled to the right of the statement "Does the resident require restraints?"

7. A review of R10's medical record revealed documentation to include whether R10 required continuous medical services, continuous nursing services, intermittent nursing services or restraints. However, the part of the document signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant signature was wet ink, the remainder of the document appeared to be pre-filled and photocopied, and the word "Yes" was circled to the right of the statement "Does the resident require restraints?"

8. A review of R1's medical record revealed a service plan for personal care services dated in November 2022. R1's service plan revealed R1 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R1 on the following dates and shifts was not available for review:
-March 6, 2023 (Day Shift);
-March 11, 2023 (Day Shift);
-March 13, 2023 (Day Shift);
-March 18, 2023 (Day Shift);
-March 25, 2023 (Night Shift); and
-April 7, 2023 (Evening Shift).

9. A review of R2's medical record revealed a service plan for personal care services dated in January 2023. R2's service plan revealed R2 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R2 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 4, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21, 2023 (Evening Shift);
-March 24-31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 15-16, 2023 (Night Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

10. A review of R3's medical record revealed a service plan for personal care services dated in November 2022. R3's service plan revealed R3 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R3 on the following dates and shifts was not available for review:
-March 5, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21, 2023 (Evening Shift);
-March 24-31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 15-16, 2023 (Night Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

11. A review of R4's medical record revealed a service plan for personal care services dated in February 2023. R4's service plan revealed R4 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R4 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21-24, 2023 (Evening Shift);
-March 27-29, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 22, 2023 (Evening Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

12. A review of R5's medical record revealed a service plan for personal care services dated in December 2022. R5's service plan revealed R5 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R5 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 21-24, 2023 (Evening Shift);
-March 27-29, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 7, 2023 (Evening Shift);
-April 10-11, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 19, 2023 (Evening Shift);
-April 24, 2023 (Night Shift); and
-April 30, 2023 (Night Shift).

13. A review of R6's medical record revealed a service plan for personal care services dated in February 2023. R6's service plan revealed R6 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R6 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 5, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21-23, 2023 (Evening Shift);
-March 27-28, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 23-24, 2023 (Night Shift); and
-April 30, 2023 (Night Shift).

14. A review of R7's medical record revealed a service plan for directed care services dated in March 2023. R7's service plan revealed R7 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R7 on the following dates and shifts was not available for review:
-March 4-9, 2023 (Evening Shift);
-March 12, 2023 (Day Shift);
-March 16, 2023 (Evening Shift);
-March 19, 2023 (Day Shift);
-March 19, 2023 (Evening Shift);
-March 23-25, 2023 (Evening Shift); and
-March 29-31, 2023 (Evening Shift).

15. A review of R3's medication administration record dated in April 2023 revealed a section to document blood sugar monitoring. However, R3's blood sugar was not documented as required in the medication order.

16. A review of R1's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for two of eleven current employees sampled and one of one previous employee sampled. The deficient practice posed a TB exposure risk to residents, the Department was provided false or misleading documentation during the inspection, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E8's (hired in 2023) personnel record revealed documentation of "TB Skin Test Consent Form" dated March 3, 2023. However, the documentation revealed E8's name, signature, date given and date read were filled in with wet ink; and E1's signature, site, lot number and expiration date were photo copied.

2. A review of E10's (hired in 2022) personnel record revealed documentation of "TB Skin Test Consent Form" dated December 15, 2022. However, the documentation revealed E10's name and signature were filled in with wet ink; and E1's signature was a photo copy.

3. In an interview, E1 acknowledged the photocopied signature was E1's signature. The findings were further discussed with E1. E1 did not confirm the documentation was altered and no additional comment or documentation was provided for review.

4. A review of E12's (hired in 2023) personnel record revealed documentation of freedom from infectious TB was not available for review.

5. In a joint interview, E1 and E2 acknowledged E12 did not provide documentation of freedom from infectious TB.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documention of the individual's education and experience applicable to the individual's job duties, for one of eleven current personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E1's (hired in 2022) personnel record revealed a document titled "Job Description; Wellness Director" signed by E1 and dated on May 16, 2022. The section titled "Certificates and Licenses:"stated "Must possess an active Registered Nurse license valid in this state...". However, documentation to include evidence E1 was a registered nurse was not available for review.

2. A review of the National Council of State Boards of Nursing website revealed E1 was licensed in the state of Arizona as a Practical Nurse.

3. In a joint interview with E1 and E2, E1 acknowledged the aforementioned job description identified E1's education and experience did not meet the required education and experience found in E1's signed job description.

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 in-service education, for four of eleven current personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer.

1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery" (dated October 1, 2021). The policy and procedure stated "...Staff training: All staff will receive their initial training immediately and this training will also will be part of general orientation for all new employees ..."

2. A review of E3's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

3. A review of E5's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

4. A review of E6's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

5. A review of E7's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

6. In a joint interview, E1 and E2 acknowledged E3's, E5's, E6's, and E7's initial training in fall prevention and fall recovery were not completed according to the facility's policies and procedures.

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 individual was accepted by the assisted living facility; dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of twelve current residents sampled and one of one discharged residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was provided false or misleading documentation during the inspection, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R8's medical record revealed documentation to include whether R8 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. However, the document was not dated and the word "Yes" was circled to the right of the statement "Does the resident require restraints?"

2. In an interview, E1 reported R8 did not require restraints and was unsure why the section of the form was filled out indicating R8 required restraints.

3. A review of R10's medical record revealed documentation to include whether R10 required continuous medical services, continuous nursing services, intermittent nursing services or restraints. However, the part of the document signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant signature was wet ink, the remainder of the document appeared to be pre-filled and photocopied, and the word "Yes" was circled to the right of the statement "Does the resident require restraints?"

4. In an interview, the findings regarding R10's document were discussed with E1. E1 did not confirm the documentation was altered and no additional comment or documentation was provided for review.

This is a repeat defiency from the onsite compliance inspection conducted on October 7, 2022.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for seven of twelve current residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (admitted in 2020) medical record revealed a service plan for personal care services dated in November 2022. R1's service plan revealed R1 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R1 on the following dates and shifts was not available for review:
-March 6, 2023 (Day Shift);
-March 11, 2023 (Day Shift);
-March 13, 2023 (Day Shift);
-March 18, 2023 (Day Shift);
-March 25, 2023 (Night Shift); and
-April 7, 2023 (Evening Shift).

2. A review of R2's (admitted in 2023) medical record revealed a service plan for personal care services dated in January 2023. R2's service plan revealed R2 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R2 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 4, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21, 2023 (Evening Shift);
-March 24-31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 15-16, 2023 (Night Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

3. A review of R3's (admitted in 2020) medical record revealed a service plan for personal care services dated in November 2022. R3's service plan revealed R3 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R3 on the following dates and shifts was not available for review:
-March 5, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21, 2023 (Evening Shift);
-March 24-31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 15-16, 2023 (Night Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

4. A review of R4's (admitted in 2016) medical record revealed a service plan for personal care services dated in February 2023. R4's service plan revealed R4 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R4 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21-24, 2023 (Evening Shift);
-March 27-29, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 22, 2023 (Evening Shift);
-April 23-24, 2023 (Evening Shift); and
-April 30, 2023 (Evening Shift).

5. A review of R5's (admitted in 2022) medical record revealed a service plan for personal care services dated in December 2022. R5's service plan revealed R5 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R5 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 21-24, 2023 (Evening Shift);
-March 27-29, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 7, 2023 (Evening Shift);
-April 10-11, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 19, 2023 (Evening Shift);
-April 24, 2023 (Night Shift); and
-April 30, 2023 (Night Shift).

6. A review of R6's (admitted in 2022) medical record revealed a service plan for personal care services dated in February 2023. R6's service plan revealed R6 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R6 on the following dates and shifts was not available for review:
-March 1-31, 2023 (Night Shift);
-March 5, 2023 (Evening Shift);
-March 9, 2023 (Evening Shift);
-March 12, 2023 (Evening Shift);
-March 21-23, 2023 (Evening Shift);
-March 27-28, 2023 (Evening Shift);
-March 31, 2023 (Evening Shift);
-April 4-5, 2023 (Night Shift);
-April 9-10, 2023 (Night Shift);
-April 16-17, 2023 (Night Shift);
-April 23-24, 2023 (Night Shift); and
-April 30, 2023 (Night Shift).

7. A review of R7's (admitted in 2019) medical record revealed a service plan for directed care services dated in March 2023. R7's service plan revealed R7 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R7 on the following dates and shifts was not available for review:
-March 4-9, 2023 (Evening Shift);
-March 12, 2023 (Day Shift);
-March 16, 2023 (Evening Shift);
-March 19, 2023 (Day Shift);
-March 19, 2023 (Evening Shift);
-March 23-25, 2023 (Evening Shift); and
-March 29-31, 2023 (Evening Shift).

8. In a joint interview, E1 and E2 acknowledged documentation to indicate services were provided to R1, R2, R3, R4, R5, R6 and R7 were not documented.

Based on record review and interview, the manager failed to ensure a resident was treated with consideration. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R3's medical record revealed an order dated March 9, 2023 and signed by a nurse practitioner. The order stated "Monitor blood sugar 1 x weekly related to DM2."

2. A review of R3's medication administration record dated in April 2023 revealed a section to document blood sugar monitoring. However, R3's blood sugar was not documented as required in the medication order.

3. In a joint interview, E1 and E2 reported to be unsure if R3's blood sugar was being checked.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for seven of twelve current residents sampled, and one of one discharge residents sampled. The deficient practice posed a TB exposure risk to residents, the Department was provided false or misleading documentation during the inspection, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the date read, induration and PPD test result were filled in with wet ink; and R1's name, the date given, site, lot number, expiration date and E1's signature were photo copied.

2. A review of R3's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the R3's name, date read, induration and PPD test result were filled in with wet ink; and the date given, site, lot number, expiration date and E1's signature were photo copied.

3. A review of R4's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the R4's name, date read, induration and PPD test result were filled in with wet ink; and the date given, site, lot number, expiration date and E1's signature were photo copied.

4. A review of R6's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the date read, induration and PPD test result were filled in with wet ink; and R6's name, the date given, site, lot number, expiration date and E1's signature were photo copied.

5. A review of R7's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the R7's name, date read, induration and PPD test result were filled in with wet ink; and the date given, site, lot number, expiration date and E1's signature were photo copied.

6. A review of R9's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the R9's name, date read, induration and PPD test result were filled in with wet ink; and the date given, site, lot number, expiration date and E1's signature were phto copied.

7. A review of R10's medical record revealed documentation of "Tuberculosis Skin Test Form" dated July 2, 2022. . However, the "Date Read" was blank; and the induration, PPD test result,and E1's signature were filled in with wet ink.

8. A review of R12's medical record revealed documentation of "Tuberculosis Skin Test Form" dated September 7, 2022. However, the documentation revealed the date read, induration and PPD test result were filled in with wet ink; and R12's name, the date given, site, lot number, expiration date and E1's signature were photo copied.

9. In a telephonic interview conducted on May 4, 2023, E10 reported O2 asked E1 to sign in the "Administered By" and "results read by" sections of the "Tuberculosis Skin Test Form."

10. In an interview, E1 acknowledged the photocopied signature was E1's signature. The findings were further discussed with E1. E1 did not confirm the documentation was altered and no additional comment or documentation was provided for review.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, for one of twelve residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 36-406(1)(d) The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized.

1. A review of R3's medical record revealed documentation of notification of the availability of vaccination for flu and pneumonia vaccination dated in 2021. However, documentation of the notification for the flu and pneumonia vaccinations available to R3 on site on a yearly basis was not available for review.

2. In a joint interview, E1 and E2 acknowledged documentation of R3's notification of the availability of the vaccination for flu and pneumonia on a yearly basis was not available for review.

This is a repeat deficiency from the onsite compliance inspection conducted on October 7, 2022.

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R4's medical record revealed a document titled "Resident/Resident Representative Consent for Chair or Non-Ambulatory Status/Stage 3 or 4 Wound" dated and signed by a medical practitioner in September 2022. The document revealed an "X" to the left of the following statement: "Non-ambulatory. By definition per the State of Arizona, this means they have the inability to ambulate even with assistance and is confined to a bed or chair." However, R4's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months.

2. A review of R9's medical record revealed a document titled "Resident/Resident Representative Consent for Chair or Non-Ambulatory Status/Stage 3 or 4 Wound" dated and signed by a medical practitioner in September 2022. The document revealed an "X" to the left of the following statement: "Non-ambulatory. By definition per the State of Arizona, this means they have the inability to ambulate even with assistance and is confined to a bed or chair." However, R9's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months.

3. In an interview, E1 stated the requested documentation was "in a binder in my office."

4. In a joint interview, E1 and E2 acknowledged the statements required from the resident's primary care provider or other medical practitioner every six months during R4's and R9's residency were not provided for review.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for three of twelve current residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R4's medical record revealed a service plan dated in February 2023 for personal care services. The service plan revealed R4 received medication administration.

2. A review of R4's medical record revealed a medication order dated in April 2023 and signed by a medical practitioner for the following:
-Mirtazapine Tablet Disintegrating 15 MG Give 1 tablet by mouth at bedtime for INSOMNIA;
-Tamsulosin HCI Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH;
-Trazodone HCI Tablet 50 MG Give 1 tablet by mouth at bedtime for INSOMNIA;
-Furosemide Oral Tablet 40 MG Give 1 tablet by mouth two times a day for edema;
-Carbidopa-Levodopa Tablet 25-100 MG Give 1 tablet by mouth three times a day for Parkinsons; and
-Tylenol Extra Strength Tablet 500 MG Give 2 tablet by mouth every 8 hours for PAIN.

3. A review of R4's medical record revealed a medication administration record (MAR) for April 2023. The MAR revealed medication administration was not documented as administered on R4's MAR for the following medications on the following dates:
-Mirtazapine Tablet Disintegrating 15 MG Give 1 tablet by mouth at bedtime for INSOMNIA (April 16, 2023);
-Tamsulosin HCI Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH (April 16, 2023);
-Trazodone HCI Tablet 50 MG Give 1 tablet by mouth at bedtime for INSOMNIA (April 16, 2023);
-Furosemide Oral Tablet 40 MG Give 1 tablet by mouth two times a day for edema (April 16, 2023 at 8PM);
-Carbidopa-Levodopa Tablet 25-100 MG Give 1 tablet by mouth three times a day for Parkinsons (April 16, 2023 at 8PM); and
-Tylenol Extra Strength Tablet 500 MG Give 2 tablet by mouth every 8 hours for PAIN (April 28, 2023 at 8PM).

4. In a joint interview, E1 and E2 acknowledged medication administered to R4 was not documented in R4's medical record.

5. A review of R5's medical record revealed a service plan dated in December 2022 for personal care services. The service plan revealed R5 received medication administration.

6. A review of R5's medical record revealed a medication order dated in March 2023 and signed by a medical practitioner for the following:
-Gabapentin Capsule 300 MG Give 1 capsule by mouth at bedtime for nerve pain;
-Hydroxyzine HCI Oral Tablet 25 MG Give 2 tablet by mouth at bedtime for itching;
-Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for INSOMNIA;
-Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth two times a day for DEPRESSION; and
-Lactulose Solution 10 GM/15ML Give 15 ml by mouth three times a day for BOWEL CARE.

7. A review of R5's medical record revealed a MAR for April 2023. The MAR revealed medication administration was not documented as administered on R5's MAR for the following medications on the following dates:
-Gabapentin Capsule 300 MG Give 1 capsule by mouth at bedtime for nerve pain (April 1, 2023 and April 16, 2023);
-Hydroxyzine HCI Oral Tablet 25 MG Give 2 tablet by mouth at bedtime for itching (April 1, 2023 and April 16, 2023);
-Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for INSOMNIA (April 1, 2023 and April 16, 2023);
-Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth two times a day for DEPRESSION (April 1, 2023 and April 16, 2023); and
-Lactulose Solution 10 GM/15ML Give 15 ml by mouth three times a day for BOWEL CARE (April 1, 2023 and April 16, 2023 at 8PM).

8. In a joint interview, E1 and E2 acknowledged medication administered to R5 was not documented in R5's medical record.

9. A review of R6's medical record revealed a service plan dated in February 2023 for personal care services. The service plan revealed R6 received medication administration.

10. A review of R6's medical record revealed a medication order dated in March 2023 and signed by a medical practitioner for the following:
-Aricept Tablet 5 MG Give 1 tablet by mouth at bedtime for Dementia;
-Atorvastatin Calcium Tablet 20 MG Give 1 tablet by mouth at bedtime for HLD;
-Trazodone HCI Tablet 150 MG Give 1 tablet by mouth at bedtime for Depression;
-Eliquis Oral Tablet 5 MG Give 1 tablet by mouth two times a day for DVT; and
-Rivastigmine Tartrate Capsule 3 MG Give 1 capsule by mouth two times a day for Dementia.

11. A review of R6's medical record revealed a MAR for April 2023. The MAR revealed medication administration was not documented as administered on R6's MAR for the following medications on the following dates:
-Aricept Tablet 5 MG Give 1 tablet by mouth at bedtime for Dementia (April 1, 2023 and April 16, 2023 at 8PM);
-Atorvastatin Calcium Tablet 20 MG Give 1 tablet by mouth at bedtime for HLD (April 1, 2023 and April 16, 2023);
-Trazodone HCI Tablet 150 MG Give 1 tablet by mouth at bedtime for Depression (April 1, 2023 and April 16, 2023);
-Eliquis Oral Tablet 5 MG Give 1 tablet by mouth two times a day for DVT (April 1, 2023 and April 16, 2023); and
-Rivastigmine Tartrate Capsule 3 MG Give 1 capsule by mouth two times a day for Dementia (April 1, 2023 and April 16, 2023).

12. In a joint interview, E1 and E2 acknowledged medication administered to R6 was not documented in R6's medical record.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include: the time of the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed a disaster plan review dated April 3, 2023. However, the disaster plan review did not include documentation of the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.

2. In a joint interview, E1 and E2 acknowledged the disaster plan review did not include the above mentioned requirements.

Based on documentation review and interview, the manager failed to ensure a caregiver or assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future, for one of twelve current residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed an incident report for R3 dated in January 2023. The document stated, "...Resident pressed pendant for assistance, caregiver entered resident's room, observer [sic] [R3] laying on the floor, skin tear noted to right forearm and right eye, 911 called, resident taken [hospital] for eval and treatment, ..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. A review of facility documentation revealed an incident report for R3 dated in October 2022. The document stated, "...Resident c/o vomiting coffee ground emesis, NP notified, orders given to send resident to [hospital] for eval and treatment ..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.

3. In a joint interview, E1 and E2 acknowledged the incident reports for R3 did not contain any actions taken to prevent the accident, emergency, or injury from occurring in the future.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected to prevent, minimize, and control illness or infection. The deficient practice posed a health risk to residents, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. The Compliance Officers observed a brown substance resembling feces on the toilet seat in R6's bathroom and a sticky substance on R6's bathroom floor and bedroom floor.

2. In an interview, R6 reported housekeeping cleaned R6's residential unit every Friday.

3. The Compliance Officers observed a brown substance resembling feces on the toilet seat in R8's and R12's shared bathroom.

4. In a joint interview, E1 and E2 acknowledged the substances in R6's bathroom and residential unit and R8's and R12's shared bathroom.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents. The deficient practice posed a burn risk to residents, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. The Compliance Officers observed the water temperature from R1's kitchen sink to be 122.6\'ba F. The temperature was measured using a Department-issued thermometer.

2. The Compliance Officers observed the water temperature from R4's bathroom sink to be 122.2\'ba F. The temperature was measured using a Department-issued thermometer.

3. The Compliance Officers observed the water temperature from R5's bathroom sink to be 122.2\'ba F. The temperature was measured using a Department-issued thermometer.

4. In a joint interview, E1 and E2 acknowledged the water temperatures in the resident bathrooms were not maintained between 95\'ba F and 120\'ba F.

This is a repeat deficiency from the onsite compliance inspection conducted on October 7, 2022.