BROOKDALE NORTH MESA

<p>Based on record review and interview, the manager failed to ensure service plans included the<span style="background-color: rgb(255, 255, 255);"> amount, type, and frequency of assisted living services and ancillary services being provided, for five of eight sampled residents.</span></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p>1. A review of R3's service plan dated May 19, 2025, reflected R3 required assistance with dressing and grooming, showering or bathing, bathroom, assistance due to R3's inability to stand independently during dressing or grooming, however R3's service plan did not include the amount, type and frequency of dressing services that would be provided.</p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);"> 2. A review of R4's service plan reflected R4 required assistance with showering and bathing Tuesday and Friday, however there was no frequency R4 would be provided showers or baths. R4's service plan also reflected R4 required assistance with dressing and grooming, as states "dates and times of showers, laundry, and housekeeping may vary depending on resident preferences and as needed"; However, the amount, type, and frequency of services was not noted.</span></p><p><br></p><p><br></p><p><br></p><p>3. A review of R5's service plan reflected R5 required assistance with toileting, dressing, grooming and showering and assistance, h<span style="background-color: rgb(255, 255, 255);">owever, the amount, type, and frequency of services was not noted.</span></p><p><br></p><p><br></p><p><br></p><p>4. A review R6's service plan dated April 24, 2025, reflected R6 <span style="background-color: rgb(255, 255, 255);">required assistance with toileting, dressing, grooming and showering and escorts, however, the amount, type, and frequency of services was not noted.</span></p><p><br></p><p><br></p><p><br></p><p>5. A review of R8's service plan dated May 16, 2025, reflected R8 required assistance with dressing, grooming, and showering, however <span style="background-color: rgb(255, 255, 255);">the amount, type, and frequency of services was not noted.</span></p><p><br></p><p><br></p><p><br></p><p>6. In an interview, E1 reviewed the above service plans and acknowledged being unable to locate the amount, type and frequency of the above service plan at the time of the survey.</p>

<p>Based on record review, observation, documentation 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 eight sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p> 1. A review of R4's service plan reflected R4 required assistance with showering and bathing Tuesday and Friday. A review of documentation of provided services reflected R4 was not provided a shower on Friday, June 6, 2025.</p><p><br></p><p><br></p><p>2. In an interview, E1 reviewed and acknowledged a review of R4's documentation reflected R4 was not provided a shower on <span style="background-color: rgb(255, 255, 255);">Friday, June 6, 2025, as required by R4's service plan.</span></p>

<p>Based on the record review and interview, the manager failed to ensure that medication was administered to a resident in compliance with a medication order for three of three residents sampled. </p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review R1's medical record revealed a service plan dated November 12, 2024, that reflected R1 received medication administration services.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed a medication order dated October 31, 2023 for Losartan Potassium 100 mg administer one tablet daily for HTN hold for systolic blood pressure less than 100 and pulse less than 60 bpm.</p><p><br></p><p><br></p><p><br></p><p>3. A review of R2's December 2024 medication administration record (MAR) revealed <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">the following:</span></p><ul><li>on December 4, 2025, R2's blood pressure was 131/75 and R2 was not administered Losartan;</li><li>on December 7, 2025, R2's blood pressure was 99/57, R2 was administered Losartan;</li><li>on December 10, 2025, R2 blood pressure was 135/79, R2 was not administered Losartan;</li><li>on December 14, 2025, <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">R2 blood pressure was not documented and R2's Losartan was not administered.</span></li></ul><p><br></p><p><br></p><p><br></p><p>4. In an interview, E1 reviewed and acknowledged there was no additional documentation R2's Losartan medication was given in compliance with an order.</p>

Based on observation and interview, the manager failed to ensure food was protected from potential contamination which posed a health and safety risk.

Findings include:

1. During an environmental tour of the facility's kitchen, the Compliance Officer observed the dry storage area. The dry storage area contained plastic containers of flour, sugar, and brown sugar with the lids not attached. The uncovered and opened food items were not protected from the potential contamination.

2. In an interview, E2 acknowledged food was not protected from potential contamination.

Based on observation and interview, the manager failed to ensure the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was conspicuously posted.

Findings include:

1. During a facility tour, E1 and the compliance officer observed there was no conspicuously posted notice of the most recent Department inspection report and any plan of correction resulting from the Department inspection that was available to the public at all times. To be "conspicuously posted" defined in A.A.C. R9-10-101(54) as it was not in an area that was visible and available and was not within the area that the public enters the premises of the health care institution.

2. In an interview, E1, after searching the common area of the facility, acknowledged the required inspection notice was not conspicuously posted. E1 reported, "can't find".

Based on record review and interview, the manager failed to ensure a resident medical record contained the required information from a home health agency, for one of one resident record reviewed who had been receiving home health services, which posed a health and safety risk.

Findings include:

1. In an interview, E1 and E2 reported R1 was being treated by home health for a foot wound.

2. The only available required documentation from the home health visits were dated from September 1, 2022 to September 8, 2022. There was no other available documentation of the required information from each of the home health visits regarding the treatment for this foot wound.

3. In an interview, R1 reported that home health was still coming for the wound care.

4. In an interview, E1 and E2 acknowledged there was no documentation, as required, each time home health services were provided for R1's wound.

Based on record review and interview, the manager failed to ensure one of one sampled resident's written service plan was updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, which posed a health and safety risk.

Findings include:

1. During an interview, E1 and E2 reported that R3 had a significant change in condition in September (2022). R3 went from able to walk with assistance to unable to walk even with assistance.

2. Review of R3's medical record and current service plan that was dated August 8, 2022 stated the resident required personal care services. There was no updated service plan within 14 days after R3's change in condition regarding R3 being unable to walk even with assistance.

3. In an interview, E1 and E2 acknowledged the service plan had not been updated within 14 days to reflect the significant change in R3's physical and functional condition.

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

Findings include:

1. Review of R2's medical record revealed that R2's service plans, based on the date of acceptance, were updated September 21, 2022 and November 2, 2022. The service plan stated the resident required personal services. There were no other service plans available for review during the past 12 months.

2. In an interview, E1 and E2 acknowledged that R2's service plan had not been updated as required. E1 and E2 acknowledged R2 was receiving personal care services.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for two of three sampled residents receiving directed care services.

Findings include:

1. Review of R5's medical record revealed written service plans for directed care services which were updated on August 20, 2022 and November 11, 2022. There were no other service plans available for review. The service plans stated the resident required directed care services. Based on the date of acceptance and the level of care the service plans needed to be updated at least every three months during the past 12 months.

2. Review of R6's medical record revealed written service plans for directed care services which were updated on September 16, 2022, October 18, 2022, and December 8, 2022. There were no other service plans available for review. The service plans stated the resident required directed care services. Based on the date of acceptance and the level of care the service plans needed to be updated at least every three months during the past 12 months.

3. In an interview, E1 and E2 acknowledged the sampled residents had been receiving directed care services for the past 12 months. The service plans were not updated every three months as required.

Based on record review and interview, the manager failed to ensure one of six sampled resident's written service plan when initially developed and updated was signed and dated by the resident or the representative, the manager and if applicable, by the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Based on date of acceptance and review of R7's service plans for the past 12 months that were provided during the compliance inspection revealed the service plans dated February 2, 2022 and May 20, 2022, according to the computer printouts, had not been signed and dated by the resident or the representative, manager, and the nurse or medical practitioner.

2. In an interview, E1 and E2 reported R7 was receiving directed care and medication administration services. E1 and E2 acknowledged R7's service plans had not been signed and dated as required.

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, which posed a health and safety risk; for one of one sampled resident.

Findings include:

1. In an interview, E1 and E2 reported that R1 had a foot wound that was being treated by home health. Home health documentation dated September 1, 2022 indicates R1 was receiving wound care services at that time.

2. In an interview, R1 reported that home health was still coming to treat this wound.

3. Review of R1's current service plan that was dated October 20, 2022 did not document the treatment of this wound which posed a health and safety risk for this resident who was also diabetic.

4. In an interview, E1 and E2 acknowledged that R1's current service plan did not include documentation of the treatment of this foot wound.

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

Findings include:

1. In an interview, E1 and E2 reported R2 was unable to ambulate even with assistance since accepted, R3 has been unable to ambulate even with assistance since September (2022), R5 was unable to ambulate even with assistance for "a long time", and R6 was unable to ambulate even with assistance since returning from the hospital about five to six weeks ago.

2. Review of R2's medical record contained no documented determination at the time of acceptance. There was a documented determination completed on March 24, 2022, however, the determination was not completed at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required personal care services.

3. Review of R3's medical record contained no documented determination at the time of the onset and a documented determination to be completed at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required personal care services.

4. Review of R5's medical record contained no documented determination completed at least every six months throughout the duration of the resident's condition. In the past 12 months the only determination completed was dated November 3, 2022. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required directed care services.

5. Review of R6's medical record contained no documented determination at the time of the onset and a documented determination to be completed at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required directed care services.

6. In an interview, E1 and E2 acknowledged the determinations for these sampled residents were not completed as required.

Based on observation, record review, and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving directed care services which posed a health and safety risk.

Findings include:

1. During a facility tour of randomly selected residents in the memory care unit, E2, E7, and the surveyor observed R5's, R6's, and R7's bedrooms were not equipped with a bell, intercom, or other mechanical means available for these sampled residents to alert employees to a resident's needs or emergencies.

2. Review of these residents' service plans and interview with E2 revealed that these residents required directed care services.

3. In an interview, E1 and E2 acknowledged there was no bell, intercom, or other mechanical means available for these sampled residents to alert employees of their needs. E1 and E2 reported there was no call system available and accessible to residents in the memory care unit.

Based in observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu is served.

Findings include

1. During a facility tour at the beginning of the compliance inspection, E1 and the compliance officer observed there was no menu conspicuously posted. There were sixty-seven residents residing at the facility.

2. In an interview, E1 acknowledged the facility did not have a pre-planned current menu with snacks conspicuously posted that should have been posted at least one calendar day before the first meal on the food menu was served.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers which posed a health risk.

Findings include:

1. During a facility tour of randomly selected areas of the facility, E2, E7, and the compliance officer observed in the hall adjacent to residents units near unit 73 there was a facility hamper overflowing with soiled linen and clothing.

2. In an interview, E2 and E7 acknowledged the uncovered soiled linen and clothing the facility was stored in the residents' hall.

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

Findings include:

1. During a facility tour, E2, E7, and the compliance officer observed, while walking down the hall where residents' units in assisted living were located, there was an unlocked resident spa room that contained an unlocked housekeeping cart that was left unattended with chemicals. There was stored in the housekeeping cart an unlabeled spray bottle of a clear solution, disinfectant spray, surface cleaner spray, unlabeled spray bottle of a blue solution, laundry fresh spray, and glass cleaner spray.

2. In the unlocked prep kitchen next to the residents' common dining room there was stored Lime-a-Way cleaner.

3. In the unlocked facility's laundry room in an unlocked metal cabinet there was stored carpet cleaner, spray paint, coil cleaner, and stainless steel cleaner.

4. No employees were observed in these areas where unlocked chemicals were observed stored by the facility.

5. In an interview, E2 and E7 acknowledged the unlocked poisonous or toxic materials the facility was storing.

Based on observation and interview, the manager failed to ensure equipment at the assisted living facility was maintained in working order which posed a safety risk.

Findings include:

1. During a facility tour of randomly selected residents' bedrooms, E2, E7, and the compliance officer observed the exhaust fans in R4's and R6's bathrooms did not work when tested. The bathroom exhaust fans were located in a bathroom that had no window or any other means of ventilation.

2. During this facility tour, E2, E7, and the compliance officer observed broken toilet paper holders in the resident spa room and in R5's bathroom.

3. In R5's bedroom the closet sliding door was bent and unable to open properly.

4. In an interview, E2 and E7 acknowledged the sampled residents' bathrooms exhaust fans, the toilet paper holders, and the closet door were not kept in good repair.

Based on observation, record review, and interview, the manager failed to ensure two sampled dogs residing at the facility were licensed consistent with local ordinances.

Finding include:

1. In an interview, E1 reported the facility had two dogs residing at the facility.

2. The surveyor requested and was not provided with any documentation that O1 and O2 had a current license from the Maricopa County Animal Care and Control, as required.

3. In an interview, E1 acknowledged there was no record that O1 and O2 had a current license as required.