INSPIRA ARROWHEAD

INSP-0130884

Complete

Date: 5/6/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-06-03

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00129341, 00104636, and 00104444 conducted on May 06, 2025:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.B.2. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition B. Each health care institution: 2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times.

Evidence/Findings:

Based on record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of eleven residents sampled. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of R1's medical record revealed an incident report dated November 04, 2024, at 6:15 PM. The incident report stated, "Resident had non injury fall [R1] slid down from [R1] bed after transfer and sitting to close to the edge. Call 911 to get assistant to lift [R1] to [R1's] bed." 2. A review of R1's medical record revealed an incident report dated February 05, 2025, at 7:45 AM. The incident report stated, ”Caregiver was pulling up resident’s pants when [R1] could no longer bear weight. Caregiver guided resident to the floor. Fire department was called to get resident off the floor no apparent injuries.” 3. In an interview, E1 reported that the staff called 911 to assist E1 off the floor. E1 and E11 acknowledged the facility failed to provide appropriate first aid to R1 who had fallen and appeared to be uninjured.

Temporary Solution:

Bethany Park, Manager has inserviced all staff to ensure they understand all residents must be assisted off the floor before emergency personal arrive, if safe to do so.

Permanent Solution:

Manager ordered lift device to assist with getting residents off the floor ongoing.

Person Responsible:

Bethany Park, Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; 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; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. Review of E2’s, E3’s, E5’s, E6’s, E7’s, E8’s, E9’s, and E10’s personnel records did not include documentation of initial training and education related to recognizing the signs and symptoms of TB. Based on E2’s, E3’s, E5’s, E6’s, E7’s, E8’s, E9’s, and E10’s hire dates this training was required. 3. In an interview, E1 acknowledged E2, E3, E5, E6, E7, E8, E9, and E10 did not complete initial training and education related to recognizing the signs and symptoms of TB.

Temporary Solution:

TB Signs and Symptoms inservice was completed 7/9/2025 at All Staff Meeting to ensure all staff are trained, ongoing annual trainings scheduled to occur every September

Permanent Solution:

Bethany Park, Manager updated new associate onboarding paperwork to include TB signs and symptoms training.

Person Responsible:

Bethany Park, Executive Director

Deficiency #3

Rule/Regulation Violated:

R9-10-803.L.2.a-c. Administration L. If a resident is receiving services from a home health agency or hospice service agency, a manager shall ensure that: 2. Any care instructions for a resident provided to the assisted living facility by the home health agency or hospice service agency are: a. Within the assisted living facility's scope of services, b. Communicated to a caregiver, and c. Documented in the resident's service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure, care instructions were documented in the resident's service plan, for one of one sampled resident receiving home health services. Findings include: 1. A review of R1's medical record revealed a service plan, dated April 28, 2025, for directed care services. The service plan stated, "[R1] has home health for wound care. Home Health (Enhabit) and Wound Nurse (AZ Wound) manages BLE wounds from Lymphedema." However, the service plan did not include any wound care instructions. 2. A review of R1's medical record revealed a signed order (dated April 2025). The order stated "Barrier Cream 12% External cream, Apply topically to affected area twice a week ... (May shower with protection on days wound care will be provided)." 3. In an interview, E1 and E11 acknowledged that R1's service plan did not include the care instructions provided to the facility by R1's home health agency for wound care.

Temporary Solution:

Bethany Park, Manager will ensure all resident's receiving services from a Home Health or Hospice agency has the correct documentation including care instructions on their care plan by 7/31/2025

Permanent Solution:

Bethany Park, Manager will ensure all resident's receiving services from a Home Health or Hospice agency has the correct documentation including care instructions on their care plan by 7/31/2025. Ongoing, the Manager will ensure any new residents or current residents that begin utilizing Home Health or Hospice Services get their care plan updated to reflect changes within 24 hours.

Person Responsible:

Bethany Park, Executive Director

Deficiency #4

Rule/Regulation Violated:

R9-10-806.A.1.a-b. Personnel A. A manager shall ensure that: 1. A caregiver: a. Is 18 years of age or older; and b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Admin- istrators and Assisted Living Facility Manag- ers; ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998; iii. For supervisory care services or personal care services, employment as a manager or care- giver of a supportive residential living center before November 1, 1998; or iv. For supervisory care services, personal care services, or directed services, one of the follow- ing: (1) A nursing care institution administrator’s license issued by the Board of Examiners; (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a man- ager or caregiver of an unclassified resi- dential care institution before November 1, 1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult fos- ter care home before November 1, 1998;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of ten personnel sampled. The deficient practice posed a risk if the employee was not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. A review of E9's personnel record revealed E3 was hired as a caregiver on July 23, 2024. The personnel record contained a caregiver training certificate from "Cactus Wren Caregiver and Managerial Training" (the ALTP #0115) dated May 20, 2011. Additionally, the personnel record revealed no former employers listed in the job application. 2. A review of E9's personnel record revealed a Fingerprint Clearance Card (FCC) issued on March 29, 2021. However, no FCC cards were available under E9's name issued prior to that date. 3. In an interview, the Compliance Officers questioned E9 about the caregiver certificate and the previous work experience since 2011. However, E9 was not able to provide a clear answer on when he attended the caregiver school. E9 wanted the Compliance Officers to speak to O1. 4. In a telephonic interview with O1, O1 reported that E9 did not complete the caregiver training in 2011 because E9 was too young at the time and only completed the training approximately six years ago, in 2019. 5. In an interview, E9 reported that the timeline stated by O1 made more sense and stated that the caregiver certificate was issued by a previous assisted living facility where E9 had been employed. 6. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E9. 7. A review of facility documentation revealed E9 was on the work schedule for the months of January 2025, February 2025, and April 2025 2:00 PM - 10:30 PM in the memory care unit. 8. In an interview, E1 and E11 reported E9 was working at the facility as a caregiver and actively providing services to residents. However, when questioned about the timeline of the caregiver certificate and the previous work experience not listed in the job application, E1 acknowledged that the caregiver certificate could be false and that the Department may have been provided with false or misleading information.

Temporary Solution:

Associate referenced, E9 is no longer an employee of the community.

Permanent Solution:

Bethany Park, Manager will not hire any certified caregivers moving forward unless they have a valid cg certificate that was obtained after August 2013 and able to be verified. If certificate is dated prior, associate will be brought on as an assistant until they are able to complete the caregiver certification and provide a valid caregiver certificate. At that point they will be promoted to Caregiver.

Person Responsible:

Bethany Park, Executive Director

Deficiency #5

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure two of ten sampled employee personnel records contained documentation indicating a caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services. The deficient practice posed a health and safety risk. Findings include: 1. A review of facility documentation revealed a policy titled "GP13 – Staffing, Training, Cardiopulmonary Resuscitation (CPR) & First Aid Training, and Emergency Responses," reviewed December 13, 2024 that stated "e. Initial Training: i. All care staff must complete the required initial training as per state regulations. ii. Care staff knowledge and skills must be verified and documented before they are allowed to provide services to residents. 1. The Health & Wellness Director is responsible for verifying and documenting these skills and knowledge." 2. A review of facility documentation revealed E5 and E6 were on the work schedule for April 2025, 2:00 PM - 10:30 PM in the Assisted Living area. 3. A review of E5's and E6’s personnel records revealed no documentation showing E5's and E6’s skills and knowledge were verified prior to providing physical health services. 4. In an interview, E1 acknowledged that E5's and E6's personnel records did not include documentation of the verification of skills and knowledge.

Temporary Solution:

Bethany Park, Manager will audit all care staff files and ensure all current care staff have a skills and knowledge checklist.

Permanent Solution:

Bethany Park, Manager will ensure moving forward that all care staff receive a skills and knowledge verification that is signed off on. Bethany Park will utilize a tracker to ensure the care staff's skills and knowledge is verified and documented within 30 days of hire and in file.

Person Responsible:

Bethany Park, Executive Director

Deficiency #6

Rule/Regulation Violated:

R9-10-808.A.3.f. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on interview and record review, the manager failed to ensure a service plan included how the medication was stored and controlled, for two of three resident sampled, who stored medication in the resident's residential units. The deficient practice posed a health and safety risk if medications were not stored in a safe manner. Findings include: 1. In an interview, E11 reported that R6 and R9 received personal care services and self-administered medication. 2. A review of R6's medical record revealed a written service plan dated April 29, 2025. The service plan stated "Resident will maintain and/or maximize current level of functioning with medication, Resident self-administers medications." This service plan did not include how the medication would be stored and controlled in R6's room. 3. A review of R9's medical record revealed a written service plan dated February 18, 2025. The service plan stated "Resident will maintain and/or maximize current level of functioning with medication, Resident self-administers medications." This service plan did not include how the medication would be stored and controlled in R9's room. 4. In an interview, E1 and E11 acknowledged that the service plans did not indicate how the medications would be stored and controlled for R6, and R9.

Temporary Solution:

Bethany Park, Manager will immediately audit all residents self administering medications to ensure service plan lists how their medications are stored and kept secure in resident apartment.

Permanent Solution:

Manager will work with community nurses to ensure any incoming residents that will be administering their own medications will have the storage of mediation information listed on their initial and ongoing service plans.

Person Responsible:

Bethany Park, Executive Director

Deficiency #7

Rule/Regulation Violated:

R9-10-811.C.13.b. Medical Records C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: b. The name, strength, dosage, and route of administration;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the dose administered, for one of one resident sampled who was administered insulin. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of R2's medical record revealed a signed medication order dated September 25, 2024. The medication order stated the following: "LISPRO INS 100 UNIT/ML PEN; INJECT SUBCUTANEOUSLY BEFORE BREAKFAST PER SLIDING SCALE: IF BS LESS THAN 70 = 0U; 70–100= 12U; 101–150= 14U; 151–200= 16U; 201–250= 18U; 251–300= 20U; GREATER THAN 300= 22U.INJECT SUBCUTANEOUSLY BEFORE LUNCH PER SLIDING SCALE: IF BS LESS THAN 70 = 0U; 70–100= 10U; 101–150= 12U; 151–200= 14U; 201–250= 16U; 251–300= 18U; GREATER THAN 300= 20U.INJECT SUBCUTANEOUSLY BEFORE DINNER PER SLIDING SCALE: IF BS LESS THAN 70 = 0U; 70–100= 10U; 101–150= 12U; 151–200= 14U; 201–250= 16U; 251–300= 18U; GREATER THAN 300= 20U." 2. A review of R2's medical record revealed an April 2025 medication administration record (MAR) that showed LISPRO INS 100 UNIT/100 ML PEN was administered from April 01, 2025, to the present, and R2's blood sugar reading was taken at 8:00 AM, 12:00 PM, 5:00 PM and 8:00 PM. However, documentation was not available showing how many units of insulin were administered on the days listed above, according to the medication order. 3. In an interview, E1 and E11 reported that the medication had been administered according to the medication order but acknowledged that R2’s medical record did not indicate the number of units of sliding scale insulin administered.

Temporary Solution:

Bethany Park, Manager worked with EMAR system to immediately correct system to require associate to document units given.

Permanent Solution:

Bethany Park, Manager worked with EMAR system to ensure the system requires the associate to document units given, to correct the deficiency immediately and ongoing.

Person Responsible:

Bethany Park, Executive Director

Deficiency #8

Rule/Regulation Violated:

R9-10-812.1-3. Behavioral Care A manager shall ensure that for a resident who requests or receives behavioral care from the assisted living facility, a behavioral health professional or medical practitioner: 1. Evaluates the resident: a. Within 30 calendar days before acceptance of the resident or before the resident begins receiving behavioral care, and b. At least once every six months throughout the duration of the resident's need for behavioral care; 2. Reviews the assisted living facility's scope of services; and 3. Signs and dates a determination stating that the resident's need for behavioral care 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.

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure that a behavioral health professional or medical practitioner completed and signed a written determination, 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months thereafter, stating that the resident’s behavioral health needs could be met by the facility and were within the facility’s scope of services, for one of one residents sampled who were receiving behavioral care. The deficient practice posed a health and safety risk by potentially retaining a resident whose needs were not properly assessed or supported by the facility. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. A review of R7's medical record revealed a current written service plan for personal care services dated February 2025. This service plan revealed no diagnosis for R7. 3. A review of R7's medical record revealed R7 received administration of psychotropic medications. Additionally, R7's medical record revealed an assessment (dated March 20, 2025) from a behavioral health professional that stated "Diagnosis: Delusional disorders; Schizophrenia, unspecified; Depression, unspecified; Anxiety disorder, unspecified; Unspecified dementia, mild, with agitation". However, no documentation indicating that R7's behavioral health professional or medical practitioner examined R7 30 days prior to acceptance or before the resident began receiving behavioral care, signed and dated a determination stating R7's needs were being met by the facility, and reviewed the facility's scope of services was available. 4. In an interview, E1 and E11 acknowledged R7's behavioral health professional or medical practitioner did not provide a written determination at least 30 days before acceptance or before the resident began receiving behavioral care.

Temporary Solution:

Resident mentioned, R7, is no longer a resident of the community.

Permanent Solution:

Bethany Park, Manager will ensure if any residents move into community with behavioral needs that can be managed by the community, has a current determination signed by their Behavioral Health Professional that residents needs were/can be met and will be reviewed and signed every 6 months.

Person Responsible:

Bethany Park, Executive Director

Deficiency #9

Rule/Regulation Violated:

R9-10-818.A.5.a. Emergency and Safety Standards A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of the facility's employee and resident evacuation drills revealed the following;-February 13, 2025 at 10:00 AM-June 10, 2024 at 9:30 AM-October 22, 2023 at 9:45 AM 2. In an interview, E1 acknowledged the employee and resident evacuation drills were not conducted at least once every six months.

Temporary Solution:

Evacuation Drill has been scheduled for 8/7/2025

Permanent Solution:

Bethany Park, Manager scheduled evacuation drills in advance to ensure ongoing compliance within correct time period

Person Responsible:

Bethany Park, Executive Director

Facility Information

Inspection History

INSP-0158977

Summary:

INSP-0130884

Summary:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0103850

Summary: