MARAVILLA SCOTTSDALE

Based on record review, and interview, for one of two residents reviewed, the administrator failed to document the actions taken to prevent an alleged incident of abuse from occurring in the future, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for a resident who resided in the assisted living facility.

Findings include:

1. In record review, R1's medical record (received personal care services) included an "Incident Form," which documented, "Informed by visiting P.T. service that resident reported being physically attached by ... spouse... When questioned resident denied any physical alt... emotional abuse only." A "progress note," documented, "4/28/2023... Spoke with PT... as... was reporting resident notified... had been physically attacked by ... spouse. Writer immediately ... spoke with resident to obtain a statement and denied
any physical interactions and reported only emotional and verbal abuse. Resident counseled on utilizing ... pendant to call for assistance, removing ... self from the situation.. reported to APS. Will continue to monitor."

2. During an interview, E1 and E2 reported R1 reported to PT being hit by R1's spouse; however, R1 denied during a follow up interview with E2. The facility reported the allegation to APS, as required; however, did not document actions taken by the manager to prevent the suspected abuse from occurring in the future.

Based on record review and interview, for one resident reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

A.R.S. \'a7 36-401.38 defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

A.R.S. \'a7 36-401.38 defines " Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

A.R.S. \'a7 36-401.38 defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. In record review, R1's medical record included a service plan dated March 24, 2023; however, did not include documentation of the level of service the resident was expected to receive.

2. During an interview, E1 acknowledged R1's service plan did not include the level of service R1 was expected to receive, and that R1 received personal care services.

Based on record review, and interview, for one resident reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided.

Findings include:

"Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident.

1. In record review, R1's medical record (received personal care services) included documentation R1 was not feeling well, was hospitalized for a few days, and returned to the facility with Hospice services initiated. R1's record included a service plan, dated March 24, 2023. Based on R1's change of condition, an updated service plan was required.

2. During an interview, E1 reported R1 wasn't feeling well, was sent to the hospital and diagnosed with a "mass." R1 returned to the facility and Hospice services were initiated. E1 reported R1's service plan was not reviewed and updated, and acknowledged a service plan was required no later than 14 days after a resident's change in condition.