THE MONTECITO SENIOR LIVING

<p>Based on documentation review, record review, and interview, the manager failed to ensure that an assisted living center maintained a copy of the document provided to the emergency responders and documentation of the actions required for a period of two years after the date of the emergency. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).” </p><p><br></p><p><br></p><p>2. A review of R1’s medical record revealed no copies of the packet given to Emergency Services (EMS) for the incident on August 29, 2025, at 1:00 pm.</p><p><br></p><p> </p><p>3. In an interview, E3 reported that the staff did complete a packet for EMS but forgot to save a copy. </p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E3 and E4, and no additional information was provided. </p>

<p>Based on record review, documentation review, and interview, the manager failed to ensure that when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, <span style="color: rgb(68, 68, 68);">for one of one resident</span>. The deficient practice posed a health and safety risk.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed the following: </p><ul><li>A progress note for August 29, 2025, at 1:00 pm stated, “Resident finished lunch in the dining area, when [R1] asked staff if [R1] could go lay down in her room. Caregiver was walking resident to [R1's] room with a chair behind [R1] for safety precautions due to new onset of weakness. Resident sat down in the chair and began to have seizure like activity, became unresponsive with shallow breathing, an shortly after lifesaving measures were started. Paramedics and POA were contacted. Once paramedics arrived on scene they took over lifesaving measures and resident was transported to Arrowhead hospital where [R1] was later pronounced deceased.” </li><li>There was no documentation that the physician was notified of the August 29, 2025, incident at 1:00 pm. </li></ul><p><br></p><p><br></p><p>2. A review of the facility’s policies and procedures revealed a policy titled “Incident Reports.” The policy stated, “Incidents are immediately reported to the resident’s family/responsible party and physician.”</p><p><br></p><p><br></p><p>3. In an interview, E3 reported not being aware whether the staff contacted R1’s physician after the incident. </p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E3 and E4, and no additional information was provided.</p>

<p>Based on record review, documentation review, and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident. The deficient practice posed a health and safety risk.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed the following:  </p><ul><li>An incident report for August 29, 2025, at 11:15 am stated, “Resident was being escorted by staff to the common area when [R1] collapsed to the floor, hitting the back of [R1's] head. EMS came and assessed resident and POA declined to send resident to hospital for further evaluation. No visible injury no complaint of pain to head. POA, Physician and supervisor.”</li><li>A progress note for August 29, 2025, at 1:00 pm stated, “Resident finished lunch in the dining area, when [R1] asked staff if [R1] could go lay down in [R1] room. Caregiver was walking resident to [R1] room with a chair behind [R1] for safety precaution due to new onset of weakness. Resident sat down in the chair and began to have seizure like activity, became unresponsive with shallow breathing, an shortly after lifesaving measures were started. Paramedics and POA were contacted. Once paramedics arrived on scene they took over lifesaving measures and resident was transported to Arrowhead hospital where [R1] was later pronounced deceased.” However, the progress note was missing the names of individuals who observed the incident and any action taken to prevent the incident from occurring in the future. </li></ul><p><br></p><p><br></p><p>2. A review of the facility’s policies and procedures revealed a policy titled “Incident Reports.” The policy stated, “An Internal Occurrence Report is completed by staff for all unusual occurrences, injuries, injuries of unknown origin, and incidents.” </p><p><br></p><p><br></p><p>3. In an interview, E3 acknowledged that the progress note did not include the action taken to prevent the incident in the future.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E3 and E4, and no additional information was provided.</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 one of two resident sampled who received an opioid.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure titled "MP31 - Pain Management and Opioid Medications" last revised December 2024. The Policy stated "f. Opioid Administration and Assistance with self-administration must include: i. Identification and documentation of the resident's pain level prior to medication using the pain scale. 1. The Pain Rating forms may be used. ii. Monitoring resident's response to medication. iii. Documenting the effectiveness of medication forty-five (45) minutes after administration in resident's record. g. Document on the MAR the resident's need, monitoring, and response to the medication. This documentation shall include: i. The name of the staff member responsible for administering/assisting the resident with the opioid medication, ii. The resident's level of pain prior to administering the medication, iii. How the resident's level of pain was assessed, iv. How the resident's response was monitored, including the time and person(s) responsible for monitoring, and v. The resulting effect of the medication on the resident."</p><p><br></p><p>2. A review of R9's medical record revealed a service plan for personal care services and received medication administration. A review of R9's medication orders dated February 2025 revealed "Morphine Sulf 15MG Tablet, Take 1 Tab by Mouth Twice Daily for chronic back pain." A review of R9's medication administration record (MAR) for February 2025 revealed "Morphine Sulf 15MG Tablet," was documented as administered. </p><p>However, documentation to include an identification of R9's need for the opioid before the opioid was administered and the effectiveness of the opioid administered was not available for review. </p><p><br></p><p>3. A review of R9's medical record revealed no documentation stating R9 had an end of life condition or an active malignancy.  </p><p><br></p><p>4. In an interview, E1 acknowledged R9's medical record 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><br></p>

<p>Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of eleven residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R11's medical record revealed a signed medication order dated January 13, 2025. The medication order stated the following: </p><p>"Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution Pen-injector Subcutaneous sig: inject insulin SQ based on sliding scale three times a day after meals, inject SQ 2 units if BS is 151-199, 3 units if BS is 200-249, 4 units if BS is 250-299, 5 units if BS is 300-349, 6 units 350-399, call PCP if BS is greater than 400."</p><p><br></p><p>2. A review of R11's medical record revealed a February 2025 medication administration record (MAR) that showed Insulin Lispro (1 Unit Dial) 100 UNIT/ML was administered from February 01, 2025, to the present and R11's blood sugar reading was taken at 12:00 PM, 4:00 PM and 8:00 AM.  </p><p>However, documentation was not available showing how many units of insulin were administered on the days listed above according to the medication order.</p><p><br></p><p>3. During the environmental tour with E1, the Compliance Officer observed Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution Pen-injector was available with R11's medication.</p><p><br></p><p>4. In an interview, E1 reported the medication was administered per the medication order. However, the exact units that were given to the resident were not documented on the MAR. </p>

<p>Based on documentation review, observation, 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><br></p><p>Findings include:</p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p><br></p><p>2. The Compliance Officer observed multiple ambulatory residents.</p><p><br></p><p>3. During the environmental tour with E1, the Compliance Officer observed the following poisonous and toxic materials in an unlocked kitchen pantry cabinet in the secured memory care unit:</p><p>- one Lysol Clean & Fresh Multi-Surface Cleaner, 144 Oz Bottle</p><p>- one Pine-Sol Cleaner Lemon Scent, 80 oz Bottle</p><p><br></p><p>4. In an interview, E1 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.</p>

Based on record review, documentation review, and interview, the manager failed to ensure the facility had sufficient caregivers with the qualifications, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, to meet the needs of a resident, and to ensure the health and safety of a resident. The deficient practice posed a health and safety risk to a resident, who suffered an arm fracture during a transfer, by a caregiver.

Findings include:

1. In documentation review, the Department received notification from O1, which documented, "... has only lived a facility two days. Is Bedbound, has left sided weakness/paralysis. Facility staff did not use lift provided by family for transfers. A single staff member responded to patient when ... called to use the bathroom - did not use the lift - resulted in patient injuring ... dangling arm - as it is paralyzed. Pt complained of pain - was given ice - hours later they called 911 - after pt ' s son requested pt be sent to ER where it was determined left arm was broken during incident. Patient also shared earlier that night same staff member witnessed pt hitting ... head on wall during transfer and also did not address head injury -patient has bruise to right side of her head, left arm fracture confirmed by radiologist. right sided head bruising near eyebrow."

2. In record review, R1's medical record included documentation as follows:
- Note, "5/2/2024 7:42 am... Incident... resident left arm has a skin tear on writs when ... was transferring back into ... wheel chair from the toilet... left arm got caught between [R1] and the wheelchair, the forearm is swollen, ice was applied incident happen around 4:30am resident asked to see the doctor today explained there is not a doctor here... it... wishes to see a doctor I would need to send out... stated ... would wait for the nurse, but ... thinks it might be broken. When asked if ... armed hurt... stated no due to it being numb. resident was asked about x 3 if ... wanted to go to the ER.. stated. want to wait for the nurse"

3. During an interview, E1 reported facility had Sara Lift brought to facility with R1; however, [E1] visited R1 at prior facility and assessed [R1] required only a one person assist with transfers.

4. During an interview, R1 reported [R1] was recovering from a recent stroke which left the left arm numb and hanging, and a weakened left let. R1 was unable move the arm or leg independently. R1 had two incidents during transfers for toileting, by a caregiver on May 2, 2024. R1 was unable to recall the caregiver name(s). During the first toileting transfer, (by one caregiver), R1 fell forward and hit forehead "on a bar, said ouch," and told the caregiver. At 4:00am, during the second toileting transfer, (by one caregiver), R1's arm got caught, "I heard a crack," and thought it was broken. "I can only use one arm to hold the bar during toileting transfer, so my other arm was just hanging." R1 told the caregiver the arm might be broken and asked the caregiver to call [R1's] son and POA, and the caregiver "shrugged it off," so R1 called ... son, who came to the facility.

5. During an interview, O2 reported R1 called [O2], and informed of the incidents and possible broken arm. At approximately 6:00am, O2 went to the facility, and observed a bump on R1's head, and R1's arm was swollen. O2 requested R1 be sent to the hospital to be treated. O2 reported the Sara Lift was brought for R1 from the rehab facility where the staff used the lift, and were able to transfer the resident with a one person assist. O1 thought the facility would either use the lift or have two persons to transfer R1.

6. In documentation review, a follow up report from the hospital documented an arm fracture and bruising on the forehead.

7. During an interview, E1 reported the facility was unaware R1 hit [R1's] head during the first toileting transfer incident, and R1's medical record did not include documentation [R1] hit head or had a bump. "No one saw a bump." E1 acknowledged the findings reported by the Compliance Officer, based on interviews, and a review of documentation, and reported that following R1's injury, the facility trained the staff on the use of the Sara Lift, and now require R1 to be transferred by two persons.

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

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Staff Training and Competency Requirements" (dated June 17, 2019). The policy stated "A. A manager shall ensure that: 1. A caregiver: ... b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers."

2. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated " ... The Montecito's scope of services includes three different levels Supervisory Care, Personal Care and Directed Care ... Basic Services A. Licensed staff on duty 24 hours a day ... Additional Services A. Dressing B. Grooming C. Bathing D. Incontinence Management ... H. Medication Management."

3. A review of facility documentation revealed a job description for "Medication Care Partner" (dated December 3, 2020). The job description stated " ... Directly responsible for: All care of residents ... IV. Responsibilities a. Provides activities of daily living assistance to the residents as directed from each resident's service plan. b. Assist in monitoring the medication program."

4. A review of facility documentation revealed staffing schedule for June 2, 2023 through July 22, 2023. The staffing schedule revealed E5 was scheduled to work (as a medication technician) from 2:00PM to 10:00PM on the following days:
-June 25-29, 2023;
-July 2-6, 2023;
-July 9-13, 2023; and
-July 16-20, 2023.

4. A review of E5's (hired in 2022) personnel record revealed E5 was hired as a "medication care partner." E5's personnel record revealed documentation of completion of a caregiver training program from Platinum Training Services LLC, ALTP-0185 (issued February 11, 2012).

5. A review of the NCIA Board website for caregiver training programs (https://nciaboard.az.gov/news/caregiver-certificate-verification) revealed Platinum Training Services LLC, ALTP-0185 was in operation from July 16, 2012 to August 2, 2013.

6. A review of https://az.tmuniverse.com revealed E5 had not completed a caregiver training program.

7. In an interview, E1 acknowledged E5 did not provide documentation of completion of a caregiver training program approved by the Department or NCIA Board.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, and frequency of assisted living services being provided to the resident, for two of nine residents sampled. The deficient practice posed a risk as 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 service plan for directed care services (dated in June 2023). The service plan stated "Dressing ... Total: Resident is dependent upon others to do all dressing/undressing." However, the service plan did not include the amount and frequency of this assisted living service being provided to R1.

2. A review of R1's medical record revealed an activities of daily living (ADL) sheet for July 2023. The ADL sheet stated "Level of Assistance-Dressing: Extensive ... 2 time(s) per day, every day."

3. A review of R5's medical record revealed a service plan for personal care services (dated in March 2023). The service plan stated "Toileting ... Total: Resident requires physical assistance with all tasks related to toileting. With or without supplies ... Adult Pull-up/protective underwear." However, the service plan did not include the amount and frequency of this assisted living service being provided to R6.

4. In an interview, E1 acknowledged the amount and frequency of assisted living services being provided to R1 and R5 was not included on R1's and R5's service plans.