YASHUA'S CEDAR

INSP-0136399

POC

Date: 7/23/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-09-03

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00133180 and 00105668 conducted on July 23, 2025.

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document 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: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 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. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 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. 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. 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. 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.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure that emergency responders were provided a written document that included: reason for request on behalf of the resident, a list of medications, current pharmacy, medical history, advanced directives, HIPAA release, primary care physician, patient representative, and facility contact. The deficient practice posed a risk if safety measures were not in place to meet a resident's needs. Findings include: 1. A review of Department documentation from an incident dated May 19, 2025, revealed an intake report which included sworn testimony which stated, “No patient care form was given to the crew with accordance of SB 1157 [for R1]." 2. A review of Department documentation from an incident dated January 25, 2025, revealed an intake report which included sworn testimony which stated, “No patient care form was given to the crews [for R2]." 3. A review of R1's medical records titled "Incident report" dated May 19, 2025, revealed the resident complained of stomach issues. The resident asked the facility staff to call 911 and was transported to the hospital. 4. A review of R2's medical records, revealed no incident report available for review. 5. A documentation review of the facility's Policies and Procedures titled, "SB1157 Emergency Responder Policy and Procedure" stated, " 5. A form will be used for a written document to emergency responders that includes the reason for the emergency response." 6. In an interview, E4 acknowledged that the manager failed to ensure emergency responders were provided a written document for R1 and R2 that included: reason for request on behalf of the resident, a list of medications, current pharmacy, medical history, advanced directives, HIPAA release, primary care physician, patient representative, and facility contact.

Temporary Solution:

An Emergency Responder form was adopted with all the requirements of A,R.S. 36-420.04.A.1-9.

Permanent Solution:

An Emergency Responder form was adopted July24, 2025. In-service training was conducted July 24, 2025 for all caregivers to explain the importance of the form, when and who to give the form. To prepare the caregivers on duty for emergency situations, the owner/caregiver prepared an emergency responder form for each resident filling out the following information (facility contact, address information, resident representative (POA), resident Primary Care Physician, Pharmacy name and phone number and the resident insurance. Also, the owner/caregiver will explained and get the POA signatures for the Medical Record release form. The forms will be filed in the EMERGENCY RESPONDER (911) binder. On the day of emergency, the caregivers are instructed to make a copy of the current resident Medical Administration Record (MAR) as an attachment to the Emergency Responder form. In every 911 call, the owner/caregiver and manager will check that the emergency forms (Emergency Responder, Resident Medical Release, current resident MAR) are provided to the 911 crew. A signature of receipt and date is needed for the facility record. Incident report will also be filled out and filed. Copies will be filed with the incident report and to the Monthly monitoring binder/resident files.

Person Responsible:

SHELLA MICHEL

Deficiency #2

Rule/Regulation Violated:

R9-10-807.E.1-4. Residency and Residency Agreements E. Before or within five working days after a resident’s acceptance by an assisted living facility, a manager shall obtain on the documented agreement, required in subsection (D), the signature of one of the following individuals: 1. The resident, 2. The resident’s representative, 3. The resident’s legal guardian, or 4. Another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual’s behalf.

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to obtain, on the documented residency agreement, the signature of the resident, the resident’s representative, the resident’s legal guardian, or another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual’s behalf, for one out of three sampled residents. The deficient practice posed a risk if the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under A.R.S. § 36-3221 was not informed of the terms of residency. Findings include: 1. A review of R3's medical records, revealed that the "Determination for Admission" form signed by the resident's physician on February 5, 2025, determined that the resident was eligible to receive services at the Directed Care level. 2. A review of R3's medical records revealed the Residency Agreement was signed by R3 on February 3, 2025. 3. In an interview, E4 acknowledged the manager did not obtain the signature of the resident's representative on the residency agreement as required.

Temporary Solution:

Upon verification of R3 admission records, the Determination of Admission signed by the PCP (2/5/2025) conforms to the resident admission to the facility. The resident representative (POA) signed the resident agreement and all the admission documents after his visit/inspection of the facility.

Permanent Solution:

The owner/caregiver and manager will continue to monitor the Resident Admission process. Determination of Admission is "on or before" admission (move-in) to the facility. Attached is the resident Medical Administration record (MAR) to show that services was started 2/5/2025. Also the service plan shows a date of admission as 2/5/2025.

Person Responsible:

SHELLA MICHEL

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.5.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. A review of the medical records for R2 and R3 revealed, both residents received Directed Care services per their service plans. 2. A review of R2's medical records revealed, the resident's service plan dated May 12, 2025, was not signed by the resident's representative. 3. A review of R3's medical records revealed, the resident's service plan dated May 10, 2025 and February 12, 2025, were not signed by the resident's representative. 4. In an interview, E4 acknowledged the manager did not obtain the signature of R2 and R3's resident's representatives on the service plans as required.

Temporary Solution:

The owner/caregiver talked to the resident representative (POA) of both R2 and R3 and stressed the importance of signing the Service Plan. Although updates of the resident condition and services are made on the phone, the POA still has to acknowledge it by signing the service plans. POA's of both R2 and R3 agreed. Sent the service plan to R3 POA who lives in Texas for his signature.

Permanent Solution:

For out of state and busy resident POA's- the owner/caregiver or manager will update the resident POA's of the resident service plan; scan or fax service plan and ensure that it is signed and received by the facility.

R2 - unfortunately passed away.
R3 - attached are the signed service plans

Person Responsible:

SHELLA MICHEL

Deficiency #4

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review, documentation review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk if the facility was unable to meet a resident's needs. 1. A review of R2's medical records, revealed the “Approval For Continued Residency (Non Ambulatory)” form, was last completed by a medical professional on January 10, 2019. 2. A review of R2's medical records, revealed R2's service plan stated, "Bed bound or wheelchair if out of bed." 3. In an interview, E4 acknowledged that the manager failed to obtain documentation to demonstrate R2's primary care provider or other medical practitioner examined the bedbound resident at least once every six months throughout the duration of the resident's condition.

Temporary Solution:

After the admission process for our bed bound residents, subsequent PCP approval for their continued residency was transferred to our Doctor's Order form (bottom before the PCP signatures) to reduce on paper monitoring.
R2 - admission was 1/10/2019; last Doctor's Order before she was put in hospice was 12/23/2023/01/4/2024 for both bed bound status and behavioral care. Our Doctor's Order form is provided to Hospice for signature. Can't find it on resident file. Will request copies.

Permanent Solution:

Continue to use our Doctor's Order for medicine approval as well as for the resident continued residency and behavioral issues documentation after the initial approval included in the admission process.

R2 passed away.

Person Responsible:

SHELLA MICHEL

Deficiency #5

Rule/Regulation Violated:

R9-10-815.A. Directed Care Services A. A manager shall ensure that a resident’s representative is designated for a resident who is unable to direct self-care.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident’s representative was designated for a resident who was unable to direct self-care. The deficient practice posed a risk as no individual was designated to participate in decisions concerning the assisted living services the resident was to receive. Findings include: 1. A review of R3's medical records revealed the resident received services at the Directed Care level. 2. A review of R3's medical records revealed, the residency agreement; resident emergency orientation; and the Flu/Pneumonia vaccine election form, were signed by R3 on February 5, 2025. 3. In an interview, E4 acknowledged R3’s representative was not designated for a resident who was unable to direct self-care.

Temporary Solution:

Review of R3 resident admission papers showed that the POA (Lewis Williams III) signed for Lewis Williams Jr.(resident) instead of his name/signature. He does not sign Lewis Williams III but rather sign only Lewis Williams.
The owner/caregiver explained that he should by signing his name as the POA rather than signing with his Dad's name.
Sent admission documents to POA to re sign with his signature.

Permanent Solution:

In cases that the resident and POA has the same names, the owner/caregiver or manager should request a copy of the driver's license to verify the signatures. Explained to POA that the power of attorney allows him to sign/affix his signature on documents and not sign with his Dad's name. The facility has the Resident Info as part of it's admission documentation; POA information is indicated.
Manager will double check admission documentation before being filed in the resident binder. All admission documentation were re-sign by the POA with his signature.

Person Responsible:

SHELLA MICHEL

Deficiency #6

Rule/Regulation Violated:

R9-10-819.D.2.a-f. 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: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Evidence/Findings:

Based on record review, documentation review, and interview, the manger failed to ensure that a caregiver immediately notified a resident’s emergency contact, primary care provider, and document the date and time of the accident or emergency, a description of the accident, emergency, or injury, actions taken by the caregiver, the individuals notified by the caregiver, and action taken to prevent the accident, emergency or injury from occurring in the future. Findings include: 1. A review of Department documentation from an incident dated January 25, 2025, revealed an intake report which included sworn testimony which stated, “No patient care form was given to the crews [for R2]." 2. A review of R2's medical records, revealed no incident report available for review. 3. A documentation review of the facility's Policies and Procedures titled, "Incident Report" stated, "3. The manager shall ensure the incident, emergency, injury is noted in the resident's Progress Notes. INCIDENT REPORT will be filed in the resident's medical record as well as the Monthly Monitoring binder and kept for at least 12 months". 4. In an interview, E4 acknowledged an incident form was not completed as required for R2 who needed emergency services for an accident, injury, or emergency.

Temporary Solution:

Double checked all incidents are covered with an incident report.

Permanent Solution:

Conducted an in-service training for all caregivers July 24, 2025 on the importance of the incident report. Timely manner of filling it up and in a way is protecting themselves in cases of emergency. Incident report forms are filed in a way that is easily accessible to everyone.
The owner/caregiver will review and notify the POA and PCP of the incident. The manager will double check the incident reports monthly. Incident report will be filed with the Emergency Response documents.

Person Responsible:

SHELLA MICHEL

Facility Information

Inspection History

INSP-0158632

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0136399

Summary:

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0055285

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings: