SEARLES CARE HOME

<p>Based on record review and interview, for two of two sampled residents, the assisted living home failed to maintain a standardized form including all required information in <span style="background-color: rgb(255, 255, 255); font-size: 14px;">A.R.S. § 36-420.04(A)(1-9).</span></p><p><br></p><p><br></p><p><span style="font-size: 14px;">A.R.S. § 36-420.04.A. States: 1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document</span></p><p><span style="font-size: 14px;">A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:</span></p><p><span style="font-size: 14px;">1. The reason or reasons the emergency responder was requested on behalf of the resident.</span></p><p><span style="font-size: 14px;">2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.</span></p><p><span style="font-size: 14px;">3. The name, address and telephone number of the resident's current pharmacy.</span></p><p><span style="font-size: 14px;">4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.</span></p><p><span style="font-size: 14px;">5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.</span></p><p><span style="font-size: 14px;">6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.</span></p><p><span style="font-size: 14px;">7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.</span></p><p><span style="font-size: 14px;">8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization.</span></p><p><span style="font-size: 14px;">9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives.</span></p><p><br></p><p><span style="font-size: 14px;">Findings include:</span></p><p><br></p><p><span style="font-size: 14px;">1. A review of emergency responder forms for R1 and R2 revealed completed documentation was not available for either resident.</span></p><p><br></p><p><span style="font-size: 14px;">2. In an exit interview with E1, the findings were reviewed and no additional information was provided. </span></p>

<p>Based on record review, <span style="background-color: rgb(255, 255, 255);">documentation review,</span>, and interview, the chief administrative officer failed to implement tuberculosis control activities to include baseline screening for each individual employed by or admitted to the health care institution, annual training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution, and annually assessing the health care institution's risk of exposure to infectious tuberculosis, for two of two sampled employees and two of two sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of E2's personnel record revealed E2's baseline screening was incomplete. E2's <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">documentation of freedom from infectious tuberculosis included a single negative skin test dated within a year prior to E2's date of hire and a second negative skin test dated more than a year prior to the other test. </span></p><p><br></p><p>2. A review of E1's and E2's personnel records revealed documentation of annual training and education related to <span style="background-color: rgb(255, 255, 255);">recognizing the signs and symptoms of tuberculosis was not available for review.</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">3. A review of R1's medical record revealed documentation of baseline screening with seven calendar days after R1's date of acceptance was not available for review.</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">4. A review of R2's medical record revealed incomplete documentation of baseline screening. R2's record included documentation of R2's freedom from infectious tuberculosis However, R2's medical record did not include documentation of as</span>sessing R2's risks of prior exposure to infectious tuberculosis or of determining if R2 had signs or symptoms of tuberculosis.</p><p><br></p><p>5. A review of facility documentation revealed documentation of a<span style="background-color: rgb(255, 255, 255);">nnually assessing the health care institution's risk of exposure to infectious tuberculosis was not available for review.</span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">6. In an exit interview with E1, the findings were reviewed and no additional information was provided.</span></p>

<p>Based on record review and interview, the manager failed to ensure a residency agreement was signed by the resident or resident's representative within five working days after a resident's acceptance, for one of two sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R2's medical record revealed a residency agreement signed by the facility manager on the date of acceptance. However, the residency agreement had been signed by the resident's representative fifteen days after acceptance.</p><p><br></p><p>2. In an interview E1 reported R2 was directed care and did not have a representative when R2 was accepted.</p><p><br></p><p>3. In an exit interview with E1, the findings were reviewed and no additional information was provided.</p>

<p>Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R1's medical record revealed a service plan, dated August 1, 2025, for directed care services including medication administration.</p><p><br></p><p>2. A review of R1's medical record revealed the following order, "Aspirin 81 MG Tab, Oral 1 tab daily cardiac prophy, start effective date 08/19/2024."</p><p><br></p><p>3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated August 2025. The MAR indicated, "Aspirin EC 81 MG Tablet Daily" had been held with the note, "Hold blood urine," between August 4, 2025 until August 19, 2025.</p><p><br></p><p>4. A review of R1's medical record revealed a hospice plan of care update dated August 4, 2025, which stated, "Recieved call from facility that [R1] had some blood in brief this morning. Upon arrival to facility, I was informed that [R1] had a fall and sustained small laceration to back of head when [R1] was being changed due to [R1] refusing to let them change [R1] they are trying to make [R1]. Head wound cleansed and left open to air at this time. I did have a discussion with them that if [R1] refuses, they need to walk away, let [R1] settle down and readdress in few minutes. I did change [R1's] brief and clothes while I was there without any difficulty. Head to toes assessment performed and completed." The update indicated no changes were made to the hospice care plan. However, an order to hold Aspirin was not available.</p><p><br></p><p>4. In an interview, E1 reported E1 had contacted hospice about the bleeding and advised hospice had not ordered R1's aspirin to be held. E1 reported Aspirin is a blood thinner and E1 would not provide Aspirin to someone that was bleeding.</p><p><br></p><p>5. <span style="background-color: rgb(255, 255, 255);">A review of R2's medical record revealed a service plan, dated August 3, 2025, for directed care services including medication administration.</span></p><p><br></p><p>5. A review of R2's medical record revealed orders for the following medications:</p><ul><li>"Apixaban Oral Tablet 5 MG, Give 5 mg by mouth every 12 hours for a-fib";</li><li>"Polyethylene Glycol 3350 Powder, give 17 gram by mouth one time a day for bowel care, hold if loose stools present";</li><li>"Metoprolol Tartrate Tablet, Give 12.5 mg by mouth two times a day for HTN, afib hold if HR less than 60 or systolic BP less than 100"; and</li><li>"Acetaminophen Oral Tablet 500 MG, Give 1000 mg by mouth every 8 hours for pain."</li></ul><p>6. A review of R2's medical record revealed a MAR, dated August 2025. The MAR documented the following medication administration errors:</p><ul><li>for "Apixaban Oral tablet 5 MG, give 5 mg by mouth every 12 hours," the MAR indicated the medication had been administered at 8 AM and 6 PM each day;</li><li>for "Polyethylene Glycol, give 17 gram by mouth one time a day for bowel care," the medication had been marked, "PRN" and had not been administered to R2 at all in August 2025;</li><li>for "Metoprolol Tartrate, Give 12.5 mg by mouth two times a day for HTN, afib, hold if HR less than 60 or systolic BP less than 100," the MAR indicated the medication had been administered each day at 8 AM and 6 PM, however, documentation of R2's heart rate and blood pressure prior to each administered dose was not available for review; and</li><li>for, "Acetaminophen Oral Tablet 500 MG, Give 1000 mg by mouth every 8 hours for pain," the medication had been marked, "PRN" and had not been administered to R2 at all in August 2025.</li></ul><p>7. In an interview, E1 reported the MAR forms already have 8 AM and 6 PM on the template, so it was easier to leave it like that instead of making the administration times twelve hours apart as ordered. E1 reported the vital records for Metoprolol had been documented, but when they took R2 to a doctor's appointment they gave the doctor the original vital record and did not have a copy. E1 reported the acetaminophen order says, "for pain," so it is an as needed medication. After being provided education on reading medication orders, E1 reported R2 was just going to refuse the medication anyway, so it will be marked refused from now on.</p><p><br></p><p>8. In an exit interview with E1, the findings were reviewed and no additional information was provided.</p>

<p>Based on observation, record review, and interview, the manager failed to ensure medication was stored in a locked area.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental inspection of the facility, the Compliance Officer observed a multi-dose medication container (medi-set) in R2's bedroom. The Compliance Officer observed the medi-set included prescription medications including Apixaban.</p><p><br></p><p>2. In an interview, R2 reported R2 had brought the medi-set from home and the medications in it were old.</p><p><br></p><p>3. A review of R2's medical record revealed a service plan, dated August 3, 2025, for directed care services including medication administration.</p><p><br></p><p>4. During an environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen which was accessible to residents. Inside the refrigerator, the Compliance Officer observed containers of "Kisqali," "Insulin Lispro," "Ozembic," and "Lantus Solostar," were not in a locked area and were accessible to residents.</p><p><br></p><p>5. In an exit interview with E1, the findings were reviewed and no additional information was provided.</p>

<p>Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officer observed the facility had two separate buildings. One building included the kitchen, dining room, and several bedrooms. A second building located in the back yard included three bedrooms, a bathroom, and a small living area. The Compliance Officer observed a paved and fenced walkway connected the back door of the first building to the front door of the second building. </p><p><br></p><p>2. During an environmental tour of the facility, the Compliance Officer observed a black futon in the living area of the second building. The Compliance Officer observed when the futon was converted into a bed, it partially blocked the door to exit the second building.</p><p><br></p><p>3. In an interview, E1 reported there is a second caregiver always present in the second building and they are a live-in caregiver who sleeps on the futon in the living area. E1 reported the futon blocks the door partially when used as a bed. E1 reported they would no longer block the exit with the futon.</p><p><br></p><p>4. In an exit interview with E1, the findings were reviewed and no additional information was provided.</p>

<p>Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental inspection of the facility, the Compliance Officer observed a shared bathroom adjacent to bedroom #7. The Compliance Officer observed a cabinet below the bathroom sink had a lock, however, the lock was loose and the Compliance Officer was able to open the cabinet without a key. Inside the cabinet, the Compliance officer observed containers of,"Amdro Insect Killer," "Lysol," and "Windex."</p><p><br></p><p>2. In an exit interview with E1, the findings were reviewed and no additional information was provided.</p><p><br></p><p>This is a repeat deficiency from the on-site compliance inspection conducted on April 8, 2024.</p>

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

Findings include:

1. A review of the facility's work schedule revealed the facility had two shifts.

2. A review of facility documentation revealed a disaster drill conducted, on March 31, 2024. No other disaster drills were provided for review.

3. In an interview, E1 acknowledged disaster drills were not conducted and documented on each shift at least once every three months. E3 reported the facility recreated their disaster drill form and somehow they missed completing the disaster drills.

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

Findings include:

1. During the facility tour, the Compliance Officer observed an unlocked cabinet in a facility bathroom, which contained "Clorox" toilet cleaner, and "Lysol" disinfectant spray.

2. During the facility tour, the Compliance Officer observed an unlocked cabinet under the kitchen sink, which contained, a bucket of "Cascade" dishwashing pods.

3. In an interview, E1 acknowledged the toxic materials were unsecured. E1 was unable t get the lock to re-close on the bathroom cabinet and reported the lock would be replaced.

This is a repeat citation from the compliance inspection conducted on April 19, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of the facility's policies and procedures revealed no documented evidence to indicate a fall prevention and fall recovery training program was implemented for all employees.

2. A review of E1's, E3's, E4's, E5's, E6's, E7's, E8's, and E9's personnel records revealed no documentation of fall prevention and fall recovery training.

3. In an interview, E1 acknowledged a fall prevention and fall recovery training program for all staff was not developed and implemented.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for five of nine employee records reviewed.

Findings include:

1. A.R.S. \'a7 36-411 states:
"A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.

C. Owners shall make documented, good faith efforts to:

1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.

2. Verify the current status of a person's fingerprint clearance card.

D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.

E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.

F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.

G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.

H. For the purposes of this section:

1. "Direct supportive services":


(a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:

(i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.

(ii) Assistance with self-administration of medication.

(iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.

(iv) Transportation services, including van services.

(b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.

2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.

3. "Home health services" has the same meaning prescribed in section 36-151."

2. A review of E2's personnel record revealed no documentation of good faith efforts made to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.

3. A review of E3's personnel record revealed no documentation of good faith efforts made to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.

4. A review of E3's Personnel record also revealed a copy of a fingerprint clearance card issued on February 6, 2018, though there was no documentation to confirm the card was verified through the Department of Public Safety. A review of the status on the DPS website revealed the status of "Invalid". The website also revealed another application was received by DPS, on April 9, 2022, with a status listed as "Application complete - Results mailed to applicant".

5. A review of E4's personnel record revealed no documentation of good faith efforts made to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.

6. A review of E7's personnel record revealed no documentation of reference checks, a fingerprint clearance card, or an application for a fingerprint clearance card. personnel record revealed no documentation of good faith efforts made to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.

7. A review of E8's personnel record revealed no evidence of a fingerprint clearance card or an application of a fingerprint clearance card.

8. In an interview, E1 reported E8 wasn't actually an employee but a family member. A review of E8's personnel record revealed a hire date in 2018 and a review of a posted designation of management for 2022 revealed E8 to be a designee.

9. In an interview, E1 acknowledged the personnel records provided for E2, E3, E4, E7, and E8 did not include documentation of compliance with A.R.S. \'a7 36-411.

Based on observation, document review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Findings include:

1. Upon arriving at the facility, the Compliance Officer observed E2 and E5 were the only personnel on the premises. E7, E3, and E10 arrived later.

2. The Compliance Officer observed a posted designation did not include either of the two personnel on the premises, or the three which arrived later.

3. In an interview E1 acknowledged there was no caregiver present in the facility, which was designated, in writing, and accountable for the assisted living facility when the manager was not present.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees including the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's ability to perform CPR and the documentation that verifies that the employee has received CPR training, for two of five sampled personnel records. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the facility's personnel records revealed a document titled "Caregiver Checklist Prior to Hiring ...Records Required: ... 2. Copy of CPR certification ..."

2. A review of E3's personal record revealed a document titled "Certificate of Completion ...for a Training course in Adult/Child/Infant CPR", dated November 15, 2022. The certificate stated, "This student has Passed Basic Skills Education in Accordance with the eCPRcertification.com Terms and Conditions." A review of eCPRcertification's website revealed it offered online certification only. No other documentation was provided to show E3 completed a demonstration of the employee's ability to perform CPR.

3. A review of E4's personal record revealed no evidence of CPR certification.

4. A review of E7's personnel file revealed current proof of CPR training issued on March 26, 2023, by "NationalCPRFoundation,, an online CPR training program. E7's personnel file did not include evidence of current CPR training which included a demonstration of E7's ability to perform CPR.

5. A review of E9's personnel file revealed current proof of CPR training issued on June 20, 2022, by "NationalCPRFoundation,, an online CPR training program. E9's personnel file did not include evidence of current CPR training which included a demonstration of E9's ability to perform CPR.

6. In an interview, E1 reported to believe CPR certification could be done online after the initial certification.

7. In an interview, E1 acknowledged E3's, E4's, E7's, and E'9's files did not contain documentation of CPR certification which also included a demonstration of the employees' ability to perform CPR.

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 April 19, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- residency agreement addendums for R1 and R2;
- personnel record for E5 and E6;
- fingerprint clearance card for E8;
- documentation of freedom from Infectious Tuberculosis (TB) for E2, E3, E4, and E7;
- documentation of evacuation drill conducted on April 17, 2023; and
- incident reports.

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

Based on record review, interview, and observation, the manager failed to ensure the facility caregivers demonstrated they had the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident.

Findings include:

1. The Compliance Officer arrived at the facility and observed the employees on the premises to be E2, a certified caregiver, and E5, an assistant caregiver later reported to be a cook.

2. In an interview, E2 reported E7, another certified caregiver, had gone to the store to get fruit.

3. A review of E7's personnel record revealed no documentation of caregiver certification, from a school approved by the NCIA Board, and E7 was employed as an assistant caregiver. The personnel record did not include documented skills and knowledge or CPR certification which included a demonstration.

4. A review of facility policies and procedures revealed a policy titled, "Casita Policy & Procedure 2016 ...This Policy is in addition to the existing General Operation Policy ... 2.) Caregiver-There will be 1 caregiver assigned to the casita 24/7 with 2 to 4 residents: 1 caregiver ..."

5. During a tour of the facility, the Compliance Officer observed two residents residing in the casita.

6. In an interview, E1 acknowledged E7 did not have the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. E1 was out of town at the time of the inspection. E1 contacted E10, a Registered Nurse, who arrived at the facility to fill in as the caregiver for the casita, until E1 could return.

Based on document review, record review, and interview, the manager failed to ensure a personnel record was established and maintained, for two of nine personnel records sampled.

Findings include:

1. When the Compliance Officer arrived at the facility, E2 answered the door and E5 was working in the kitchen, before leaving to go to the casita.

2. A review of the facility work schedule for April 2023 indicated E5 worked the following dates and times:
- April 1, 2023, from 7 AM to April 2, 2023 at 7 AM;
- April 3, 2023, from 7 AM to April 7, 2023 at 5 PM;
- April 8, 2023, from 7 AM to 5 PM;
- April 10, 11, 12, 13, and 14, 2023, from 5 PM to 7 AM; and
- April 17 and 18, 2023, from 5 PM to 7 AM.

3. A review of E5's personnel record revealed no personnel record was available for review.

4. In an interview, E2 reported E5 was employed as an assistant caregiver. E2 later stated E5 was a cook and the personnel file was not available and was not complete.

5. A review of the facility work schedule for April 2023 indicated E6 worked the following dates and times:
- April 14, 2023, from 7 AM to 5 PM;
- April 15, 2023, from 5 PM to 7 AM; and
- April 16, 2023, from 7 AM to 5 PM.

6. A review of E6's personnel record revealed no personnel record was available for review.

7. In an interview, E2 reported E6 was employed as a cook and the personnel file was not available and was not complete.

8. In an interview, E1 acknowledged a personnel record had not been provided for E5 or E6.

Based on record review, document review, and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included whether the manager or a caregiver was awake during nighttime hours, and the policy and procedure for the assisted living facility to terminate residency, two of two resident records reviewed.

Findings include:

1. A review of R1's medical record revealed a documented residency agreement, signed in December 2022. However, the agreement did not state whether the staff was asleep or awake at night. The residency agreement also stated, " Management reserves the right to terminate this residency agreement without notice ...should the resident 's urgent medical needs require immediate transfer to another health care institution; or should the resident's care and service needs exceed the services the home is licensed to provide."

2. A review of R2's medical record revealed a documented residency agreement, dated in October 2021. However, the agreement did not state whether the staff was asleep or awake at night. The residency agreement also stated, " Management reserves the right to terminate this residency agreement without notice ...should the resident 's urgent medical needs require immediate transfer to another health care institution; or should the resident's care and service needs exceed the services the home is licensed to provide."

3. In an interview, E1 reported having an addendum to the residency agreement which was created in 2019. The policy and procedure manual contained an addendum with a handwritten note adding that a caregiver could sleep at night and perform resident checks every two to three hours. The Compliance Officer and E2 reviewed R1's and R2's medical record and found no evidence of the addendum in either record.

4. In an interview, E1 acknowledged R1's and R2's medical records did not contain residency agreements which included the requirements in R9-10-807(D)(1-10).

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two resident records reviewed.

Findings include:

1. A review of R2's medical record revealed an updated service plan for directed care level services, dated March 10, 2023. However, the service plan was not signed and dated by the resident or the resident's representative.

2. In an interview, E1 acknowledged R2's service plan was not signed and dated by the resident or resident's representative.

Based on observation, document review, and interview, the manager failed to ensure the key to the door of a lockable bedroom was available to a manager, caregiver, or assistant caregiver.

Findings include:

1. During a tour of the facility, the Compliance Officer noticed a bedroom door in the casita was locked and had a note taped to the door which stated, "[E3]'s Bedroom You are welcome here but not your shoes." The caregiver on duty was unable to locate a key to access the bedroom. The door lock looked like it needed a straight key. The caregiver attempted to unlock the door with numerous items and was unable to open the door.

2. A review of facility documentation on file with the Bureau of Residential Licensing, revealed a floor plan of the licensed facility. The locked room was listed as resident bedroom number one.

3. In an interview E2 reported the room was for the [E3], an overnight caregiver, to nap.

4. In an interview, E1 and E2 acknowledged the key to the door of of the lockable bedroom was not available at the time of the on-site inspection.