BY YOUR SIDE ASSISTED LIVING

INSP-0130498

SOD

Date: 4/30/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-06-10

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00127246 conducted on April 30,2025:

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for three of five employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. ARS § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to:[...](3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry under section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee.(4) On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency shall take action to terminate the employment of that employee." 2. A review of E1, E3, and E4 personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. In an interview, E2 reported E2 had checked the adult protective services registry only after E3 was no longer working at the facility. E2 acknowledged a good faith effort to verify that each employee was not on the adult protective services registry pursuant to section 46-459 was not conducted.

Deficiency #2

Rule/Regulation Violated:

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

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for two of four personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E4 working at the facility and providing health services to the residents. 2. A review of facility documentation staff schedules for April 2025 revealed E3 worked at the facility as a living-in caregiver. The facility documentation staff schedules for April 2025 also revealed E4 worked at the facility as a living-in assistant caregiver. 3. A review of E3's personnel record revealed E3 was hired as a caregiver, however, it did not include documentation of the verification of E3's skills and knowledge. 4. A review of E4's personnel record revealed E4 was hired as an assistant caregiver, however, it did not include documentation of the verification of E4's skills and knowledge. 5. In an interview, E2 acknowledged E3 and E4 personnel records did not include documentation of the verification of E4's skills and knowledge. This is a repeat deficiency from the on-site complaint/compliance inspection conducted on April 10, 2024.

Deficiency #3

Rule/Regulation Violated:

R9-10-806.A.10. Personnel 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 that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of four personnel records sampled. 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 policies and procedures revealed a policy titled "Personnel Records." The policy stated, "3. The record shall include… h. CPR and First Aid training....” 2. A review of facility documentation staff schedules for April 2025 revealed E3 worked at the facility as a living-in caregiver. 3. A review of E3's personnel record revealed E3 was hired as a caregiver, however, it did not include documentation of current documentation of first aid training and cardiopulmonary resuscitation. 4. In an interview, E2 acknowledged E3 personnel records did not include documentation of current documentation of first aid training and cardiopulmonary resuscitation.

Deficiency #4

Rule/Regulation Violated:

R9-10-810.B.2.i. Resident Rights B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. During the environmental inspection of the facility, the Compliance Officer observed two chairs pushed against the side of R2’s bed. 3. In an interview, E2 reported the staff at the facility put the chairs against R2’s bed to keep R2 from falling out of the bed.

Deficiency #5

Rule/Regulation Violated:

R9-10-819.A.6. Environmental Standards A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a bathroom sink accessible and used by residents. The water temperature of the sink measured 134.6º F. 2. In an interview, E2 acknowledged the water temperature was not maintained between 95º F and 120º F in an area used by residents.

Deficiency #6

Rule/Regulation Violated:

A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery that included initial training. The deficient practice posed a risk as organized instruction and information related to resident care and safety were not implemented. Findings include: 1. A review of E1's (date of hire of March 2025), E3’s (date of hire of February 2025), and E4’s (date of hire of March 2025) personnel records revealed the records did not include initial training in fall prevention and fall recovery. 2. In an interview, E2 acknowledged documentation was not available that showed E1, E3, and E4 had not completed initial training in fall prevention and fall recovery.

INSP-0065340

Complete

Date: 4/10/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2024-04-22

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00208281 conducted on April 10, 2024:

Deficiencies Found: 13

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for staff regarding fall prevention and fall recovery, for one of four personnel reviewed. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a fall prevention and fall recovery training program was available.

2. In an interview, E4 reported E4 was hired April 1, 2024.

3. A review of E4's personnel record revealed the facility did not administer initial training for fall prevention and fall recovery.

4. In an interview, E2 acknowledged the facility did not administer initial training in fall prevention and fall recovery for E4.

Deficiency #2

Rule/Regulation Violated:

A. A governing authority shall:
7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;

Evidence/Findings:

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), when there was a change in the manager and identifying the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager.

Findings include:

1. A.R.S. \'a7 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..."

2. Review of Department records revealed E5 listed as the manager.

3. The Compliance Officer arrived at the facility at 8:15 AM and observed E1's manager's certificate posted near the front door of the facility.

4. Review of E1's personnel record revealed a date of hire as June 1, 2023.

5. In an interview, E2 and E3 reported E1 was the current manager and acknowledged the Department was not notified in writing of the change in manager.

Deficiency #3

Rule/Regulation Violated:

A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of four employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... 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..."

2. In an interview, E2 and E3 reported E4 was an assistant caregiver.

3. In an interview, E4 reported E4 provided services to residents starting April 1, 2024.

4. A review of E4's personnel record revealed E4's employment start date was April 10, 2024. However, the personnel record did not include documentation of compliance with the requirements in A.R.S. \'a7 36-11(C) to include documented, good faith attempts to contact prior employers.

5. In an interview, E2, E3 and E4 reported E4's personnel file was not complete due to the fact E4's starting date was supposed to be April 10, 2024.

6. In the exit interview, E2 and E3 acknowledged documentation was not available that showed E4's work references were obtained upon hire at the facility.

Deficiency #4

Rule/Regulation Violated:

A. A manager shall ensure that:
2. An assistant caregiver:
b. Interacts with residents under the supervision of a manager or caregiver;

Evidence/Findings:

Based on documentation review, observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services.

Findings include:

1. The facility is licensed at the directed care level.

2. A.R.S. \'a7 36-401.A.42. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity.

3. During an environmental tour, the Compliance Officer observed E4 providing care to R3 without supervision from a manager or caregiver.

4. In an interview, E3 reported E4 was an assistant caregiver.

5. A review of E4's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E4 was not qualified to be left alone with the residents based on the lack of caregiver training.

6. In an interview, E2, E3 and E4 acknowledged E4 was not qualified to be left alone with the residents based on the lack of caregiver training.

Deficiency #5

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of four employees reviewed. The deficient practice posed a risk as required information could not be verified.

Findings include:

1. In an interview, E2 and E3 reported E4 was an assistant caregiver.

2. In an interview, E4 reported E4 provided services to residents starting April 1, 2024.

3. A review of E4's personnel record revealed no documentation of verification of skills and knowledge.

4. In an interview, E2 and E3 acknowledged documentation was not available that showed E4's skills and knowledge were verified and documented.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four employees reviewed. The deficient practice posed a potential TB exposure risk to residents and the required information could not be verified.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. In an interview, E2 and E3 reported E4 was an assistant caregiver.

4. In an interview, E4 reported E4 provided services to residents starting April 1, 2024.

5. A review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required.

6. In an interview, E2 and E3 acknowledged E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Deficiency #7

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to ensure a personnel record included the correct documentation of the individual's starting date of employment, for four of four personnel sampled. The deficient practice posed a risk as required information could not be verified for E1, E2, E3, and, E4 and the Department was provided false or misleading information.

Findings include:

1. During an environmental tour, the Compliance Officer observed a document posted titled "DELEGATION OF AUTHORITY" revealed E1 was listed as a designee on May 1, 2023.

2. Review of E1's personnel record revealed E1's starting date of employment was June 1, 2023.

3. In an interview, E3 reported E1's starting date of employment was around April 2023.

4. During an environmental tour, the Compliance Officer observed a document posted titled "DELEGATION OF AUTHORITY" revealed E2 was listed as a designee on May 1, 2023.

5. Review of E2's personnel record revealed E2's starting date of employment was November 1, 2023.

6. In an interview, E2 reported E2's starting date of employment was April 2023.

7. During an environmental tour, the Compliance Officer observed a document posted titled "DELEGATION OF AUTHORITY" revealed E3 was listed as a designee on May 1, 2023.

8. Review of E3's personnel record revealed E3's starting date of employment was June 1, 2023.

9. In an interview, E3 reported E3's starting date of employment was around August 2023.

10. Review of E4's personnel record revealed E4's starting date of employment was April 10, 2024.

11. In an interview, E4 reported E4's starting date of employment was April 1, 2024.

12. In an interview, E2, E3 and E4 acknowledged that E4 was supposed to start work on April 10, 2024. However, E4 started work on April 1, 2024 before the personnel file was complete.

13. In the exit interview, E2 and E3 acknowledged E1's, E2's, E3's and E4's personnel records provided to the Department revealed false or misleading information.

Deficiency #8

Rule/Regulation Violated:

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 and interview, the manager failed to obtain 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. \'a7 36-3221 to make health care decisions on the individual's behalf, when a new residency agreement was created, for one of two residents sampled. 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. \'a7 36-3221 was not informed of the terms of residency.

Findings include:

1. A review of R1's medical record revealed an admission date of July 2017.

2. A review of R1's medical record revealed a residency agreement signed by the manager on July 1, 2023. However, the residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed.

3. In an interview, E2 reported new residency agreements were created on July 1, 2023. However, E2 acknowledged R1's residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed.

Deficiency #9

Rule/Regulation Violated:

A. A manager shall ensure that:
5. A resident's medical record is protected from loss, damage, or unauthorized use.

Evidence/Findings:

Based on observation, interview, and documentation review, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge.

Findings include:

1. During an environmental tour, the Compliance Officer observed R1's medication administration record (MAR) on an open area near the kitchen.

2. In an interview, E2 reported the MAR was from the pharmacy and the facility used there own MAR.

3. In an interview, E2 acknowledged the MAR was a part of a R1's medical record and needed to be protected from unauthorized use.

Deficiency #10

Rule/Regulation Violated:

F. A manager of an assisted living facility authorized to provide directed care services shall ensure that:
2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following:
a. Provides access to an outside area that:
i. Allows the resident to be at least 30 feet away from the facility, and
ii. Controls or alerts employees of the egress of a resident from the facility;

Evidence/Findings:

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if facility staff were unaware of the egress of a resident from the facility.

Findings include:

1. A review of Department records revealed the facility was licensed to provide directed care services.

2. During an environmental tour, the Compliance Officer observed a door located in the dining room leading to the back porch. However, the door was not secured and the door alarm was not activated.

3. Throughout the inspection, the Compliance Officer observed residents exiting the facility to the back porch multiple times without alerting the employees.

4. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility.

This is a repeat deficiency from the complaint investigation conducted October 24, 2022.

Deficiency #11

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated January 01, 2024. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated October 10, 2023. This medication order stated the following:
- "Quetiapine 25 mg 1/2 TAB PO BID"
- "Quetiapine 25 mg 1 TAB PO BID"
- "Trazodone 50mcg 1 1/2 TAB PO HS"
- "Citalopram 10 mg 1 TAB PO QD"

3. Review of R1's medical record revealed a medication administration record (MAR) dated April 2024. The MAR stated the following:
- "Quetiapine 25 mg 1/2 TAB PO BID" however, did not include documentation this medication was administered at 8:00 AM April 10th.
- "Quetiapine 25 mg 1 TAB PO BID" however, did not include documentation this medication was administered at 6:00 PM April 9th.
- "Trazodone 50mcg 1 1/2 TAB PO HS" however, did not include documentation this medication was administered at 6:00 PM April 9th.
- "Citalopram 10 mg 1 TAB PO QD" however, did not include documentation this medication was administered at 8:00 AM April 10th.

4. Review of R2's medical record revealed a current written service plan dated February 02, 2024. This service plan indicated R2 received medication administration.

5. Review of R2's medical record revealed a signed medication order dated April 10, 2024. This medication order stated the following:
-"Citalopram 10 mg 1 TAB PO QD "
- "Amlodipine 5 mg 1 TAB PO QD"
- "Levothyroxine 75 mcg 1 TAB PO QD"
- "Fexofenadine 180 mg 1 TAB PO HS"

6. Review of R2's medical record revealed a MAR dated April 2024. The MAR stated the following:
- "Citalopram 10 mg 1 TAB PO QD" however, did not include documentation this medication was administered at 8:00 AM April 10th.
- "Amlodipine 5 mg 1 TAB PO QD" however, did not include documentation this medication was administered at 8:00 AM April 10th.
- "Levothyroxine 75 mcg 1 TAB PO QD" however, did not include documentation this medication was administered at 7:00 AM April 10th.
- "Fexofenadine 180 mg 1 TAB PO HS - administered at 8:00 PM" however, did not include documentation this medication was administered at 8:00 PM April 9th.

7. In an interview, E3 reported the medication for R1 and R2 were administered per the medication order.

8. In an interview, E1 and E2 acknowledged R1's and R2's medical record did not include documentation the medications were administered on April 9th evening and April 10th morning.

Deficiency #12

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication.

Findings include:

1. During an environmental tour, the Compliance Officer observed eight ambulatory residents on the premises.

2. During an environmental tour, the Compliance Officer observed an unlocked caregiver room. Inside the room, the Compliance Officer observed the following medications in an unlocked box stored in the caregiver room;
-"MUCUS RELF TAB 600 MG ER"
-"DOXYCYC MONO TAB 100 MG"
-"MYRBETRIQ TAB 50 MG"
-"IRBESARTAN TAB 150 MG"
-"TAMSULOSIN CAP 0.4 MG"

3. In an interview, E2 and E3 reported the medications were R3's and the medications were stored in the caregiver room because the medication storage cabinet was full.

4. In an interview, E2 and E3 acknowledged the medications were stored in an unlocked area.

Deficiency #13

Rule/Regulation Violated:

C. A manager shall ensure that food is obtained, prepared, served, and stored as follows:
5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer.

Findings include:

1. During an environmental tour, the Compliance Officer observed a refrigerator on the back porch which stored resident food. However, the refrigerator did not contain a thermometer.

2. In an interview, E3 acknowledged the refrigerator on the back porch did not contain a thermometer.

Technical assistance was provided on compliance and complaint investigation conducted April 17, 2023.

INSP-0065337

Complete

Date: 4/17/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-05-01

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints AZ00179092, AZ00183728, and AZ00184345 conducted on April 17, 2023:

Deficiencies Found: 9

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 documentation review, 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.

Findings include:

1. The Compliance Officer requested documentation of the following at 11:05 AM:
-Employee disaster drills;
-Resident and employee evacuation drills;
-Disaster plan and annual review;
-Three personnel records;
-Three medical records;
-A list of residents discharged from the facility between January 1, 2022 and April 17, 2023;
-Policies and procedures;
-Employee work schedules for the previous twelve months; and
-The facility's quality management plan.

2. The Compliance Officer conducted an exit interview with E1 at 1:15 PM and the following documentation was not provided for review:
-Two of three requested personnel records;
-A list of residents discharged from the facility between January 1, 2022 and April 17, 2023; and
-Employee work schedules for the previous twelve months.

3. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

Deficiency #2

Rule/Regulation Violated:

B. A manager of an assisted living home shall ensure that:
1. An individual residing in an assisted living home, who is not a resident, a manager, a caregiver, or an assistant caregiver:
a. Either:
i. Complies with the fingerprinting requirements in A.R.S. § 36-411, or
ii. Interacts with residents only under the supervision of an individual who has a valid fingerprint clearance card; and

Evidence/Findings:

Based on observation, interview, and record review, the manager failed to ensure an individual residing in an assisted living home, who was not a resident, a manager, a caregiver, or an assistant caregiver, complied with the fingerprinting requirements in A.R.S.\'a7 36-411, or interacted with residents only under the supervision of an individual who had a valid fingerprint clearance card.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed O1 alone in a bedroom labeled Bedroom 5.

2. In an interview, O1 reported moving in to the home on April 16, 2023 and would be residing at the home "for a short time". O1 reported being "friends" with E4.

3. In an interview, E1 acknowledged O1 was residing in the home, and there was no documentation of O1's compliance with fingerprinting requirements available for review.

4. In a interview, E1 acknowledged the manager failed to ensure an individual residing in an assisted living home, who was not a resident, a manager, a caregiver, or an assistant caregiver complied with the fingerprinting requirements in A.R.S.\'a7 36-411, or interacted with residents only under the supervision of an individual who had a valid fingerprint clearance card.

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 dated within 90 calendar days before the individual was accepted, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of three residents sampled.

Findings include:

1. A review of R2's medical record revealed no documentation dated within 90 calendar days before R2 was accepted by the assisted living facility to include whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant.

2. In an interview, E1 acknowledged not being familiar with the electronic medical records and acknowledged E1 was unable to locate a document for R2 dated within 90 calendar days before R2 was accepted by the assisted living facility to include whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant.

Deficiency #4

Rule/Regulation Violated:

D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes:
1. The individual's name;
2. Terms of occupancy, including:
a. Date of occupancy or expected date of occupancy,
b. Resident responsibilities, and
c. Responsibilities of the assisted living facility;
3. A list of the services to be provided by the assisted living facility to the resident;
4. A list of the services available from the assisted living facility at an additional fee or charge;
5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours;
6. The policy for refunding fees, charges, or deposits;
7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident's service plan;
8. The policy and procedure for an assisted living facility to terminate residency;
9. The complaint process; and
10. The manager's signature and date signed.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, there was a documented residency agreement with the assisted living facility, for two of three residents sampled.

Findings include:

1. A review of R2's medical record revealed documentation of a residency agreement was not available for review.

2. A review of R3's medical record revealed documentation of a residency agreement was not available for review.

3. In an interview, E1 acknowledged no documentation of residency agreements for R2 or R3 were available for review. E1 acknowledged the manager failed to ensure there was a documented residency agreement with the assisted living facility to include the requirements in Arizona Administrative Code (A.A.C.) R9-10-807(D)(1)-(10).

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the dining area out to the back yard as well as a door leading to the front yard. Both doors had a device to alert employees of the egress of a resident from the facility, however the devices did not sound when the Compliance Officer opened the doors leading to the back yard and to the front yard. The Compliance observed the outside area in the back yard allowed residents to be at least 30 feet away from the facility.

3. In an interview, E1 acknowledged the devices to alert employees of the egress of a resident from the facility to the outside areas through the front and back door were in working order, but they were turned off at the time of the inspection.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A food menu:
c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served,

Evidence/Findings:

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

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed a food menu conspicuously posted for residents on the wall of the dining room. The menu was dated for the weeks of April 2, 2023 through April 6, 2023 and April 7, 2023 through April 14, 2023.

2. In an interview, E1 and E3 acknowledged the facility's posted food menu was out of date.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
3. Garbage and refuse are:
a. Stored in covered containers lined with plastic bags, and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed garbage containers in R1's and R3's bedrooms. The containers were uncovered.

2. During the environmental inspection of the facility, the Compliance Officer observed a garbage container in the kitchen. The container was uncovered and contained soiled tissues and food.

3. In an interview, E3 acknowledged garbage containers observed in resident bedrooms and the facility's kitchen were uncovered.

Deficiency #8

Rule/Regulation Violated:

A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

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 environmental inspection of the facility, the Compliance Officer observed an unlocked kitchen cabinet. The cabinet contained a bottle of "Great Value Bleach".

2. During the environmental inspection of the facility, the Compliance Officer observed a bottle of "Fabuloso all purpose cleaner" and a bottle of "Ralen Bleach" sitting on a shelf in the hallway bathroom.

3. The Compliance Officer observed three ambulatory residents on the premises.

4. In an interview, E1 and E3 acknowledged the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents.

Deficiency #9

Rule/Regulation Violated:

C. A manager shall ensure that:
3. A resident bathroom provides privacy when in use and contains:
g. Nonporous surfaces for shower enclosures and slip-resistant surfaces in tubs and showers.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed the facility's common area bathroom contained a shower. However, the shower did not contain a slip-resistant surface.

2. In an interview, E1 and E3 acknowledged the shower in the common area bathroom did not contain a slip-resistant surface.

Facility Information

Inspection History

INSP-0130498

Summary:

Deficiencies Found: 6

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:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

INSP-0065340

Summary:

Deficiencies Found: 13

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:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #11

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #12

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #13

Rule/Regulation Violated:

Evidence/Findings:

INSP-0065337

Summary:

Deficiencies Found: 9

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: