BROOKDALE ORO VALLEY

INSP-0159761

Enforcement

Date: 9/12/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-10-17

Summary:

The following deficiencies were found during the on-site investigation of complaints 00144654, 00144655, and 00141936, conducted on September 12, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-803.C.1.g. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the facility’s policy and procedure covering how a caregiver will respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual was implemented. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. A review of facility policy and procedure, last reviewed October 1, 2024, revealed a policy covering how a caregiver was to respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The policy indicated caregivers were to take actions such as removing other residents in the area, using calm language, and redirecting the resident. The policy made no mention of employees secluding themselves from the resident displaying the behavior. 2. A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door." The progress notes also indicated “Care staff barricaded in med room and called 911.” Evidence of documentation of any other residents in the area, or attempts to calm or redirect R2, was unavailable for review. 3. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2, towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” Evidence of documentation of any other residents in the area, or attempts to calm or redirect R2, was unavailable for review. 4. A review of staffing schedules revealed E3 and E6 were the only two care staff on duty during the “10 pm – 6 am” shift on September 2, 2025. 5. In an interview, E1 said E1 did not know where R2 had gotten the rocks R2 threw at care staff during the September 2, 2025 incident. E1 advised E1 did not know if any other residents were near R2 when R2 was displaying aggressive and out-of-control behavior. E1 stated E1 did not know how long R2 was left alone to roam the facility, while E3 and E6 were barricaded in the medication room. E1 acknowledged E3 and E6 did not implement the facility’s policy on how to respond to a resident’s sudden, intense, or out-of-control behavior.

Deficiency #2

Rule/Regulation Violated:

R9-10-806.A.5.a-c. Personnel A. A manager shall ensure that: 5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to: a. Provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living facility’s scope of services; b. Meet the needs of a resident; and c. Ensure the health and safety of a resident;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door. The progress notes also indicated “Care staff barricaded in med room and called 911.” Evidence of documentation of any other care staff in the area, or attempts to calm or redirect R2, or ensure the safety of any other residents in the building was unavailable for review. 2. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2 towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” Evidence of documentation of any other care staff in the area, or attempts to calm or redirect R2, or ensure the safety of any other residents in the building was unavailable for review. 3. A review of staffing schedules revealed E3 and E6 were the only two care staff on duty during the “10 pm – 6 am” shift on September 2, 2025. 4. In an interview, E1 said E1 did not know where R2 had gotten the rocks R2 threw at care staff during the September 2, 2025 incident. E1 advised E1 did not know if any other residents were near R2 when R2 was displaying aggressive and out-of-control behavior. E1 stated E1 did not know how long R2 was left alone to roam the facility, while E3 and E6 were barricaded in the medication room. E1 added E1 was not aware of any efforts taken by E3 or E6 to calm or redirect R2, nor was E1 aware of any efforts by R3 or R6 to contact E1 or any other employee for assistance, before they locked themselves in the medication room. E1 acknowledged E3 and E6 did not have the qualifications, experience, skills, and knowledge necessary to meet R2's needs and ensure the health and safety of the residents.

Deficiency #3

Rule/Regulation Violated:

R9-10-807.G.1. Residency and Residency Agreements 2. Maintain the original of the residency agreement in subsection (D) in the resident’s medical record. 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to terminate residency in a manner compliant with R9-10-807(G)(1) for a resident whose behavior posed an immediate threat to the health and safety of other individuals in the assisted living facility. The deficient practice posed a health and safety risk. Findings include: 1. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2 towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” The report included a section titled “Follow-Up Information:” which stated, “No Follow Up entries exist.” 2. A review of incident reports filed after September 2, 2025, revealed an incident report involving R2, dated September 10, 2025. The report reflected the incident involved an act of aggression by R2, against R3, which occurred at approximately 12:15 AM. The report indicated R3, who is non-verbal, was sitting alone in the dining room when R2 approached R3 and began to speak to R3. When R3 did not respond, R2 “struck [R3] in the face and then again on the top of [R3’s] head.” According to the report, [R3] was “bleeding profusely from [R3’s] head.” According to the report, R2 struck R3 in the head with “a tape dispenser wrapped in a t-shirt.” A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door. The progress notes also indicated “Care staff barricaded in med room and called 911.” 3. A review of progress notes for R2 revealed an entry on September 2, 2025, which read “Resident refused to go to bed and also refused to take [R2’s] medication. Resident was very agitated and aggressive towards care staff. Resident threw rocks at staff and was trying to break the windows and door. Resident was exit seeking. Care staff barricaded in med room and called 911. Resident was taken out to [the hospital].” Entries on September 10 and September 11 read as follows: -September 10, 2025: “Resident attacked another resident [R3] unprovoked. Resident hit the resident with an item [R2] had in [R2’s] hands twice claiming that [R3] was trying to kill him.” -September 11, 2025: “[Alternate Facility] has agreed to accept [R2]. They are waiting for paperwork from the family, the transfer to their community should happen on Monday 9-15-25. Resident has responded to the increase in his anxiety medications. From 6 am to 10 pm Brookdale staff is sitting with the resident. Family hasn’t set up the sitter yet.” 4. In an interview, E1 advised R2’s representative was not provided a notification of immediate termination of residency on September 11, 2025, but the family agreed to relocate R2 after R2 attacked R3 on September 10, 2025. E1 acknowledged R2’s representative was not provided with a notification of immediate termination of residency after care staff barricaded themselves in a room to protect themselves from R2.

Deficiency #4

Rule/Regulation Violated:

R9-10-819.D.1. Emergency and Safety Standards D. 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: 1. Immediately notifies the resident’s emergency contact and primary care provider; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's primary care provider or emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed two reports where medical services were called after a resident suffered an emergency or injury. A review of the incident report dated September 2, 2025, revealed at approximately “2:30 AM,” R2 was transported to the hospital after displaying aggressive behaviors, in which caregivers barricaded themselves in a room and called 911. The report included a section for documenting contact efforts of “Family,” which reflected a time of “3:00 AM.” The report also included a section for contacting R2’s “Physician,” which reflected a time of “10:15 AM.” A review of the incident report dated September 10, 2025, revealed at approximately “12:15 AM,” R3 was a victim of an attack and suffered head injuries requiring emergency medical services. The report included a section for documenting contact “Family,” which reflected a time of “9:30 AM,” and a section for contacting R3’s “Physician,” which reflected a time of “8:45 AM.” 2. In an interview, E1 agreed there was no evidence to indicate emergency contacts and/or primary care providers were immediately notified, for incidents in which R2 or R3 required medical services.

INSP-0132809

Complete

Date: 7/14/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-08-20

Summary:

The following deficiencies were found during the on-site investigation of complaints 00136214, 00135297, and 00132158 conducted on July 14, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-808.C.1.a-g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident’s service plan; b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; c. Provides assistance with activities of daily living according to the resident’s service plan; d. If applicable, suggests techniques a resident may use to maintain or improve the resident’s independence in performing activities of daily living; e. Provides assistance with, supervises, or directs a resident’s personal hygiene according to the resident’s service plan; f. Encourages a resident to participate in activities planned according to subsection (E); and g. Documents the services provided in the resident’s medical record; and

Evidence/Findings:

Based on record review and interview the manager failed to ensure a caregiver or assistant caregiver documented services provided in the resident's medical record. Findings include: 1. A review of R2’s medical record revealed a current service plan indicating R2 received directed care services, which included a variety of assisted living services, including “Night Checks, Resident will receive night checks every 2-4 hours or as determined by the resident’s need.” 2. A review of R2’s medical record revealed documentation of activities of daily living, which included “Night Check every 2 hours.” The service was documented as being provided on every shift during June 2025, with the exception of the 10:00 p.m. to 6:00 a.m. shift on June 3, 5, and 30, 2025. 3. In an interview, E1 acknowledged R2’s medical record did not contain evidence of documentation of R2 receiving night checks on each night shift in June 2025.

Temporary Solution:

Care Associates will be re-in-serviced on proper documentation of ADLs and completion of Point of Care Tasks by the Health and Wellness Director by September 18, 2025.

Permanent Solution:

Daily compliance checks will be completed by the Health and Wellness Director or designee.

Person Responsible:

Health and Wellness Director or designees

Deficiency #2

Rule/Regulation Violated:

R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a resident is treated with dignity, respect, and consideration. Findings include: 1. A review of R1’s medical record revealed a service plan, dated April 23, 2025, for directed care services, which included the service “Bathroom Assistance.” The service plan indicated R1 is “unable to use the bathroom on their own and requires assistance pulling up/down pants, handling toilet paper, wiping, changing protective undergarments and getting onto/off of toilet.” The service plant also indicated R1 “required a bathroom schedule; frequently during the day and as needed at night.” 2. A review of facility documentation revealed an email dated June 28, 2025, from O1 to several facility employees, including E2, documenting O1’s observation of R1 not being toileted for eight hours, between 11:45 a.m. and 7:45 p.m. The email indicated O1 had a conversation with E2 the week prior, inquiring about “how many hours a resident sits in wet briefs before they are changed.” Additionally, the email indicated R1 had “… a pressure ulcer…” on R1’s backside and received ointment on R1’s backside to control rashes. 3. A review of facility documentation revealed an incident report dated July 1, 2025, documenting receipt of O1’s June 28, 2025, email. The report documented “no injury” to R1 after a skin evaluation, but indicated R1’s service plan would be changed to reflect O1’s request to change R1 every 4 hours, if needed. 4. In an interview, E1 agreed R1’s service plan had not been updated to reflect an increase in frequency of toileting assistance for R1. E1 acknowledged R1 had not been treated with consideration when R1 was not checked for toileting needs for eight hours.

Temporary Solution:

Health and Wellness Director will re-in-service all staff on Resident Rights on September 18, 2025. The Executive Director (ED) and Health and Wellness Director or designee will audit current service plans to verify service plans correlate to Point of Care tasks (ADLs) assigned in Point Click Care by October 3, 2025.

Permanent Solution:

HWD or designee will verify Point of Care tasks (ADLs)are updated along with Service Plans a resident has a change in condition

Person Responsible:

Health and Wellness Director (HWD) or designee

INSP-0132388

Complete

Date: 5/23/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-26

Summary:

No deficiencies were found during the on-site investigation of complaint 00131538 conducted on May 23, 2025.

✓ No deficiencies cited during this inspection.

INSP-0064754

Complete

Date: 11/12/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-11-21

Summary:

An on-site investigation of complaint AZ00218581 was conducted on November 12, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0064753

Complete

Date: 8/7/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-08-14

Summary:

An on-site investigation of complaint AZ00214170 was conducted on August 7, 2024, and no deficiencies were cited.

✓ No deficiencies cited during this inspection.

INSP-0064750

Complete

Date: 5/13/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-05-24

Summary:

An on-site investigation of complaint AZ00210178 and AZ00210298 was conducted on May 13, 2024, and the following deficiencies were cited :

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
b. As follows:
iii. At least once every three months for a resident receiving directed care services; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of three residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. A review of R1's medical record revealed a service plan for directed care services dated December 19, 2023, however, a service plan for March 19, 2024, was not available for review.

2. In an interview, E1 acknowledged R1 was receiving directed care services and the R1's service plan was not updated at least once every three months.

INSP-0064749

Complete

Date: 4/9/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-04-22

Summary:

This Statement of Deficiencies (SOD) supercedes the SOD sent on April 22, 2024: An on-site investigation of complaint AZ00208642 was conducted on April 9, 2024, and the following deficiencies were cited :

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

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

Findings include:

1. A review of R2's medical record revealed a service plan dated February 28, 2024, for directed care services. However, the service plan was not signed or dated by the resident's legal representative, which was required.

2. A review of R3's medical record revealed an initial service plan dated March 21, 2024, for directed care services. However, the service plan was not signed or dated by the resident's legal representative, which was required.

3. In an interview, E1 acknowledged the service plans provided for R2, and R3, had not been signed, or dated by the legal resident's representatives when the service plans were developed and updated.

This is an uncorrected deficiency from the compliance and complaint inspection conducted on February 6, 2024.

Deficiency #2

Rule/Regulation Violated:

C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes:
1. The requirements in R9-10-814(F)(1) through (3);
2. If applicable, the determination in R9-10-814(B)(2)(b)(iii);
3. Cognitive stimulation and activities to maximize functioning;
4. Strategies to ensure a resident's personal safety;
5. Encouragement to eat meals and snacks;
6. Documentation:
a. Of the resident's weight, or
b. From a medical practitioner stating that weighing the resident is contraindicated; and
7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for one of three directed care residents sampled.

Findings include:

1. A review of R3's medical record revealed documentation of service plans indicating R3 was receiving directed care services. However, the service plans did not contain the following:

- Encouragement to eat meals and snacks.

2. In an interview, E1 acknowledged R3's service plan did not contain encouragement to eat meals and snacks as required for directed care residents per R9-10-815(C)(1-5).

INSP-0064747

Complete

Date: 2/6/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-02-12

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00202159 conducted on February 6, 2024:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for one of five caregivers and assisted caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in July 2023.

2. A review of E4's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection.

3. A review of staff schedules revealed in January and February 2024, E4 worked the following days;

- January 2, 3, 5, 6, 7, 8, 12, 14, 15, 19, 20, 22, 26, 27, 28, 29, 2024; and
- February 2, 2024, E4 worked D Hall.

4. In an interview, E1 acknowledged E4 did not have documentation of first aid training during the time of the inspection.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;

Evidence/Findings:

Based on record review, documentation review, observation, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's license or certification for one of five personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not provided during the inspection.

Findings include:

1. A review of E5's personnel record revealed R5 was hired as a caregiver on October 11, 2023. The Compliance Officer observed no documentation of a valid caregiver certificate.

2. A review of a staffing schedule for January and February revealed E5 worked the following days:

- January 1, 7, 8, 2, 11, 15, 21, 22, 24, 28, and 29, 2024; and
- February 4, and 5, 2024.

3. The Compliance Officer made an Internet search on azcg.tmutest.com to verify E5's certificate. E5 does have a certificate, however a copy was not provided to the Compliance Officer while on-site.

4. In an interview, E1 reported being unable to locate E5's caregiver's certificate. E1 acknowledged E5's personnel record did not include documentation of E5's certification.

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Based on record review, observation, and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated was signed and dated by the resident or resident's representative, the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for two of three directed care residents sampled. 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 December 13, 2023, which indicated R1 was receiving directed care services and medication administration. The service plan revealed the following required date and signatures were not present:

- The resident's representative;
- The manager; and
- The nurse or medical practitioner who reviewed the service plan.

2. The Compliance Officer observed a pink sticky note attached with "emailed 1/16/24". No other documentation was available for review.

3. A review of R3's medical record revealed a service plan dated December 11, 2023, which indicated R3 was receiving directed care services and medication administration. The service plan revealed the following required dates and signatures were not present:

- The signature and date signed by R3's representative;
- The manager: and
- The nurse signed the document, however, the nurse did not date the document.

4. 2. The Compliance Officer observed a handwritten note on the document "emailed to Jeff 12/13/2023". No other documentation was available for review.

5. In an interview, E1 acknowledged the service plans for R1 and R3 were not dated and signed as required in R9-10-808.

INSP-0064745

Complete

Date: 2/28/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-03-14

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints AZ00180734, AZ00187127, AZ00188554, and AZ00187557 conducted on February 28, 2023:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

E. A manager shall ensure that, unless otherwise stated:
1. Documentation required by this Article is provided to the Department within two hours after a Department request; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure documentation required by this Article 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 as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On February 28, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- Incident report involving R4;
- Documentation of a the facility's disaster plan review;
- 90 Day determination documentation for R1, R2, and R4; and
- Documentation on services provided (ADLs') to R4.

However, this documentation was not provided.

2. In an interview, E1 acknowledged this information was not provided to the Compliance Officer within two hours after a Department request.

Deficiency #2

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on record review, documentation review, observation, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse, and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Findings include:

1. A review of documentation provided by The Adult Protective Services (APS) revealed an incident occurred on October 7, 2022, involving R2, and E6. The allegation was suspected abuse. This document was sent to the Department on October 27, 2023.

2. A review of R2's medical record revealed R2 was receiving directed care services.

3. A review of documentation sent to the Department revealed O1 sent a self report notification to APS and to the Department dated October 27, 2022.

4. A review of documentation provided by E1 revealed a document titled "Incident Investigation" dated October 27, 2023. This incident stated the following "The reporter states that on 10/7/2022, [R2] was pent up against the wall with [R2's] walker by the alleged perpetrator. The reporter states there were no injuries to the adult. The reporter states that the alleged perpetrator has been removed from the community due to medical reasons".

5. Upon review of the incident investigation report, the Compliance Officer observered the following requirements in R9-10-803.J.1-6 were missing:

- d. The actions taken by the manager to prevent the suspected abuse, from occurring in the future.

6. In an interview, E1 reported R6 was put on administrative leave immediately, and after the investigation was completed E6 was terminated on November 15, 2022.

7. A review of documentation provided by The Adult Protective Services (APS) revealed an incident occurred on November 28, 2022, involving R4. The allegation was suspected abuse. The alleged date was November 23, 2022.

8. A review of R4's medical record revealed R4 was receiving directed care services.

9. The compliance officer requested a copy of the facility's incident report. E1 reported not having an incident report only progress notes on this incident.

10. A review of documents titled "General Progress Note" dated November 23, 2022, and November 29, 2022, revealed R4 had visited a neuro-psych physician. The neuro-psych physician reported to APS that R4 was stating being abused by the staff at the facility.
This document had a date and time however, was missing the following:

- Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. \'a7 46-454;
- Document the suspected abuse, neglect, or exploitation;
- Any action taken according to subsection (J)(1);
- The report in subsection (J)(2);
- Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
- Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
- The dates, times, and description of the suspected abuse, neglect, or exploitation;
- A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
- The names of witnesses to the suspected abuse, neglect, or exploitation;
- The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
- Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

11. In an interview, E1 acknowledged not documenting the actions taken by the manager to prevent the suspected abuse, from occurring in the future for R2, and not documenting the allegation of abuse for R4 per R9-10-803.J.1-6 and A.R.S. \'a7 46-454.

Deficiency #3

Rule/Regulation Violated:

B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and
2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility:
a. Includes whether the individual requires continuous behavioral health services, and
b. Is signed and dated by a behavioral health professional.

Evidence/Findings:

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 that was dated within 90 calendar days before the individual was accepted which included the requirements in R9-10-807(B)(1-2) for four of four residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R1's medical record revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility which included the requirements in R9-10-807(B)(1-2).

2. A review of R2's medical record revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility which included the requirements in R9-10-807(B)(1-2).

3. A review of R4's medical record revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility which included the requirements in R9-10-807(B)(1-2).

3. A review of R3's medical record revealed a document titled, "Authorization for Residency". However, the document date was 30 days after R3 was accepted by the assisted living facility.

4. In an interview, E1 acknowledged R1, R2, and R4's medical records did not include documentation dated within 90 calendar days before the individual was accepted by the assisted living facility, and R3's documentation was not submitted before or at the time of acceptance by the assisted living facility.

This is a repeat citation from the compliance survey conducted on January 31, 2022.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
a. Provides a resident with the assisted living services in the resident's service plan;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan for one of four resident records reviewed.

Findings include:

1. A review of the facility's policies and procedures, revealed a policy titled, "Job Title: Caregiver". The policy stated, " Job Summary.
Provides direct care to residents following an individual service plan, treats each resident with respect and dignity, recognizes individual needs, and encourages independence. Fosters a homelike atmosphere throughout the community. Essential Functions , 1. Assist residents with activities of daily living, including bathing, dressing, grooming, toileting, transferring, and getting to and from activities and meals according to the individual service plan. Allows and encourages residents to do as much of their own care as possible".

2. A review of R3's medical record revealed a service plan, dated February 4, 2023, for directed care services. The service plan indicated R3 was to receive assistance with all activities of daily living, including bathing, dressing, grooming, toileting.

3. A review of R3's medical record revealed a document titled, "Resident Personalized Service Plan Signature Sheet". This document was blank with only R3's name. E1 reported this is the Activities of Daily Living (ADL) document caregivers use to chart when services are provided to the resident. E1 reported the facility was unable to locate any other documentation showing R3 had been receiving assistance with ADLs' per R3's service plan. Based on R3's date of admittance R3 should have had a January and February ADL chart documented in R4's medical record.

4. In an interview, E1 acknowledged the ADL document indicated R3 had not received assistance with ADL's as required by R3's service plan.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
3. Documentation of the disaster plan review required in subsection (A)(2) includes:
a. The date and time of the disaster plan review;
b. The name of each employee or volunteer participating in the disaster plan review;
c. A critique of the disaster plan review; and
d. If applicable, recommendations for improvement;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure documentation of the disaster plan review required in subsection (A)(2) 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 included:

1. A review of documentation revealed no evidence of a disaster plan review.

2. In an interview, E1 reported to be unable to locate the disaster plan review.

This is a repeat citation from the compliance survey conducted on January 31, 2022.

Facility Information

Inspection History

INSP-0159761

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

INSP-0132809

Summary:

Deficiencies Found: 2

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:

INSP-0132388

Summary:

INSP-0064754

Summary:

INSP-0064753

Summary:

INSP-0064750

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064749

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064747

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

INSP-0064745

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated: