INSPIRA GATEWAY

<p><span style="font-size: 12px; color: black;">Based on documentation review and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. § 36-420.04, for four out of four applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.</span></p><p><br></p><p><span style="font-size: 12px; color: black;">Findings include:</span></p><p><span style="font-size: 12px;"> </span></p><p><span style="font-size: 12px; color: black;">1. 36-420.04. requires: 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: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives.</span></p><p><span style="font-size: 12px; color: black;"> </span></p><p><span style="font-size: 12px; color: black;">2. A review of facility documentation revealed an incident report dated April 17, 2025. The incident report revealed R1 had an accident, emergency, or injury, the facility contacted an emergency responder, and R1 was taken to the hospital. However, the documented form provided to the emergency responder did not include the following:</span></p><p><span style="font-size: 12px; color: black;">-A copy of R1's </span><span style="font-size: 12px; background-color: rgb(255, 255, 255);">health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R1's discharge</span></p><p><br></p><p><span style="font-size: 12px;">3. A review of facility documentation revealed an incident report dated July 12, 2025. </span><span style="font-size: 12px; color: black;">The incident report revealed R2 had an accident, emergency, or injury, the facility contacted an emergency responder, and R2 was taken to the hospital. However, the documented form provided to the emergency responder did not include the following:</span></p><p><span style="color: black; font-size: 12px;">-A copy of R2's </span><span style="font-size: 12px; background-color: rgb(255, 255, 255);">health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R2's discharge</span></p><p><br></p><p><span style="font-size: 12px;">4. A review of facility documentation revealed an incident report dated October 3, 2025. </span><span style="font-size: 12px; color: black;">The incident report revealed R4 had an accident, emergency, or injury, the facility contacted an emergency responder, and R4 was taken to the hospital. However, the documented form provided to the emergency responder did not include the following:</span></p><p><span style="font-size: 12px; color: black;">-A copy of R4's </span><span style="font-size: 12px; background-color: rgb(255, 255, 255);">health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R4's discharge</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); font-size: 12px;">5. </span><span style="font-size: 12px;">A review of facility documentation revealed an incident report dated 9/14/2025. </span><span style="font-size: 12px; color: black;">The incident report revealed R5 had an accident, emergency, or injury, the facility contacted an emergency responder, and R5 was taken to the hospital. However, the documented form provided to the emergency responder did not include the following:</span></p><p><span style="color: black; font-size: 12px;">-A copy of R5's </span><span style="font-size: 12px; background-color: rgb(255, 255, 255);">health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R5's discharge</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); font-size: 12px;">6. In an interview, E2 and E3 </span><span style="font-size: 12px;">acknowledged the documentation provided to emergency medical services did not include all information required in A.R.S. § 36-420.04.</span></p><p><br></p><p><span style="font-size: 12px;">7. In an exit interview, the findings were reviewed with E2 and E3 and no additional information was provided. </span></p>

<p>Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. ARS § 11-593.B. stated, "Reporting is required in the following circumstances: 1. Death when not under the current care of a health care provider as defined pursuant to section 36-301. 2. Death resulting from violence. 3. Unexpected or unexplained death. 4. Death of a person in a custodial agency as defined in section 13-4401. 5. Unexpected or unexplained death of an infant or child. 6. Death occurring in a suspicious, unusual or non natural manner, including death from an accident believed to be related to the deceased person's occupation or employment. 7. Death occurring as a result of anesthetic or surgical procedures. 8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety. 9. Death involving unidentifiable bodies."</p><p><br></p><p>2. A review of Department documentation revealed R5's unexpected death occured on September 17, 2025.</p><p><br></p><p>3. A review of facility documentation revealed an incident report dated September 14, 2025. The report stated, "The resident's daughter called the Concierege and asked for help from the medtech on duty. E6 responded to the Resident's apartment. The Resident was in her bed and the daughter stated that she was not responsive. Resident appeared very drowsy and could not follow instructions...E6 proceeded to call 911. The Resident was transported to Banner Gateway Hospital." Further review revealed, "On 9/17/2025 the Executive Director, [E1], received an email from [R5's family member] stating that the Resident passed away on 9/17/2025 in the early morning."</p><p><br></p><p>4. In an interview, E3 reported R5’s death was not expected. E3 reported R5’s death was not reported because R5 was not at the facility when R5 passed away. However, R5 residency agreement was not terminated.</p><p><br></p><p>5. In an exit interview, the findings were reviewed with E2 and E3 and no additional information was provided. </p>

Based on records reviewed and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive, which posed a health and safety risk for four of ten sampled residents.

Findings include:

1. Review of R3's current service plan dated May 2, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services.

2. Review of R5's current service plan dated May 8, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services.

3. Review of R8's current service plan dated May 10, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services.

4. Review of R9's current service plan dated June 9, 2023 stated the resident was capable of storing and controlling R9's own medications, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "supervisory" care services.

5. In an interview, E1 acknowledged these service plans were lacking documentation of the level of service each resident required.

Based on record review and interview, the manager failed to ensure that one of eight sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk.

Findings include:

1. Review of R5's medical record revealed that R5 required personal care services. The service plans for the past twelve months were dated: August 24, 2022, April 1, 2023, and May 8, 2023. R5's service plan was not updated at least every six months.

2. In an interview, E1 acknowledged R5's service plan had not been updated as required. E1 acknowledged R5 was receiving personal care services.

Based on record review and interview, the manager failed to ensure two of ten sampled residents' written service plans reviewed when initially developed and updated were signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Review of R3's service plan that was printed on the day of the compliance inspection dated May 2, 2023 stated the resident required medication administration services. This service plan had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan. In an interview, E1 reported the resident was receiving personal care services.

2. Review of R5's service plan dated May 8, 2023 stated the resident required medication administration services. This service plan had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan. In an interview, E1 reported the resident was receiving personal care services.

3. In an interview, E1 acknowledged that R3's and R5's service plans had not been signed and dated as required.

Based on observation, record review, and interview, the manager failed to ensure that a service plan for a resident who is receiving personal care services included the treatment of bruises, injuries, pressure sores, and infections, which posed a health and safety risk; for two of two sampled residents.

Findings include:

1. Review of R3's current service plan dated May 2, 2023 did not document the treatment of this chronic skin issue that is being treated by an outside service.

2. Review of R5's current service plan dated May 8, 2023 did not document the treatment of a pressure sore on the resident's foot since returning to the facility in April.

3. In an interview, E1 acknowledged the wounds that were being treated at the facility, however these sampled residents' service plans did not document the treatment of these wounds.

Based on record review and interview, the manager failed to ensure that for four of four sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the residents' needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. During an interview, E1 reported that R1, R2, and R6 were unable to ambulate even with assistance since accepted to the facility, and that R7 had a change in condition a few months ago and was now unable to ambulate even with assistance.

2. Review of R1's medical record contained no documented determination completed by R1's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R1's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services.

3. Review of R2's medical record contained no documented determination completed by R2's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R2's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services.

4. Review of R6's medical record contained no documented determination completed by R6's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R6's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required personal care services.

5. Review of R7's medical record contained no documented determination completed by R7's PCP or medical practitioner of onset. R7's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required personal care services.

6. In interviews, E1 acknowledged the required documentation for the determinations were not completed as required for these sampled residents who were unable to ambulate even with assistance.

Based on observation, 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 one of two sampled memory care residents receiving directed care services; which posed a health and safety risk.

Findings include:

1. During a facility tour, E1 and the compliance officer observed R1 laying in bed There was no bell, intercom, or other mechanical means accessible to R1 to alert employees to the resident's needs or emergencies.

2. Review of R1's record revealed R1 was receiving directed care services and was unable to ambulate even with assistance.

3. In an interview, E1 acknowledged that R1 had no access to a call bell nor an intercom, or other mechanical means to alert employees of R1's needs.

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members which posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking.

Findings include:

1. During the compliance inspection the compliance officer observed the facility was providing medication administration services. The most recent facility's current drug reference guide was the Nursing 2022 Drug Handbook by Wolters Kluwer.

2. A Google search found Nursing 2023 Drug Handbook by Wolters Kluwer and also the 2024 edition.

3. In an interview, E1 and E10 acknowledged the facility's drug reference guide was not current.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least every 12 months which posed a safety risk.

Findings include:

1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months.

2. In an interview, E1 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury which posed a health and safety risk.

Findings include:

1. During a facility tour, E1 and the surveyor observed in the facility's kitchen there were two unsecured CO2 tanks.

2. In an interview, E1 acknowledged the hazard of unsecured CO2 tanks.

Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents.

Findings include:

1. During a facility tour of randomly selected resident areas, E1 and the compliance officer observed in R3's, R4's, and R8's bathrooms the hot water registered on the compliance officer's thermometer at 125.2\'ba F.

2. In an interview, E1 acknowledge the facility's hot water was over 120\'ba F in areas of the facility that were used by residents.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were stored in a locked area and inaccessible to residents which is a health and safety risk.

Findings include:

1. During a facility tour of randomly selected areas of the facility, E1 and the compliance officer observed an unlocked facility laundry room that contained Disinfecting all-purpose and glass cleaner, bathroom cleaner, and heavy duty alkaline bathroom cleaner.

2. In an interview, E1 acknowledged the unlocked poisonous or toxic materials