ARBOR ROSE SENIOR LIVING

Based on record review, documentation review, and interview, the assisted living facility that contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all information required in A.R.S. \'a7 36-420.04, for two of two residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.

Findings include:

1. A review of R2's medical record revealed hospital documentation of two visits to the emergency department. On October 29, 2024 R2 was brought in by ambulance for vomiting; and on December 13, 2024 R2 was brought in by ambulance for "Adult sexual abuse, suspected, initial encounter."

2. A review of R7's medical record revealed hospital documentation of two visits to the emergency department. On September 29, 2024 R7 was brought in by ambulance for a ground-level fall and complaining of right hip pain and lower back pain; and on December 5, 2024 R7 was brought in by ambulance for "Near syncope."

3. A review of a facility note revealed R7 was also "sent out 911" to the hospital on December 27, 2024.

4. A review of R2 and R7's medical records did not reveal documentation that was provided to the emergency responder for any of the aforementioned incidents.

5. A review of facility documentation revealed a policy titled "Clinical 11 - Medical Emergency." The policy stated, "3. The Community summons Emergency Medical Services (call 911)* when the resident exhibits signs and symptoms of distress and/or emergency condition. 9. A copy of the Hospital-Facility Transfer Form is completed and provided to the paramedics. a) A list of current medications, DNR status, and Face Sheet form are attached to the Hospital-Facility Transfer Form and given to the paramedics."

6. In an interview, E1 and E2 acknowledged the documentation of what was given to the emergency responders for R2 and R7 for all of the aforementioned incidents was not available for review. E2 also acknowledged EMS Face Sheets/Transfer Forms were not pre-filled with resident information and placed in resident medical records for all residents as required.

7. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on May 7, 2024.

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk to the health and safety of residents as there was not a qualified manager to implement policies and procedures or provide direction to personnel.

Findings include:

1. A review of Department documentation revealed an email submitted on November 4, 2024 at 9:26 PM from O3 stating, "Good Morning - I wanted to inform you that there has been a change in the administrator position at Arbor Rose Senior Care. [O4] is no longer with the community. We are actively recruiting for a new Administrator, and in the interim, one of our licensed Operations Specialists in Colorado will be overseeing the community."

2. While on-site for a complaint investigation, the Compliance Officer observed an empty spot on the wall with just a nail/hook next to the facility's license to operate issued from the Department. When the Compliance Officer asked the staff at the desk for additional information about the manager's posting or designation, the staff member reported the manager's license had been removed from the wall on an unknown date. The staff member then offered a document as further assistance. The document was titled "Chain of Command," and it stated, "Leadership and organization are critical during a disaster. The following chain of command is implemented in the facility during an emergency or disaster." The form listed the titles, names, and phone numbers of nine individuals. Of the nine, only the Maintenance Director and Memory Care Director were still employed at the facility. The others, to include the Executive Director and Assistant Executive Director, were no longer employed at the facility.

3. A review of facility documentation revealed O4 submitted O4's 30-day notice on November 3, 2024.

4. In an interview, E1 reported O4 sent a text message later on November 3, 2024, indicating O4 was ending O4's employment effective immediately. E1 further reported that November 3, 2024 was O4's last day of employment with the facility. Both E1 and E2 acknowledged there hadn't been an Arizona licensed manager at the facility since O4 left. E1 reported a new manager was scheduled to start on January 6, 2025.

5. In a telephonic interview, O3 reported that O3 believed the governing authority had met Department requirements by making the Department aware of the situation (via the aforementioned email) and by having licensed individuals from Colorado overseeing the community. In addition, O3 reported that the Department did not respond to O3's email to advise O3 of anything different. After further discussion, O3 acknowledged the governing authority failed to designate, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06.

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for two of five personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of E4 and E6's personnel records revealed no documentation indicating verification of skills and knowledge.

2. A review of facility documentation revealed "Daily Staffing Schedules" for the month of October 2024. The schedules revealed that E4 worked on October 2, 13, 20, 25, and 27, 2024; and E6 worked on October 1, 2, 4, 7, 8, 9, 11, 14, 15, 16, 18, 21, 22, 23, 25, 28, 29, and 30, 2024.

3. In an interview, E1 and E2 acknowledged E4 and E6's personnel records did not include verification and documentation of skills and knowledge prior to the caregivers providing physical health services to the residents.

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel member who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for five of five personnel sampled. The deficient practice posed a potential TB infection risk to residents.

Findings include:

1. A review of E2's personnel record revealed a hire date of December 6, 2024. Further review revealed two negative TB skin tests, one dated November 1, 2024, and the other dated November 8, 2024; however, no documentation of a TB risk assessment and screening for signs and symptoms was available for review.

2. A review of E3's personnel record revealed a hire date of September 29, 2023. Further review revealed no documentation of baseline screening to include documentation of the individual's freedom from infectious tuberculosis, TB risk assessment, and screening for signs and symptoms was available for review.

3. A review of E4's personnel record revealed a hire date of August 8, 2024. Further review revealed one negative TB skin test dated September 15, 2023; however, no documentation of a second TB skin test and no documentation of TB Risk Assessment and screening for signs and symptoms was available for review.

4. A review of E5's personnel record revealed a hire date of October 3, 2022. Further review revealed two negative TB skin tests, one dated August 15, 2022, and the other dated September 30, 2022; however, no documentation of TB Risk Assessment and screening for signs and symptoms was available for review.

5. A review of E6's personnel record revealed a hire date of November 1, 2023. Further review revealed no documentation of baseline screening to include documentation of the individual's freedom from infectious tuberculosis, TB risk assessment, and screening for signs and symptoms was available for review.

6. A review of the facility's policies and procedures revealed a document titled "Infection Control 14 - Tuberculosis - Care Staff." The policy stated, "All care staff shall be screened for tuberculosis (TB) infection and disease per state regulations prior to beginning employment. ...Each newly hired care staff member will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment." The policy goes on to cite R9-10-113, which includes the requirements of "conducting tuberculosis risk assessments, tuberculosis screening testing, [and] screening for signs and symptoms of tuberculosis," as well as "maintaining documentation of any tuberculosis risk assessment, tuberculosis screening test, and screening for signs and symptoms of tuberculosis."

7. In an interview, E1 and E2 acknowledged the manager failed to implement TB infection control activities including baseline screening for E2, E3, E4, E5, and E6.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments for seven of seven residents reviewed. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to the residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident will maintain and/or maximize current level of functioning with oxygen."

2. A review of R2's medical record revealed a service plan dated December 28, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident's diagnoses will be monitored and followed."

3. A review of R3's medical record revealed a service plan dated November 24, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident's diagnoses will be monitored and followed."

4. A review of R4's medical record revealed a service plan dated November 23, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident's diagnoses will be monitored and followed."

5. A review of R5's medical record revealed a service plan dated December 23, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident's diagnoses will be monitored and followed."

6. A review of R6's medical record revealed a service plan dated November 28, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident will maintain and/or maximize current level of functioning with oxygen."

7. A review of R7's medical record revealed a service plan dated November 23, 2024. The service plan did not include a description of the resident's medical or health problems. Under the section heading "Diagnoses," the goal stated, "Resident's diagnoses will be monitored and followed."

8. In an interview, E1 and E2 acknowledged the service plans did not include the required documentation.

Based on record review 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 (supervisory, personal, directed) for seven of seven residents reviewed. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to the residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024. The service plan identified R1 as "Care Level 1," but did not specify whether R1 was expected to receive supervisory, personal, or directed care services.

2. A review of R2's medical record revealed a service plan dated December 28, 2024. The service plan identified R2 as "Care Level 3," but did not specify whether R2 was expected to receive supervisory, personal, or directed care services.

3. A review of R3's medical record revealed a service plan dated November 24, 2024. The service plan identified R3 as "Care Level 1," but did not specify whether R3 was expected to receive supervisory, personal, or directed care services.

4. A review of R4's medical record revealed a service plan dated November 23, 2024. The service plan identified R4 as "Care Level 1," but did not specify whether R4 was expected to receive supervisory, personal, or directed care services.

5. A review of R5's medical record revealed a service plan dated December 23, 2024. The service plan identified R5 as "Care Level 1," but did not specify whether R5 was expected to receive supervisory, personal, or directed care services.

6. A review of R6's medical record revealed a service plan dated November 28, 2024. The service plan identified R6 as "Care Level 1," but did not specify whether R6 was expected to receive supervisory, personal, or directed care services.

7. A review of R7's medical record revealed a service plan dated November 23, 2024. The service plan identified R7 as "Care Level 2," but did not specify whether R7 was expected to receive supervisory, personal, or directed care services.

8. In an interview, E1 and E2 acknowledged the service plans did not include the required documentation.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the amount, type, and frequency of assisted living services being provided to the resident for seven of seven residents reviewed. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to the residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024.

2. A review of R2's medical record revealed a service plan dated December 28, 2024.

3. A review of R3's medical record revealed a service plan dated November 24, 2024.

4. A review of R4's medical record revealed a service plan dated November 23, 2024.

5. A review of R5's medical record revealed a service plan dated December 23, 2024.

6. A review of R6's medical record revealed a service plan dated November 28, 2024.

7. A review of R7's medical record revealed a service plan dated November 23, 2024.

8. In a review of R1, R2, R3, R4, R5, R6, and R7's aforementioned service plans, the actual services or type of services being provided to each of the residents were not specific, therefore it was difficult to discern the actual service being provided, along with the amount and frequency listed for those services.

9. In an interview, E1 and E2 acknowledged the service plans did not include clear or specific services being provided to the residents, along with the amount and frequency of services.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the manager for seven of seven residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024.

2. A review of R2's medical record revealed a service plan dated December 28, 2024.

3. A review of R3's medical record revealed a service plan dated November 24, 2024.

4. A review of R4's medical record revealed a service plan dated November 23, 2024.

5. A review of R5's medical record revealed a service plan dated December 23, 2024.

6. A review of R6's medical record revealed a service plan dated November 28, 2024.

7. A review of R7's medical record revealed a service plan dated November 23, 2024.

8. As facility documentation revealed, the facility did not have a manager from November 4, 2024 through at least the date of this complaint investigation. All of the aforementioned service plans were updated after November 4, 2024, and during the time the facility did not have a manager.

9. In an interview, E1 and E2 acknowledged all of the aforementioned service plans were not signed and dated by all required individuals to include a manager.

10. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on May 7, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided a resident with the activities of daily living (ADL's) according to the resident's service plan for seven of seven residents sampled. The deficient practice posed a risk to the health and safety of the resident as the resident was not provided with the services required.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024.
- Under the title "Diagnoses," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with oxygen." The action stated, "Level of assistance-Minimal. Resident requires cueing/reminders to use supplemental oxygen as ordered by MD." Frequency stated, "1 time(s) per day, every day." (1x/day)
- Under the title "Neurocognitive," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with communication." The action stated, "No impairment. Resident is able to communicate effectively and makes needs known, with or without assistive device(s). Frequency stated, "3 time(s) per day, every day." (3x/day)
- Under the title "Psychosocial," the first service plan goal stated, "Resident will maintain and/or maximize current level of functioning with mood and depression." The related service action stated, "Resident has history of occasional depression or mood disorder," with a frequency of 3x/day. The second goal stated, "Resident will maintain and/or maximize current level of functioning with wandering." The related action stated, "Resident has history of wandering outside the community. Health and safety may be jeopardized." Frequency 3x/day.
- Under the title "Mobility/Ambulation," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with mobility/ambulation." The action stated, "Level of Assistance-Minimal. Resident may require prompts/cues for safety, does not require hands on assistance." Frequency 3x/day.
- Under the title "Fall Potential," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with fall potential." The action stated, "Ensure walkway free off clutter and call light within reach." Frequency 3x/day.
- Under the title "Medication," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with medication." The action stated, "Level of Assistance-Total. Resident is not able to take medication without assistance." Frequency 3x/day.
- Under the title "Bathing," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with bathing." The action stated, "Level of Assistance-Minimal. Resident can bathe without physical assistance but may require reminding or standby assistance." Frequency 1x/day, every week on Monday and Thursday.
- Under the title "Dressing," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with dressing." The action stated, "Level of Assistance-Minimal. Resident can dress/undress and select clothing but may need to be reminded/supervised." Frequency stated, "2 time(s) per day, every day." (2x/day)
- Under the title "Toileting," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with toileting." The action stated, "Level of Assistance-Independent. Resident does not require assistance with toileting." However, the frequency still indicated 3x/day.
- Under the title "Meal Consumption," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with meal consumption." The action stated, "Level of Assistance-Independent. Resident does not require assistance with meal consumption." However, the frequency still indicated 2x/day. The subsection goal stated, "Resident will maintain compliance with diet as ordered." The action stated, "Resident is on a regular diet." Frequency 2x/day.
- Under the title "Housekeeping and Laundry," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with housekeeping and laundry." The first action pertaining to housekeeping stated, "Level of Assistance-Total. Housekeeping to complete weekly cleaning of resident room." Frequency 1x/day on Monday. The second action pertaining to laundry stated, "Level of Assistance-Total. Resident is dependent upon others to complete all aspects of task." Frequency 1x/week on Tuesday. Subcategories included: "Daily bed making," with a frequency of 1x/day; and "Daily trash removal," with a frequency of 2x/day.
- Under the title "Activities," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with activities." The action stated, "Level of Assistance-Minimal. Resident requires may require [sic] occasional verbal reminders for scheduled activities." Frequency 2x/day.
- Under the title "Evacuation," the service plan goal stated, "Resident will maintain and/or maximize current level of functioning with evacuation." The action stated, "Level of Assistance-Minimal. Resident requires supervision and/or verbal cueing to evacuate residence or to request emergency assistance." Frequency 3x/day.

2. A review of R1's December "Monthly Task Log [ADL's]" revealed the following:
- For Diagnosis, "Level of assistance-Oxygen: Minimal:" December 1-16, 2024 was grayed out indicating an entry could not be made; and for December 17-31, 2024, "TNC" was entered, indicating "Task Not Completed."
- For Neurocognitive," the service action stated, "No impairment." From December 1-22, 2024, caregivers initialed as completing the task the majority of the time with some of the entries indicating TNC. However, this was not a service the resident needed, nor was the actual service being provided clear.
- For Psychosocial, for the service action "Resident has history of occasional depression or mood disorder," with a frequency of 3x/day: December 1-16, 2024 was grayed out indicating an entry could not be made; and for December 17-31, 2024, "TNC" was entered, indicating "Task Not Completed." For the service action, "History of wandering outside the community," with a frequency of 3x/day: December 1-16, 2024 was grayed out indicating an entry could not be made; and for December 17-31, 2024, TNC.
- For "Mobility/Ambulation," the service action stated, "Level of Assistance-Minimal. Resident may require prompts/cues for safety, does not require hands on assistance." Frequency 3x/day. From December 1-31, 2024, the task was only signed off as being completed as required for nine of those days. For one of the days the task was not completed at all, and for the remaining 21 days the task was only signed off as being completed once or twice.
- For Fall Potential, the service action stated, "Ensure walkway free off clutter and call light within reach." Frequency 3x/day. From December 1-22, 2024, the task was only completed as required on four of the days; on one of the days the task was not completed at all; and on the remaining days the task was only completed once or twice. Starting December 23, 2024, it appeared the service may have been changed to PRN status, but nothing on the service plan indicated that change.
- For Medication, "Level of Assistance-Total:" Some of the days were signed off as task being completed, other days were partially completed with a caregivers initials for one or two of the entries and TNC for the other(s).
- For Bathing, the service action stated, "Level of Assistance-Minimal. Resident can bathe without physical assistance but may require reminding or standby assistance." Frequency 1x/day, every week on Monday and Thursday. On Thursday, December 5, 2024, the service was documented as TNC.
- For

Based on documentation review, record review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.

Findings include:

1. A review of department documentation revealed an incident that occurred on October 10, 2024, in which a resident (R7) fell and staff failed to respond to R7's request for help. Another resident (R3) reportedly responded to assist R7.

2. A review of R7's medical record revealed documentation from a hospital's emergency department regarding a fall in September 2024. However, there was no additional documentation of the incident from the facility. Further review revealed no documentation of R7's fall that occurred on October 10, 2024.

3. In an interview, E1 and E2 stated the facility did not complete incident reports when residents went out to the hospital. E2 explained E2 was unaware of any previous incidents involving R7 due to E2 just recently starting at the facility.

4. In an interview, R3 confirmed the incident that occurred on October 10, 2024. At the time of the incident, R3 reported R3 heard R7 requesting help. After some time went by and no staff had responded, R3 went to R7's room to assist. R3 found that R7 had fallen out of bed and was trapped in between a wheelchair and the bed. R3 assisted R7 back into bed. R3 explained to this Compliance Officer that this put both R7 and R3 at greater risk of injury. R3 also explained that the quality of care has diminished and there are not enough caregivers to attend and/or respond to residents in need. R3 believed this was a problem with upper management not being considerate of the residents' care and needs.

5. In an interview, R3 revealed that recently there were several times when R3 had to remove R3's dirty brief and use a towel as a brief overnight because there was no staff available to respond to R3's need for a new brief. R3 stated that many of the staff members were kind and were "trying their best," but still unable to respond to the needs of the residents due to the facility being so short-staffed. While R3 did not believe R3 was intentionally treated poorly by staff, R3's dignity, respect, and consideration were jeopardized at times by not being tended to in times of need, especially when it came to toileting.

6. In an interview, R3 reported that often times there was only one caregiver assigned to cover two or three cottages, and the caregiver was responsible for medication administration as well.

7. A review of facility documentation revealed Daily Staffing Schedules for the month of October 2024. On October 13, 2024; October 14, 2024; October 17, 2024; October 18, 2024 and October 19, 2024, there were only three caregivers/med techs assigned to cover all of Assisted Living, which consisted of Buildings 1, 2, 3, and 5, with approximately 32 residents total. The schedule also indicated that two of the three caregivers/med techs were also responsible for administering medications. On October 17, 2024, one of the three caregivers/med techs was also assigned to help cover medication administration in the Memory Care building, which also consisted of approximately 30 residents. From October 27-31, 2024, there was a note on each of the schedules saying "Please Med Techs in Cottage 5 have to help Cottage 3 meals and dishes."

8. In an interview, R5 expressed similar concerns to R3 in that the facility was so short-staffed the residents' needs couldn't always be attended to. R5 stated sometimes there wasn't a cook. R5 agreed that the caregivers did not intentionally neglect the residents but the management team wasn't considering the respect and consideration of the residents by only having so few staff on the schedule.

9. R7 was not available to be interviewed.

10. In an interview, E1 and E2 acknowledged the shortage of staff and agreed that a resident's needs could not be met based on the schedule because cottages would have to be left unattended for significant periods of time while caregivers were tending to other cottages or administering medications. E1 acknowledged a resident may have felt as if they were treated without dignity, respect, and consideration.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections and offering sufficient fluids to maintain hydration for six out of six residents reviewed receiving personal care services. The deficient practice posed a health and safety risk to the residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 23, 2024. The service plan identified R1 as "Care Level 1."

2. A review of R3's medical record revealed a service plan dated November 24, 2024. The service plan identified R3 as "Care Level 1."

3. A review of R4's medical record revealed a service plan dated November 23, 2024. The service plan identified R4 as "Care Level 1."

4. A review of R5's medical record revealed a service plan dated December 23, 2024. The service plan identified R5 as "Care Level 1."

5. A review of R6's medical record revealed a service plan dated November 28, 2024. The service plan identified R6 as "Care Level 1."

6. A review of R7's medical record revealed a service plan dated November 23, 2024. The service plan identified R7 as "Care Level 2."

7. The service plans for R1, R3, R4, R5, R6, and R7 did not include any services addressing skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections or services of offering sufficient fluids to maintain hydration.

8. In an interview, E1 and E2 confirmed R1, R3, R4, R5, R6, and R7 all received personal care services. E1 and E2 acknowledged the facility's service plans do not include sections that address skin maintenance and offering sufficient fluids to maintain hydration.

Based on record review and interview, in addition to the requirements in R9-10-808(A)(3), the manager failed to ensure that the service plan for a resident receiving directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections and offering sufficient fluids to maintain hydration for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R2's medical record revealed a service plan. The service plan indicated R2 was "Level 3" but did not specify whether R2 was receiving personal or directed care services.

2. In a telephonic interview with corporate staff in Colorado, O1 checked the computer system and clarified that R2 was receiving directed care services.

3. A review of R2's service plan revealed no reference of services that included skin maintenance or offering sufficient fluids.

4. In an interview, E1 and E2 acknowledged the service plan for R2 did not include all of the requirements for directed care services.

Based on record review and interview, in order to retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance, the manager failed to obtain from the resident's primary care provider or other medical practitioner a signed and dated determination stating that the resident's needs could be met by the assisted living facility within the assisted living facility's scope of services and were being met by the assisted living facility, for one of one resident reviewed receiving directed care services.

Findings include:

1. A review of R2's medical record revealed a document titled "Arbor Rose Determination for Admission," signed and dated by a medical provider on May 10, 2022. However, R2 was admitted into the facility in 2018. The document indicated R2 would be receiving "Personal Care Services." Regarding the question of whether R2 was confined to a bed or chair and unable to ambulate, the answer was checked off as "No."

2. A review of R2's medical record revealed a service plan. The service plan indicated R2 was "Level 3" but did not specify whether R2 was receiving personal or directed care services.

3. In a telephonic interview with corporate staff in Colorado, O1 checked the computer system and clarified that R2 was receiving directed care services.

4. A review of R2's service plan revealed the following:
- Under "Mobility/Ambulation," it indicated R2's level of assistance was "Total." The description stated, "Resident is dependent on staff member(s) for all mobility/ambulation needs or requires hands on assistance on routine basis. Stand pivot transfer only. Nonambulatory." Other than the aforementioned document from 2022 indicating R2 was ambulatory, there was no other documentation available for review at the time of the inspection to indicate the resident's current needs as determined by a medical provider, including determination that the facility could meet the needs of the resident.

5. In an interview, E1 and E2 acknowledged there was no recent or current determination from a medical provider stating that the R2's needs could be met by the assisted living facility due to R2's inability to ambulate.

Based on record review and interview, in addition to the requirements in R9-10-808(A)(3), the manager failed to ensure that the service plan for a resident receiving directed care services included cognitive stimulation and activities to maximize functioning for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R2's medical record revealed a service plan. The service plan indicated R2 was "Level 3" but did not specify whether R2 was receiving personal or directed care services.

2. In a telephonic interview with corporate staff in Colorado, O1 checked the computer system and clarified that R2 was receiving directed care services.

3. A review of R2's service plan revealed the following:
- Under "Neurocognitive," R2 was documented as "Severe Impairment" for the sections of Long Term Memory, Orientation, and Short Term Memory; however, there was no reference to any cognitive stimulation or specific activities to maximize functioning.

4. In an interview, E1 and E2 acknowledged the service plan for R2 did not include all of the requirements for directed care services.

Based on record review and interview, in addition to the requirements in R9-10-808(A)(3), the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident's weight, or from a medical practitioner stating that weighing the resident was contraindicated, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R2's medical record revealed a service plan. The service plan indicated R2 was "Level 3" but did not specify whether R2 was receiving personal or directed care services.

2. In a telephonic interview with corporate staff in Colorado, O1 checked the computer system and clarified that R2 was receiving directed care services.

3. A review of R2's service plan revealed no documentation of R2's weight or documentation from a medical practitioner stating that weighing R2 is contraindicated.

4. In an interview, E1 and E2 acknowledged the service plan for R2 did not include all of the requirements for directed care services.

Based on record review and interview, in addition to the requirements in R9-10-808(A)(3), the manager failed to ensure that the service plan for a resident receiving directed care services included coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R2's medical record revealed a service plan. The service plan indicated R2 was "Level 3" but did not specify whether R2 was receiving personal or directed care services.

2. In a telephonic interview with corporate staff in Colorado, O1 checked the computer system and clarified that R2 was receiving directed care services.

3. A review of R2's service plan revealed no reference of a service indicating the coordination of communications with the resident's representative or family members.

4. In an interview, E1 and E2 acknowledged the service plan for R2 did not include all of the requirements for directed care services.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that 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 or the egress of a resident from the facility.

Findings include:

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

2. While on-site, the Compliance Officer observed mostly ambulatory residents.

3. While interviewing different residents, the Compliance Officer visited two Assisted Living Cottages - Cottage 2 and Cottage 5. The two cottages had alert systems installed on the front doors but neither of them were turned on. Cottage 2 had a bell hung above the front door but it was not positioned properly to be in working order.

4. During a tour of the Memory Care building, the Compliance Officer observed an electronic key pad installed on the entrance and exit of the Memory Care building, which served as a control of the egress of a resident from the main entrance of the building. However, there were three doors inside of the Memory Care building that led to enclosed outdoor common areas that had alerts installed on them but none of them were turned on. One of them was also broken.

5. While in the Memory Care building, E2 turned on the alert for one of the doors that was in working order. E2 asked E3 why the alert had been turned off. E3 responded that it was turned off because it made noise every time the door was open.

6. In an interview, E1 and E2 acknowledged the aforementioned doors did not control or alert employees of the egress of a resident at the time of the inspection. Only one of the five observed alerts were able to be turned on while on-site.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for two of two residents sampled who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. A review of R2 and R4's medical records revealed R2 and R4 received medication administration.

2. A review of R2's medical record revealed a signed medication list dated December 2, 2024, which included the following medications:
- Fluoxetine 40 milligrams (mg), 1 capsule (cap) by mouth (PO) one time a day (QD); and
- Furosemide 20 mg, 1 tab PO QD.

3. A review of R2's medical record revealed a medication administration record (MAR) for December 2024. However, MAR revealed the aforementioned medications were not documented as administered on December 7, 2024.

4. A review of R4's medical record revealed a signed medication list dated May 22, 2024, which included the following medications:
- Aspirin 81 mg, 1 tablet (tab) PO QD;
- Metoprolol Tart 25 mg, 1 tab PO twice a day (BID); and
- Sertraline 25 mg, 1 tab PO QD.

5. A review of R4's medical record revealed a MAR for December 2024. However, the MAR revealed the following medications were not documented as being administered on December 12, 2024 and December 23, 2024 at "AM MEDS 7-9am":
- Aspirin 81 mg, 1 tab PO QD;
- Metoprolol Tart 25 mg, 1 tab PO BID; and
- Sertraline 25 mg, 1 tab PO QD.

6. A review of the key on each resident's MAR included twelve options for documenting medication administration. However, the two aforementioned MARS did not include any of the twelve codes, indicating no entry was made on R2 and R4's MAR's for the above aforementioned dates/times.

7. In an interview, E1 and E2 were unable to determine whether R2 and R4 had been administered the medication. E1 and E2 acknowledged the manager failed to ensure that medications administered to residents were documented in the residents' medical records.

Based on record review, documentation review, and interview, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver immediately notified the resident's emergency contact and primary care provider.

Findings include:

1. A review of R2's medical record revealed a set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of October 29, 2024, in which the patient was brought in by ambulance for "Vomiting, Feared condition not demonstrated." Other than the documentation provided by the hospital, R2's medical record revealed no documentation of the incident, including notification made to R2's emergency contact and primary care provider.

2. Further review of R2's medical record reveale d another set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of December 13, 2024 and in which the patient was brought in by ambulance for "Adult sexual abuse, suspected, initial encounter."

3. A review of facility documentation revealed a file folder with handwritten notes on the inside cover by E2 indicating the various details of the incident with R2 on December 13, 2024. The alleged incident was reported by R2's son/representative, therefore notification to R2's emergency contact was not necessary. There was documentation of notifications made to the department, APS, the ombudsman, and the police; however, there was no documentation of notification made to R2's primary care provider.

4. A review of R7's medical record revealed a set of documents titled "Emergency Room Report - *Preliminary Report*," with a Date/Time of Service of September 29, 2024 9:49 MST, in which the patient arrived via EMS due to a ground-level fall and complaining of right hip pain and lower back pain. The medical record also contained a set of documents titled "Patient Discharge Instructions - Emergency Department" for the same incident. Other than the documentation provided by the hospital, R7's medical record revealed no documentation of the incident, including notification made to R7's emergency contact and primary care provider.

5. Further review of R7's medical record revealed another set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of December 5, 2024 and in which the patient was brought in by ambulance for "Near syncope." Other than the documentation provided by the hospital, R7's medical record revealed no documentation of the incident, including notification made to R7's emergency contact and primary care provider.

6. In an interview, E1 reported R7 had gone out to the hospital on December 27, 2024, and passed away on January 1, 2025. When asked for an incident report for R7 for December 27, 2024, E1 and E2 reported the facility doesn't complete incident reports for sending residents out to the hospital.

7. A review of facility documentation revealed a policy titled "GP 21 - Internal Incident Report and State Incident Report." The policy stated, "Injury and unusual incidents will be reported in compliance with state regulatory requirements. An internal incident report is completed by staff for all unusual occurrences, injury, and incidents. Incidents are reported immediately to family/responsible party and physician. Document the date and time the report was made to the family/responsible party and physician in the narrative charting section."

8. Further review of facility documentation revealed another policy titled "Clinical 11 - Medical Emergency." The policy stated, "3. The Community summons Emergency Medical Services (call 911)* when the resident exhibits signs and symptoms of distress and/or emergency condition. 5. The Resident Care Director or Med Tech on duty contacts the family/responsible party as quickly as possible...this includes anytime 24-hours a day. 6. Notify the resident's Physician's office to let them know the resident has had an emergency and 911 was called... 12. A narrative chart entry is made in the resident's record regarding the circumstances... 13. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: b) Immediately notifies the resident's emergency contact and primary care provider; and c) Documents the following: v) The individuals notified by the caregiver or assistant caregiver..."

9. In an interview, E1 and E2 acknowledged the manager failed to ensure that a caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, and/or failed to ensure that the notification was documented.

Based on record review, documentation review, and interview, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future for two of two residents sampled. The deficient practice posed a risk as critical information needed in an investigation regarding a resident's urgent medical needs were not obtained as required.

1. A review of R2's medical record revealed a set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of October 29, 2024, in which the patient was brought in by ambulance for "Vomiting, Feared condition not demonstrated." Other than the documentation provided by the hospital, R2's medical record revealed no documentation of the incident.

2. Further review of R2's medical record revealed another set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of December 13, 2024 and in which the patient was brought in by ambulance for "Adult sexual abuse, suspected, initial encounter."

3. A review of facility documentation revealed a file folder with handwritten notes on the inside cover by E2 indicating the various details of the incident with R2 on December 13, 2024. The alleged incident was reported by R2's son/representative, therefore notification to R2's emergency contact was not necessary. There was documentation of notifications made to the department, APS, the ombudsman, and the police; however, there was no documentation of notification made to R2's primary care provider.

4. A review of R7's medical record revealed a set of documents titled "Emergency Room Report - *Preliminary Report*," with a Date/Time of Service of September 29, 2024 9:49 MST, in which the patient arrived via EMS due to a ground-level fall and complaining of right hip pain and lower back pain. The report indicated R7 reported R7 was sitting in a chair when R7 fell backwards. R7 endured a headstrike but did not lose consciousness. The medical record also contained a set of documents titled "Patient Discharge Instructions - Emergency Department" for the same incident. Other than the documentation provided by the hospital, R7's medical record revealed no documentation of the incident.

5. Further review of R7's medical record revealed another set of documents titled "Patient Discharge Instructions - Emergency Department," with a hospital visit date of December 5, 2024 and in which the patient was brought in by ambulance for "Near syncope." Other than the documentation provided by the hospital, R7's medical record revealed no documentation of the incident.

6. In an interview, E1 reported R7 had gone out to the hospital on December 27, 2024, and passed away on January 1, 2025. When asked for an incident report for R7 for December 27, 2024, E1 and E2 reported the facility doesn't complete incident reports for sending residents out to the hospital. E2 was able to provide a facility note which had written as pass off information from one staff to another, which indicated "[R2] - sent out 911 on 12/27. Currently in ICU on vasopressors and requiring O2, continues to aspirate, Positive for Influenza A, AMS and dehydration, will be going to SNF."

7. A review of facility documentation revealed a policy titled "GP 21 - Internal Incident Report and State Incident Report." The policy stated, "Injury and unusual incidents will be reported in compliance with state regulatory requirements. An internal incident report is completed by staff for all unusual occurrences, injury, and incidents. Incidents are reported immediately to family/responsible party and physician. Document the date and time the report was made to the family/responsible party and physician in the narrative charting section."

8. Further review of facility documentation revealed another policy titled "Clinical 11 - Medical Emergency." The policy stated, "3. The Community summons Emergency Medical Services (call 911)* when the resident exhibits signs and symptoms of distress and/or emergency condition. 5. The Resident Care Director or Med Tech on duty contacts the family/responsible party as quickly as possible...this includes anytime 24-hours a day. 6. Notify the resident's Physician's office to let them know the resident has had an emergency and 911 was called. 12. A narrative chart entry is made in the resident's record regarding the circumstances...what care was provided by the staff, including any first aid (Action), as well as the resident's response to the action (Response). 13. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: b) Immediately notifies the resident ' s emergency contact and primary care provider; and c) Documents the following: i) The date and time of the accident, emergency, or injury; ii) A description of the accident, emergency, or injury; iii) The names of individuals who observed the accident, emergency, or injury; iv) The actions taken by the caregiver or assistant caregiver; v) The individuals notified by the caregiver or assistant caregiver; and vi Any action taken to prevent the accident, emergency, or injury from occurring in the future. (R9-10-818)"

9. In an interview, E1 and E2 acknowledged the manager failed to document the required information regarding accidents, emergencies, or injuries that resulted in a resident needing medical services for R2 and R7.

Based on record review, documentation review, and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for two of three personnel sampled. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A review of E3's personnel record revealed a hire date of September 29, 2023. Further review revealed no documentation of completed annual training or education on recognizing the signs and symptoms of TB.

2. A review of E6's personnel record revealed a hire date of November 1, 2023. Further review revealed no documentation of completed annual training or education on recognizing the signs and symptoms of TB.

3. A review of the facility's policies and procedures revealed a document titled "Infection Control 14 - Tuberculosis - Care Staff." The policy cited R9-10-113; however, the information cited was from 2005, namely, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-care Settings, 2005." The information provided in this policy does not include the requirement for annual TB training and education that was added in 2019.

4. 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: ...c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution."

5. In an interview, E1 and E2 acknowledged the chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of TB was provided annually to individuals employed by the health care institution for E3 and E6.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's caregiver certification, for one of four individuals hired as a caregiver reviewed. The deficient practice posed a risk as the Department was provided false or misleading information.

Findings include:

1. Review of E4's personnel record revealed E4 was hired as a caregiver.

2. Review of E4's personnel record revealed a caregiver certificate from Sunshine Care Training Program (ALTP 0085) with E4's name, which was dated April 13, 2013.

3. Review of Department documentation revealed that Sunshine Care Training Program (ALTP 0085) was operational December 10, 2002 through December 31, 2012.

4. In an interview, E4 reported being aware that the caregiver certificate in E4's personnel record was invalid, and reported getting a legitimate caregiver certification in 2021. E4 acknowledged that E4 worked as a caregiver at the facility starting in 2015 and was not certified until 2021.

5. A review of https://az.tmuniverse.com website revealed E4 completed a caregiver training program in 2021.

6. In an interview, E1 and E4 acknowledged that the caregiver certificate in E4's personnel record was invalid and false or misleading information was provided to the Department, and that E4's personnel record did not include documentation of E4's current caregiver certification at the time of inspection.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. During an interview with E1, regarding two residents who had fallen, E1 reported the facility used the "Relias" training for employees for training on Fall Prevention and Fall Recovery.

2. In documentation review, the facility did not have documentation of a training program for staff that included fall recovery.

3. During an interview, E1 acknowledged the Relias training covered Fall Prevention only, and E1 was working on developing a training program for all staff that included Fall Prevention and Fall Recovery training.

4. This is an uncorrected deficiency from a complaint investigation conducted on July 17, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of facility policies revealed a policy titled "Fall Response Procedures" which stated "If the resident [...] received obvious head or significant trauma, the Director of Health and Wellness or caregivers will summon Emergency Medical Services (call 911)."

2. Review of R2's medical record revealed an incident report for an unwitnessed fall which reported that R2 sustained bruises to the head and that emergency services were not notified.

3. In an interview, E7 reported not being aware of a reason to notify emergency services for R2. E1 acknowledged that fall training and policy were not followed.

Based on observation 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 residential unit 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. The Compliance Officer observed a call pendant in R1's residential unit.

2. In an interview, R1 reported suspecting that the call pendant system was not working. The Compliance Officer pressed the button on the pendant, however, no caregiver responded during the time the Compliance Officer was in R1's residential unit.

3. In an interview, E8 and E9 reported not being aware that R1's pendant had been pressed, and showed the Compliance Officer that it had not alerted caregivers on the alert system's screen.

4. In an interview, E1 acknowledged that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available in a residential unit being used by a resident receiving personal care services.

Based on documentation review, record review, and interview, the assisted living facility failed to provide the required documentation to an emergency responder, for one of one sampled residents for whom an emergency responder had been contacted.

Findings include:

1. A review of facility documentation revealed an incident report dated April 13, 2024. The incident report indicated R4 had been transported to the hospital after R4 had been found on the floor of her bedroom and "[R4's] head was bleeding."

2. A review of R4's medical record revealed a copy of any documentation given to the emergency responder was not available for review.

3. In an interview, E1 reported being aware of the implementation of A.R.S. 36-420.04, however E1 acknowledged the documentation of what was given to the emergency responder for R4 was not provided for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which when initially developed and when updated, was signed and dated by the resident or resident's representative, or by the manager for six of six residents sampled.

Findings include:

1. A review of R1's, R2's, R3's R4's, R5's and R6's medical record revealed current service plans for each resident, based upon their respective date of admission and level of care. However, R1's, R3's R4's, R5's and R6's service plans did not include the required signature of the resident or resident's representative, and none of the six service plans reviewed contained the signature of the manager as required.

2. In an interview, E1 acknowledged R1's, R3's R4's, R5's and R6's service plans were not signed by the resident or resident's representative, and R1's, R2's, R3's R4's, R5's and R6's service plans were not signed by the manager as required.

Based on documentation review, and interview, the manager failed to ensure policies and procedures for medication administration included a process for documenting an individual, authorized, according to the definition of "administer" in A.R.S. \'a7 32-1901, by a medical practitioner to administer medication under the direction of the medical practitioner. The deficient practice posed a risk as the individual was not qualified to provide the required services.

Findings include:

1. A review of the facility's policy and procedure manual, revealed a policy titled, "Medication Policies," which outlined the facility policy on medication administration. The policy included a section which read, "14. Properly trained [Med Techs] may administer medications in accordance with state regulations with authorization by a medical practioner to administer medications under the direction of the medical practitioner. (R9-10-816) The Treatment/Services Authorization form may be used."

However, the policy did not include a process for documenting an individual, authorized by a medical practitioner to administer medication under the direction of the medical practitioner.

2. In an interview, E1 reported not utilizing a "Treatment/Services Authorization" form to document an individual authorized to administer medication under the direction of a medical practioner. E1 agreed the policy did not include a process for documenting an individual, authorized, according to the definition of "administer" in A.R.S. \'a7 32-1901, by a medical practitioner to administer medication under the direction of the medical practitioner.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Findings include:

1. During a tour of the facility the Compliance Officers observed an office used by the facility's Director of Health and Wellness. The office was equipped with a door and door knob which contained an electronic keypad, locked automatically when closed and required a combination to open the door. However, the door was open and the Compliance Officers observed unsecured medication labeled, "Enoxaparin 40 mg per 0.4 ml." Also in the room was a refrigerator with an attached sign which read, "MEDICATION'S ONLY." The refrigerator was equipped with a clasp which allowed a pad lock to be used to secure the refrigerator, however no pad lock was present and the Compliance Officer opened the refrigerator with little effort. Inside the refrigerator was a plastic bag containing medications including, "Trulicity 1.5 mg/0.5 ml PEN."

2. In an interview, E2 reported they had closed and locked the door to their office when they last left it. E2 stated there were three other employees who had the combination to enter E2's office.

3. In an interview, E1 acknowledged that the medications had not been stored in a separate locked cabinet the facility uses for medication storage.

Based on documentation review and interview, the manager failed to ensure documentation of the disaster plan review included the date and time of the disaster plan review; the name of each employee or volunteer participating in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.

Findings include:

1. A review of the disaster plan review revealed the date the review was completed however the time of the review was not noted. Further review revealed the name of the person participating in the review, however the review did not contain evidence of a critique of the disaster plan or any recommendations for improvement.

2. In an interview, E1 acknowledged not having documentation to show the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:

1. A review of facility staffing schedules revealed the facility operated on three shifts, Shift 1 - 6:00 a.m. - 2:00 p.m., Shift 2 - 2:00 p.m. - 10:00 p.m., and Shift 3 - 10:00 p.m. - 6:00 a.m.

2. A review of facility documentation revealed documentation of disaster drills for employees were conducted in May 2023 on Shift 2 and Shift 3, however evidence of documentation of a disaster drill conducted on Shift 1 was unavailable for review. Evidence of documentation of disaster drills conducted in August 2023 on Shift 1, Shift 2 or Shift 3 was unavailable for review. Lastly, documentation of disaster drills conducted in February 2024 on Shift 1 and Shift 2 was available, however evidence of documentation of a disaster drill conducted on Shift 3 was unavailable for review.

3. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented as required.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area and inaccessible to residents.

Findings include:

1. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents. The Compliance Officer also observed a laundry room which was equipped with a door and locking handle. However, the lock was not engaged and the compliance officer was able to open the door with little effort. Inside a cabinet in the laundry room the Compliance Officer observed a bottle of "Betco Disinfectant," and a bottle of "Febreze Fabric Refresher." Also, inside the cabinet was an open container of "Tide" laundry detergent pods. All containers were marked, "KEEP OUT OF REACH OF CHILDREN."

2. In an interview E1 acknowledged the toxic materials were not stored in a locked area, inaccessible to residents.

Based on observation, documentation review, record review, and interview, the manager failed to ensure an assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk as a qualified personnel member was not present to meet a resident's needs and ensure the health and safety.

Findings include:

1. The Compliance Officer observed E3 working in Cottage 7 (memory care unit) of the assisted living facility.

2. A review of the facility's weekly staffing schedules for April 2023, May 2023, and June 2023 revealed E2 was scheduled to work on the following days at 10PM-6AM in Cottage 7 (memory care unit):
-April 9-15, 2023;
-April 18-22, 2023;
-April 25-29, 2023;
-May 2-6, 2023;
-June 6-9, 2023;
-June 14, 2023; and
-June 27, 2023.

3. A review of the facility's weekly staffing schedules for April 2023, May 2023, June 2023, and July 2023 revealed E3 was scheduled to work on the following days at 6AM-2PM in Cottage 7 (memory care unit):
-April 12, 2023;
-April 16-27, 2023;
-April 30, 2023-May 4, 2023;
-May 14-18, 2023;
-May 21-25, 2023;
-May 28, 2023;
-May 31, 2023-June 1, 2023;
-June 4, 2023;
-June 6-8, 2023;
-June 11-15, 2023;
-June 25-29, 2023;
-July 2-6, 2023; and
-July 9-13, 2023.

4. A review of E2's (hired in 2022) personnel record revealed E2 was hired as a caregiver. However, documentation of the verification of E2's skills and knowledge, experience, and qualifications to work as a caregiver were not available for review per 806.C.1.c.i.ii.

5. A review of E3's (hired in 2020) personnel record revealed E3 was hired as a caregiver. However, documentation of the verification of E3's skills and knowledge were not available for review per 806.C.1.c.i.

6. In an interview, O3 acknowledged the assisted living facility did not have caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident in Cottage 7.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of two caregivers sampled. The deficient practice posed a risk if E2 and E3 were unable to meet a resident's needs.

Findings include:

1. The Compliance Officer observed E3 working in Cottage 7 (memory care unit) of the assisted living facility.

2. A review of the facility's weekly staffing schedules for April 2023, May 2023, and June 2023 revealed E2 was scheduled to work on the following days at 10PM-6AM in Cottage 7 (memory care unit):
-April 9-15, 2023;
-April 18-22, 2023;
-April 25-29, 2023;
-May 2-6, 2023;
-June 6-9, 2023;
-June 14, 2023; and
-June 27, 2023.

3. A review of the facility's weekly staffing schedules for April 2023, May 2023, June 2023, and July 2023 revealed E3 was scheduled to work on the following days at 6AM-2PM in Cottage 7 (memory care unit):
-April 12, 2023;
-April 16-27, 2023;
-April 30, 2023-May 4, 2023;
-May 14-18, 2023;
-May 21-25, 2023;
-May 28, 2023;
-May 31, 2023-June 1, 2023;
-June 4, 2023;
-June 6-8, 2023;
-June 11-15, 2023;
-June 25-29, 2023;
-July 2-6, 2023; and
-July 9-13, 2023.

4. A review of E2's (hired in 2022) personnel record revealed documentation of the verification of E2's skills and knowledge were not available for review.

5. A review of E3's (hired in 2020) personnel record revealed documentation of the verification of E3's skills and knowledge were not available for review.

6. In an interview, O3 acknowledged E2's and E3's documentation of verification of skills and knowledge was not completed.

This Rule was cited on June 5, 2023. A letter sent to the facility, dated June 15, 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 record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's experience applicable to the individual's job duties, for one of four personnel records sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs.


Findings include:

1. A review of E2's (hired in 2022) personnel record revealed E2 was hired as a caregiver. However, documentation of E2's experience to work as a caregiver was not available for review.

2. In an interview, O3 acknowledged E2's personnel record had not contained documentation of E2's experience.

This Rule was cited on June 5, 2023. A letter sent to the facility, dated June 15, 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 record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for four of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R1's medical record revealed a service plan for directed care services dated in April 2023. R1's service plan revealed R1 required assistance with the following activities of daily living:
-bathing at least two times per week;
-daily bed making;
-dressing every day- AM and PM;
-grooming every day;
-transfer assist;
-safety checks every day; and
-night care- twice each shift.

2. A review of R1's activities of daily living documentation dated in June 2023 revealed documentation to indicate R1 received assistance with the following activities of daily living on the following dates were not available for review:
-bathing at least two times a week: June 1-30, 2023;
-daily bed making: June 19, 2023 and June 25-27, 2023;
-dressing every day- AM and PM: June 19, 2023 and June 25-27, 2023;
-grooming every day: June 19, 2023 and June 25-27, 2023;
-transfer assist: June 19, 2023 and June 25-27, 2023;
-safety checks every day: June 12, 2023 and June 25-30, 2023; and
-night care- twice each shift: June 12, 2023 and June 25-30, 2023.

3. A review of R2's medical record revealed a service plan for directed care services dated in March 2023. R2's service plan revealed R2 required assistance with the following activities of daily living:
-bathing at least two times per week;
-daily bed making;
-dressing every day- AM and PM;
-grooming every day;
-transfer assist;
-safety checks every day;
-night care- twice each shift; and
-toileting every day.

4. A review of R2's activities of daily living documentation dated in June 2023 revealed documentation to indicate R2 received assistance with the following activities of daily living on the following dates were not available for review:
-bathing at least two times a week: June 1-30, 2023;
-daily bed making: June 12, 2023, June 25-27, 2023;
-dressing every day- AM and PM: June 12, 2023, June 25-27, 2023;
-grooming every day: June 26, 2023 and June 30, 2023;
-transfer: June 12, 2023, June 19, 2023, and June 25-27, 2023;
-safety checks every day: June 26, 2023 and June 30, 2023;
-night care- twice each shift: June 24, 2023, June 26, 2023, and June 30, 2023; and
-toileting every day: June 17, 2023, June 26, 2023, and June 30, 2023.

5. A review of R3's medical record revealed a service plan for directed care services dated in March 2023. R3's service plan revealed R3 required assistance with the following activities of daily living:
-bathing at least two times per week;
-daily bed making;
-dressing AM and PM;
-grooming every day;
-transfer assist;
-safety checks AM and PM;
-night care- twice each shift; and
-toileting AM and PM.

6. A review of R3's activities of daily living documentation dated in June 2023 revealed documentation to indicate R3 received assistance with the following activities of daily living on the following dates were not available for review:
-bathing at least two times a week: June 1-30, 2023;
-daily bed making: June 5, 2023, June 19, 2023, and June 25-27, 2023;
-dressing AM and PM: June 5, 2023, June 19, 2023, and June 25-27, 2023;
-grooming every day: June 5, 2023, June 19, 2023, and June 25-27, 2023;
-transfer assist: June 12, 2023, June 19, 2023, and June 25-27, 2023;
-safety checks AM: June 5, 2023, June 19, 2023, and June 25-27, 2023;
-safety checks PM: June 10, 2023, June 26, 2023, and June 30, 2023;
-night care- twice each shift: June 4-5, 2023, June 11, 2023, June 19, 2023, June 25-26, 2023, and June 28-30, 2023; and
-toileting AM: June 5, 2023, June 19, 2023, and June 25-27, 2023; and
-toileting PM: June 26, 2023.

7. A review of R4's medical record revealed a service plan for personal care services dated in March 2023. R4's service plan revealed R4 required assistance with the following activities of daily living:
-bathing at least two times per week;
-daily bed making;
-dressing cueing;
-grooming cueing;
-transfer assist;
-safety checks AM and PM; and
-night care- twice each shift.

8. A review of R4's activities of daily living documentation dated in June 2023 revealed documentation to indicate R4 received assistance with the following activities of daily living on the following dates were not available for review:
-bathing at least two times a week: June 22-28, 2023;
-daily bed making: June 23, 2023;
-dressing cueing: June 23, 2023;
-grooming cueing: June 23,2023;
-safety checks AM: June 23,2023, and June 29-30, 2023;
-safety checks PM: June 30, 2023; and
-night care- twice each shift: June 30, 2023.

9. In an interview, E5 reported services were provided to R1, R2, R3, and R4 for the month of June 2023. E5 reported the caregivers who provided the services to residents forgot to document the services provided.

10. In an interview, O3 acknowledged documentation to indicate services were provided to R1, R2, R3, and R4 were not documented.

This Rule was cited on June 5, 2023. A letter sent to the facility, dated June 15, 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 record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of one resident sampled who received personal care services. The deficient practice posed a risk as a service plan directs services to be provided to a resident.

Findings include:

1. A review of R4's medical record revealed a written service plan dated in February 2023. However, documentation to indicate the service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections was not available for review.

2. In an interview, E5 acknowledged R4's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on record review and interview, the manager failed to ensure a written service plan for residents receiving directed care services included offering skin maintenance to prevent and treat bruises, injuries, pressure sores and infections, for two of three residents sampled who received directed care services. The deficient practice posed a risk as a service plan directs services to be provided to a resident.

Findings include:

1. A review of R1's medical record revealed a service plan dated in April 2023. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

2. A review of R2's medical record revealed a service plan dated in March 2023. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

3. In an interview, O3 acknowledged R1's and R2's service plans did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on documentation review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of facility documentation revealed a policy and procedure to cover fall prevention and fall recovery was not available for review.

2. A review of facility documentation revealed a training program to cover fall prevention and fall recovery was not available for review.

3. In an interview, E1 reported staff had completed training on fall prevention and fall recovery through Relias, however, the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, observation, and interview, the manager failed to implement policies and procedures to cover medication administration. The deficient practice posed a risk as the standards expected of employees were not followed, if the resident experienced a change in condition due to receiving a medication not prescribed, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

R9-10-101.134. "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Medication Administration Policy" (dated in 2000). The policy and procedure stated "...Medications may be administered to residents from a medication organizer or original pharmacy container. No resident is permitted to use or take another resident's medication..."

2. The Compliance Officer observed a bubble pack prescribed to O1 for Diphenhist (generic for Benadryl) 25 mg tab, take one tab by mouth every 6 hours as needed for itching. However, O1's name was crossed out in black marker and R2's name was written on the bubble pack.

3. In an interview, E1 stated the above mentioned medication was "overflow" medication, either from a previous or current resident.

4. A review of facility documentation provided to the Compliance Officer during the exit interview revealed a medication order for R2 dated May 28, 2023 for Benadryl Allergy 25 mg tab, one tab by mouth x 5 days give with IM injection.

5. In an interview, E1 acknowledged the facility failed to implement policies and procedures to cover medication administration.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of facility documentation revealed a policy and procedure manual dated January 1, 2000.

2. In an interview, E1 acknowledged the facility's policies and procedures had not been reviewed at least once every three years.

Based on record 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 E5's personnel record revealed documentation of the verification of E5's skills and knowledge were not available for review.

2. A review of E2's personnel record revealed a valid caregiver certificate. However, E2's documentation of experience applicable to E2's job duties was not available for review.

3. A review of E2's personnel record revealed completed orientation according to the facility's policy and procedure was not available for review.

4. A review of E5's personnel record revealed completed orientation according to the facility's policy and procedure was not available for review.

5. A review of E5's personnel record revealed documentation of evidence of freedom from infectious TB was not available for review.

6. In an interview, E1 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request.

Based on observation, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of three caregivers sampled. The deficient practice posed a risk if E2 and E5 were unable to meet a resident's needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

1. The Compliance Officer observed E2 working in "Cottage 3" and E5 working in the memory care cottage of the assisted living facility.

2. A review of the facility's monthly staffing schedules for May 2023 and June 2023 revealed E2 was scheduled to work on the following days:
-May 1, 2023;
-May 4-6, 2023;
-May 8, 2023;
-May 11-13, 2023;
-May 15, 2023;
-May 18-20, 2023;
-May 22, 2023;
-May 26-27, 2023;
-May 29, 2023; and
-June 1-3, 2023.

3. A review of the facility's monthly staffing schedules for May 2023 and June 2023 revealed E5 was scheduled to work on the following days:
-May 26-27, 2023;
-May 29-30, 2023; and
-June 2-3, 2023.

4. A review of E2's (hired in 2021) personnel record revealed a document titled "Medication Tech Onboarding Checklist" dated in October 2021. The document revealed E2's initials and signature, however, the "Supervisor" signature and date were not documented.

5. A review of E5's (hired in 2023) personnel record revealed documentation of the verification of E5's skills and knowledge were not available for review.

6. In an interview, E1 reported E2's and E5's skills and knowledge were verified before E2 and E5 provided services. E1 reported to be unsure why E2's documentation was not completed. E1 reported to be unable to locate E5's documentation of verification of skills and knowledge.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's experience applicable to the individual's job duties, for one of five 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 E2's personnel record revealed a valid caregiver certificate. However, E2's documentation of experience applicable to E2's job duties was not available for review.

2. In an interview, E1 reported E2 had experience. However, E1 was unable to locate the requested documentation.

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 orientation, for two of five 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:

R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. A review of facility documentation revealed a policy and procedure titled "Employee Orientation and Ongoing Training" (dated in January 2000). The policy and procedure stated "A licensee shall ensure that a new employee completes orientation within 10 days from the starting date of employment ..."

2. A review of E2's personnel record revealed completed orientation according to the facility's policy and procedure was not available for review.

3. A review of E5's personnel record revealed completed orientation according to the facility's policy and procedure was not available for review.

4. In an interview, E1 reported orientation was completed for E2 and E5. However, E1 was unable to locate the requested documentation.

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 one of five employees sampled. The deficient practice posed a TB exposure risk to residents, 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 E5's personnel record revealed documentation of evidence of freedom from infectious TB was not available for review.

2. In an interview, E1 reported E5 had evidence of freedom from TB. However, E1 was unable to locate the documentation.

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 acceptance to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of six residents sampled. The deficient practice posed a risk if R4 required a different level of care as an assisted living facility cannot provide continuous medical services, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of R4's (admitted in 2022) medical record revealed a document, dated in December 2022, titled "Physician's Report (Arizona)." However, the document revealed R4 required continuous medical services.

2. In an interview, E1 reviewed the document and reported to be unsure why the medical practitioner would report R4 required continuous medical services. E1 reported R4 did not receive continuous medical services at the assisted living facility.

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 six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of R3's (admitted in 2021) medical record revealed a service plan for personal care services dated in March 2023. R3's service plan revealed R3 required assistance with activities of daily living including bathing at least two times per week.

2. A review of R3's activities of daily living documentation dated in May 2023 revealed documentation to indicate R3 received bathing assistance at least two times a week during May 1-7, 2023, May 8-14, 2023, and May 15-21, 2023 was not available for review.

3. A review of R5's (admitted in 2021) medical record revealed a service plan for personal care services dated in January 2023. R5's service plan revealed R5 required assistance with activities of daily living including bathing at least two times per week.

4. A review of R5's activities of daily living documentation dated in May 2023 revealed documentation to indicate R5 received bathing assistance at least two times a week during May 8-14, 2023, May 15-21, 2023, and May 22-28, 2023 was not available for review.

5. A review of R6's (admitted in 2020) medical record revealed a service plan for directed care services dated in March 2023. R6's service plan revealed R6 required assistance with activities of daily living including bathing at least two times per week.

6. A review of R6's activities of daily living documentation dated in May 2023 revealed documentation to indicate R6 received bathing assistance at least two times a week during May 1-31, 2023 was not available for review.

7. In an interview, E1 acknowledged documentation to indicate services were provided to R3, R5, and R6 were not documented.

Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented, for three of six residents sampled. The deficient practice posed a risk if resident's were not orientated to exits and routes during an emergency, and the Department was unable to determine substantial compliance during the inspection.

Findings include:

1. A review of R2's medical record revealed a facility document. The document stated " ...8. The participant has received orientation to the facility's emergency evacuation procedure/ Fire drills upon starting and will continue quarterly ..." However, the document was not completed.

2. A review of R3's medical record revealed documentation indicating the resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R3's acceptance by the facility was not available for review.

3. A review of R5's medical record revealed documentation indicating the resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R5's acceptance by the facility was not available for review.

4. In an interview, E1 reported residents are oriented to exits upon admission and unsure why R2's documentation was not completed. E1 acknowledged documentation indicating R2, R3, and R5 received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident's acceptance by the facility was not available for review.