CARE WITH COMPASSION ASSISTED LIVING

INSP-0136267

Complete

Date: 7/17/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-07-31

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00135537 conducted on July 17, 2025:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

R9-10-811.A.5. Medical Records A. A manager shall ensure that: 5. A resident’s medical record is protected from loss, damage, or unauthorized use.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that the residents' medical records were protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed the residents' medical records were sitting out in an open area and were easily accessible, subject to unauthorized usage, loss or damage. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Temporary Solution:

The manager and the Administrator, of Care with Compassion Assisted Living made sure that all documents, medical records, that was seen in the open area was transferred to cabinet that is close and is not accessible by anyone that is not authorized and will be safe from damaged or loss.

Permanent Solution:

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #2

Rule/Regulation Violated:

R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;

Evidence/Findings:

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a medication list for the following medications:<ul><li>Alprazolam 0.5 milligrams (mg), 1 tablet by mouth (po) twice a day (bid);</li><li>Acetaminophen 325 mg, 2 tablets po bid;</li><li>Trazodone HCl 100 mg, 1 tablet po at bedtime (qhs);</li><li>Tramadol HCl 50 mg, 1 tablet po bid;</li><li>Aspirin 81 mg, 1 tablet po daily (qd);</li><li>Sennosides 8.6 mg, 1 tablet po bid;</li><li>Carvedilol 12.5 mg, 2 tablets po bid;</li><li>Amlodipine Besylate 5 mg, 2 tablets po qd; and</li><li>Clopidogrel Bisulfate 75 mg, 1 tablet po qd.</li></ul>However, the medication list was not signed by a medical practitioner as required. 3. A review of R2's medication administration record (MAR) for July 2025 revealed R2 was administered the following medications;<ul><li>Alprazolam 0.5 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present;</li><li>Acetaminophen 325 mg, 2 tablets po bid, and indicated 2 tablets were administered at 8:00 AM and 8:00 PM July 1, 2025- present;</li><li>Trazodone HCl 100 mg, 1 tablet po qhs, and indicated 1 tablet was administered at 8:00 PM July 1, 2025- present;</li><li>Tramadol HCl 50 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present;</li><li>Aspirin 81 mg, 1 tablet po qd, and indicated 1 tablet was administered at 8:00 AM July 1, 2025- present;</li><li>Sennosides 8.6 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present;</li><li>Carvedilol 12.5 mg, 2 tablets po bid, and indicated 2 tablets were administered at 8:00 AM and 8:00 PM July 1, 2025- present;</li><li>Amlodipine Besylate 5 mg, 2 tablets po qd, and indicated 2 tablets were administered at 8:00 AM July 1, 2025- present; and</li><li>Clopidogrel Bisulfate 75 mg, 1 tablet po qd, and indicated 1 tablet was administered at 8:00 AM July 1, 2025- present.</li></ul> 4. In an exit interview, the finding was reviewed with E1 and no additional information was provided.

Permanent Solution:

The Manager and the Administrator of Care with Compassion Assisted Living, conducted a meeting and emphasized the importance of Physicians Signature to Medications Order. Administrator contacted Hospice Medical provider of R2 and immediately required a signed medication order.

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #3

Rule/Regulation Violated:

R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed R1 was offered the flu and pneumonia vaccines on February 1, 2024. However, documentation of an additional offering was not available for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Permanent Solution:

The Manager and the Administrator of Care with Compassion Assisted Living immediately talk to the resident and offer Pneumonia and Flu shots also contacted R1’s Power of Atty. to offer Pneumonia and Flu vaccine for year 2025, document it and file in R1 medical record.

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #4

Rule/Regulation Violated:

R9-10-814.B.1-2. Personal Care Services B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 1. The condition is a result of a short-term illness or injury; or 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident’s primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; ii. Reviews the assisted living facility’s scope of services; and iii. Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility; and c. The resident’s service plan includes the resident’s

Evidence/Findings:

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated February 1, 2025) revealed R1 received personal care services, and was confined to a bed or chair. 3. A review of R1's medical record revealed a determination for continued residency dated February 1, 2024. However, no further documentation was available for Compliance Officer review. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Permanent Solution:

The Manager and the Administrator of Care with Compassion Assisted Living, send the Determination of Continuous Residency form to R1 Primary Care Physician, scheduled a visit and fill up the form and document.

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #5

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of the facility’s license revealed that the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the back door had an alarm. However, it was not turned on at the time of inspection. 3. In an exit interview, the finding was reviewed with E1 and no additional information was provided.

Permanent Solution:

The Manager and the Administrator of Care with Compassion Assisted Living turn on the alarm of the back door while the inspection was still doing environmental check. And made sure to always keep it on the whole time.

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #6

Rule/Regulation Violated:

R9-10-817.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed insulin was stored in an unlocked mini fridge and on the kitchen counter. Additionally, the Compliance Officers observed the facility's medication cart that held medication for all five residents, unlocked and accessible to residents. 3. In an exit interview, the finding was reviewed with E1 and no additional information was provided. Technical assistance was provided regarding this regulation during the abbreviated inspection conducted on June 12, 2024.

Permanent Solution:

After the compliance officer inspection, the manager and the Administrator of Care with Compassion Assisted Living made sure that all medication is locked on a locked medicine cart and medication fridge is locked with key and accessible only to caregiver, manager and authorized stuff.

Person Responsible:

RAYMUND VARELA, MANAGER

Deficiency #7

Rule/Regulation Violated:

R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure the premises of the facility was free from a condition or situation that may cause a resident or another individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a glass table outside sitting next to the back yard door with a large, broken shard of glass lying on top in a way that was accessible to residents and/or staff. 2. In an exit interview, the finding was reviewed with E1 and no additional information was provided.

Permanent Solution:

After the compliance officer inspection, the manager and the Administrator of Care with Compassion Assisted Living Home made sure that the broken glass and the table on the backyard was thrown away and was pick up by trash track.

Person Responsible:

RAYMUND VARELA, MANAGER

CARE WITH COMPASSION ASSISTED LIVING

Facility Information

Inspection History

INSP-0136267

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0063553

Summary:

INSP-0063552

Summary: