COPPER CREEK INN MEMORY CARE COMMUNITY

<p>Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of four personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A.R.S. § 36-411(C)(1) states, "Each residential care institution, nursing care institution and home health agency 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."</p><p><br></p><p><br></p><p>2. A review of E3's personnel record did not include documentation of the facility's good-faith effort to contact E3's previous employers.</p><p><br></p><p><br></p><p>3. A review of E4's personnel record did not include documentation of the facility's good-faith effort to contact E4's previous employers.</p><p><br></p><p><br></p><p>4. In an interview, the finding was reviewed with E2 and no additional information was provided.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four personnel sampled. The deficient practice posed a potential illness risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>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)..."</p><p><br></p><p><br></p><p>2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."</p><p><br></p><p><br></p><p>3. A review of E1's personnel record revealed a negative TB skin test that was more than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E1’s date of hire, this documentation was required.</p><p><br></p><p><br></p><p>4. <span style="color: rgb(68, 68, 68);">In an interview, the finding was reviewed with E2 and no additional information was provided. </span></p><p><br></p><p><br></p><p>5. This is a repeat deficiency from the inspection conducted on July 2, 2024.</p>

<p>Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for three of four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed a medication order, dated July 14, 2025, for Aspirin 81 milligrams (mg), 1 tablet by mouth (po) daily (qd).</p><p><br></p><p><br></p><p>2. A review of R2's medication administration record (MAR) for July 2025 revealed R2 was administered Aspirin 81 mg on July 16, 2025, and July 19, 2025.</p><p><br></p><p><br></p><p>3. While on-site for the compliance and complaint inspection, the Compliance Officers did not observe Aspirin 81 mg stored at the facility for administration to R2.</p><p><br></p><p><br></p><p>4. In an interview, E6 reported R2's family will provide Aspirin 81 mg for administration to R2. However, at the time of inspection, the medication had not been provided.</p><p><br></p><p><br></p><p>5. A review of R3's medical record revealed a medication order, dated November 21, 2024, for Famotidine 20 mg, 1 tablet po qd.</p><p><br></p><p><br></p><p>6. A review of R3's MAR for July 2025 revealed R2 was not administered Famotidine 20 mg on the following dates:</p><ul><li>July 1, 2025;</li><li>July 8, 2025;</li><li>July 9, 2025;</li><li>July 10, 2025;</li><li>July 13, 2025;</li><li>July 14, 2025;</li><li>July 15, 2025; and</li><li>July 22, 2025.</li></ul><p>However, nursing notes revealed the medication was not administered due to the medication not being available for administration.</p><p><br></p><p><br></p><p>7. While on-site for the compliance and complaint inspection, the Compliance Officers observed two bubble packs of Acid Reducer 20 mg stored for administration to R3.</p><p><br></p><p><br></p><p>8. In an interview, E6 reported the medication observed for administration to R3 was the generic for Famotidine 20 mg.</p><p><br></p><p><br></p><p>9. A review of R4's medical record revealed medication orders for the following medications:</p><ul><li>Risperidone 0.25 mg, 1 tablet po twice a day (bid);</li><li>Valproic Acid 250 mg, 5 milliliters (mL) po bid; and</li><li>Atorvastatin 10 mg, 1 tablet po at bedtime (qhs).</li></ul><p><br></p><p>10. A review of R4's MAR for July 2025 did not include documentation of administration of the aforementioned medications to R4 on July 6, 2025 during the PM shift.</p><p><br></p><p><br></p><p>11. In an interview, E6 reported R4 was currently at the facility on July 6, 2025.</p><p><br></p><p><br></p><p>12. In an interview, the finding was reviewed with E2, and no additional information was provided.</p><p><br></p><p><br></p><p>13. This is a repeat deficiency from the inspections conducted on July 2, 2024 and October 31, 2024. </p>

<p>Based on documentation review and interview, a manager failed to ensure documentation of each evacuation drill was maintained for at least 12 months after the date of the evacuation drill, and included identification of residents needing assistance for evacuation, and identification of residents who was not evacuated. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.</p><p><br></p><p><br></p><p>Findings included:</p><p><br></p><p><br></p><p>1. A review of the evacuation drills revealed a drill conducted on February 19, 2025 with no documentation of a resident roster of <span style="font-size: 14px; background-color: rgb(255, 255, 255);">the residents who required assistance and those who were not evacuated</span> during the drill.</p><p><br></p><p><br></p><p>2. In an exit interview with E2 and E5, the disaster drill requirements were discussed and no additional information was provided.</p>

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of six residents sampled.

Findings include:

1. A review of R4's medical record revealed R4 received medication administration.

2. A review of R4's medication administration record (MAR) for October 2024, revealed R4 received administration of the following medications:
- Lactulose 10 milligrams (mg), 15 milliliters (mL) by mouth (po) every 3 days;
- Benztropine 0.5 mg, 1 tablet po at bedtime (qhs);
- Mirtazapine 30 mg, 1 tablet po qhs;
- Desyrel 50 mg, 1/2 tablet po twice a day (bid);
- Abilify 5 mg, 1 tablet po bid;
- Tylenol 500 mg, 2 tablets po three times a day (tid); and
- Diclofenac Sodium 1% Gel, apply topically four times a day.

3. A review of R4's MAR for October 2024, revealed missing documentation of Lactulose 10 mg on the following days:
- October 16, 2024 at 8:00 AM; and
- October 19, 2024 at 8:00 AM.

4. A review of R4's MAR for October 2024, revealed missing documentation of Benztropine 0.5 mg and Mirtazapine 30 mg on October 30, 2024 at 8:00 PM.

5. A review of R4's MAR for October 2024, revealed missing documentation of Desyrel 50 mg on the following days:
- October 2, 2024 - October 4, 2024 at 8:00 PM; and
- October 12, 2024 at 8:00 PM.

6. A review of R4's MAR for October 2024, revealed missing documentation of Abilify 5 mg on October 12, 2024 at 8:00 AM.

7. A review of R4's MAR for October 2024, revealed missing documentation of Tylenol 500 mg on the following days:
- October 12, 2024 at 8:00 AM and 12:00 PM; and
- October 22, 2024 - October 23, 2024 at 12:00 PM.

8. A review of R4's MAR for October 2024, revealed missing documentation of Diclofenac Sodium 1% Gel on the following days:
- October 14, 2024 - October 16, 2024 at 12:00 PM;
- October 17, 2024 - October 18, 2024 at 8:00 AM and 12:00 PM;
- October 19, 2024 at 5:00 PM and 8:00 PM;
- October 20, 2024 at 8:00 AM and 12:00 PM;
- October 21, 2024 - October 23, 2024 at 12:00 PM; and
- October 26, 2024 at 12:00 PM.

9. In an interview, E1 acknowledged R4's MAR did not contain accurate documentation of medication administered to the resident.

10. This is a repeat citation from the on-site compliance/complaint inspection conducted July 2, 2024.

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

Findings include:

1. A review of R1's service plan, dated May 2024, revealed R1 required assistance with bathing, dressing, grooming, dental, toileting, and transfers. Documentation was not provided at the time of inspection that indicated these services were provided to R1.

2. A review of R2's service plan, dated August 2024, revealed R2 required assistance with bathing, dressing, grooming, dental, and incontinence care. However, documentation was not available indicating these services were provided:
- September 2nd;
- September 4th;
- September 6th;
- September 7th;
- September 8th;
- September 9th;
- September 12th; and
- September 10th.

3. In an interview, E3 checked R2's notes to see if R2 was out of the facility during the dates listed above. E3 reported there was nothing to verify that R2 was out of the facility.

4. In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided.

This is a repeat deficiency from the compliance/complaint inspection conducted July 2, 2024.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for two of two sampled residents. The deficient practice posed a health risk to the resident if the caregivers did not know how to provide the skin maintenance.

Findings include:

1. A review of R1's medical record revealed a service plan dated May 23, 2024. This service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

2. A review of R2's medical record revealed a service plan dated August 20, 2024. This service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

3. In an interview, E3 reported the facility conducted skin checks during bathing/showering.

4. In an interview, E1 and E3 acknowledged R1's and R2's service plans did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on record review and interview the manager failed to ensure that one of two sample resident records contained documentation reflecting that a resident had a written service plan that was completed no later than 14 calendar days after the resident's date of acceptance.

Findings include:

1. A review of R2's medical record revealed R2 was receiving directed care services. R2's medical record contained a service plan that had not been completed no later than 14 calendar days after the resident's date of acceptance.

2. In an interview, E1 acknowledged the service plan for R2 had not been completed within the required time frame.

This is an uncorrected deficiency from the compliance inspection and complaint investigation conducted on July 2, 2024.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for two of two residents reviewed who had an incident resulting in the residents needing medical services, which posed a health and safety risk.

Findings include:

1. A review of facility documentation revealed a policy titled "Incident Reporting". The policy stated "... 2. If the incident involves possible abuse, neglect, exploitation, or abandonment of a resident, you must also contact the AZDHS at 602-364-2536. Follow the protocol on reporting abuse, neglect, and exploitation..... a. If sexual or physical assault is suspected you must also contact the local law enforcement in addition to the DSHS Complaint Hotline. Follow the protocol on reporting abuse, neglect, or exploitation."

2. A review of R1's medical record revealed a document titled "Incident". The incident report stated "The Resident in room 16 enter resident room. The Resident became angry and started punching the resident in face and neck- room 16. The Resident in room 28 stated to the police "I told him to stay out of my room many times." The resident in room 28 is staying in room. However, the incident report did not contain information of the primary care physician being contacted.

3. A review of R2's medical record revealed a document titled "Incident". The incident report stated "Resident was running around the building all night and trying to enter other resident rooms. Resident enter Room 28 and resident in room 28 began punching the resident in the face and neck. 911 was called. The Police and paramedics arrived at 0345. Resident was taken to chandler Hospital for evaluation. The Police made a report and will contact manager the next business day." However, the incident report did not contain information of the primary care physician being contacted.

4. In an interview, E1 reported R2 was walking around the facility and walked into R1's room. E1 reported R1 got scared when R2 in the room, E1 then grabbed the shower rod started to hit R2 with it. E1 reported a staff member heard R1 and R2 screaming and ran into R1's room and seen R2 on the ground and R1 hitting R2 on the chest with the shower rod. The staff member was able to stop the attack and call emergency medical services for R2 who was bleeding from their face.

5. In an interview, E1 reported the facility only contacted the residents' emergency contacts and not the primary care providers.

Based on record review, documentation review, and interview, the manager failed to ensure, for one of four sampled caregivers, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification. 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 E4's personnel records revealed CPR and First Aid training certifications dated March 1, 2022 with a marked expiration of March 1, 2024. However, current documentation of CPR and First Aid training for E4 was not available for review.

2. A review of the facility work schedule, dated July 2024, revealed E4 worked from 10 PM until 6 AM on July 1,4,5,6,7,8,11,12,13,14,15,18,19,20,21,22,26,27,and July 28, 2024.

3. Following the survey, E1 provided a CPR and First Aid training certification for E4 dated the day of the on-site inspection with a 2 year expiration.

4. In an interview, E1 acknowledged E4's personnel record did not include documentation of current CPR and First Aid training certification.

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


Findings include:

1. A review of R1's medical record revealed an undated service plan. The service plan had been signed by a nurse on July 23, 2024. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. Based on R1's date of admission, the service plan was required.

2. A review of R2's medical record revealed an undated service plan. The service plan had been signed by a nurse on July 6, 2024. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. Based on R2's date of admission, the service plan was required.

3. In an interview, E1 acknowledged the service plans provided for R1 and R2 did not include all required signatures.

Based on record review, documentation review, and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of four employees sampled who were expected to have .

Findings include:

1. A review of E5's (hire date May 2, 2023) personnel record revealed evidence of a negative TB skin test administered and read in April 2024. However, evidence of a second negative skin test administered or read within twelve months, or evidence of documentation of a signs or symptoms or risk assessment, signed by an occupational health reviewer was unavailable for review.

2. A review of E6's (hire date August 1, 2019) personnel record revealed evidence of a prior positive TB test. Further review revealed a document titled, "Symptom Screen," which contained a section, "Symptom Screen for Patients with a History of a Positive TB Test" which read, "CXR Results: No signs of active disease." However, evidence of annual documentation demonstrating E6's freedom from infectious TB, signed by a medical practitioner, occupational health provider or local health agency was unavailable for review.

3. In an interview, E1 agreed E5's and E6's personnel record did not contain current documentation of evidence of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of four residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident.

Findings include:

1. A review of R1's (accepted in 2024) medical record revealed no service plan was available for review. Based on R1's date of acceptance a completed service plan was required.

2. In an interview, E1 acknowledged a service plan was not provided for review. E1 reported the service plan "was not completed".

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record for one of two residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan dated April 3, 2024, for directed care services, and indicated R2 would be provided numerous services to include:
"Dressing...Help put on clothes...morning dressing...bedtime undressing;"
"Grooming...Help with grooming activities...morning...bedtime;"
"Dental...Assistance with morning...bedtime dental care;"
"Toileting...Help with bathroom activities and hygiene;" and
"Vision...Frequent and unscheduled support in location, cleaning and positioning eyewear."

2. A review of R2's medical record revealed a document titled "Resident Assistant Record," for the months of April, May and June 2024, to document activities of daily living. The tracking sheet contained sections for documenting services provided by each shift, rather than sections for documenting each service provided. Three shifts were identified on the document as "Days (6:00 a.m.-2:00 p.m.), Eves (2:00 p.m.-10:00 p.m.) and NOCS (10:00 p.m.-6:00 a.m.). Evidence of documentation indicating services identified in R2's service plan were provided on the dates and shifts below was not available for review:

Days -
June 2-3, 9-10, 16, 23-24

Eves -
June 1-2, 7-8, 13-15, 19-30

NOCS -
June 19, 25, 26

3. In an interview, E1 advised the hospice ADL tracking sheet was the only tracking sheet used to document services provided to residents, and the facility utilized documentation by exception. E1 acknowledged the caregivers were not documenting all services provided for R2.

Based on record review and interview the manager failed to ensure medication administered to a resident was documented in the resident's medical record for two of four residents sampled.

Findings include:

1. A review of R2's medical record revealed a directed care service plan dated May 22, 2024, which indicated R2 received medication administration.

2. A review of a signed medication order, dated January 26, 2024, revealed R2 was prescribed the following medication:

"Quetiapine Fumarate Tab 25 mg sig: 2 tablet orally daily at bedtime;"
"Donepezil Tab 10 mg sig: 1 tablet orally daily at bedtime;" and
"Latanoprost Ophthalmic Solution 0.005% sig: 1 drop in both eyes."

3. A review of R2's medication administration record (MAR) for June 2024 revealed no documentation of administration of the following medications on the dates indicated:

"Quetiapine Fumarate Tab 25 mg," on June 2, 6, 9, 17-23, 29 or 20, 2024;
"Donepezil Tab 10 mg," on June 1, 2, 17-23, 2024; and
"Latanoprost Ophthalmic Solution 0.005% 1 drop in both eyes," on June 22 and 23, 2024.

4. A review of R4's medical record revealed a directed care service plan, dated May 22, 2024, which indicated R4 received medication administration.

5. A review of a signed medication order, dated January 9, 2024, revealed R4 was prescribed the following medications:

"Alprazolam Oral Tablet 0.5 MG give one tablet by mouth every night at bedtime;"
"Synthroid Oral Tablet 25 MCG give one tablet by mouth every morning on empty stomach;" and
"Ketoconazole External Shampoo 2% Apply Topically to Scalp 3 Times Weekly with Every Shower, leave on for 5 minutes then rinse."

6. A review of R4's MAR for June 2024 revealed no documentation of administration of the following medications on the dates indicated:

"Alprazolam Oral Tablet 0.5 MG," June 4-6 and 16, 2024;
"Synthroid Oral Tablet 25 MCG," June 14, 15, 19, 26, and 28-30, 2024; and
"Ketoconazole External Shampoo 2%," June 3,10, 14, 16, 18 and 20, 2024

7. In an interview E1 acknowledged evidence of documentation R2 and R4 had received administration of medication as ordered was unavailable for review..

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed an undated policy titled "Steps for Fall Prevention." However, the policy did not include initial training and continued competency training.

2. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.

Based on documentation 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 following documentation was not provided for review: the facility's fall prevention and fall recovery training program including initial training and continued competency training.

Findings include:

1. A review of the facility's policies and procedures revealed an undated policy titled "Steps for Fall Prevention." However, the policy did not include initial training and continued competency training.

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