GLASSFORD PLACE

<p>Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online."</p><p><br></p><p>2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay."</p><p><br></p><p>3. In an interview, E1 reported E1 learned about a series of incidents between R1 and O1 on October 23, 2025. E1 reported R1 started sharing complaints of pain and other worries after R1 and O1 (R1’s spouse) had sexual relations. E1 reported R1’s hospice nurse also learned of the complaints and submitted a complaint to Adult Protective Services (APS).</p><p><br></p><p>4. A review of facility documentation revealed an incident report which confirmed E1’s report. However, the review revealed no report to a peace officer or to the APS central intake unit filed by E1 or another employee of the facility.</p><p><br></p><p>5. In an interview, E1 reported E1 did not feel comfortable with the situation between R1 and O1 but did not report it to APS because the hospice nurse had already done so. E1 further reported R1’s previous physician’s assistant told E1 that E1 did not need to report the suspected abuse because the hospice nurse had already reported it.</p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for four of the four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p> </p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed no documentation of the services provided for September 2025.</p><p> </p><p><br></p><p>2. A review of R2's medical record revealed no documentation of the services provided for September 2025.</p><p><br></p><p><br></p><p>3. A review of R3's medical record revealed no documentation of the services provided for September 2025.</p><p> </p><p><br></p><p>4. A review of R4's medical record revealed no documentation of the services provided for September 2025.</p><p><br></p><p><br></p><p>5. In an interview, E1 reported that R1, R2, R3, and R4 received assisted living services from the caregivers; however, documentation was not provided during the inspection showing the services were provided. </p><p> </p><p><br></p><p>6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p><br></p><p>7. This is a repeat deficiency from the inspections conducted on April 10, 2023, and April 2, 2024. </p>

<p>Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan, and the route to be used was documented for four of four residents reviewed.</p><p><br></p><p><br></p><p> Findings include:</p><p><br></p><p><br></p><p> 1. A review of R1's, R2's, R3's, and R4's medical records revealed no documentation indicating the residents received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility.</p><p> </p><p><br></p><p>2. In an interview, E4 reported that all new residents received orientation to the exits from the assisted living facility as part of their move-in process. However, was unaware that a signed document was needed.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E2, and no additional information was provided. </p>

<p>Based on documentation review and interview, the manager failed to ensure disaster drills were conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.</p><p><br></p><p><br></p><p>FIndings include:</p><p><br></p><p><br></p><p>1. No disaster drills were available for review. </p><p><br></p><p><br></p><p>2. In an interview, E1 reported, the maintenance person was not available, and E1 did not know where to locate the drills.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

<p>Based on documentation review and interview, the manager failed to ensure evacuation drills were conducted at least once every six months and documented. The deficient practice posed a risk to employees and residents to properly implement an evacuation.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. No evacuation drills were available for review.</p><p><br></p><p><br></p><p>2. In an interview, E1 reported, the maintenance person was not available, and E1 did not know where to locate the drills.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

<p>Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. During the environmental inspection, the Compliance Officer observed a can of "Lysol Disinfecting Spray" and "Pacific Bouquet Air Freshener" sitting on top of a plastic storage container next to the medication cart in the hallway that was accessible to residents.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p><br></p><p>3. This is a repeat deficiency from the inspection conducted on October 9, 2024. </p>

Based on observation, documentation review, and interview, the manager failed to ensure the premises was cleaned according to policies and procedures. The deficient practice posed a potential threat to the health and safety of residents.

Findings include:

1. The Compliance Officer observed a toilet in R1's room which had feces throughout the interior of the toilet bowl.

2. Documentation review established that the facility had a policies and procedures section titled "Job Title: Housekeeper". This section had a subsection titled "Essential Functions, Duties and Responsibilities". This subsection contained the following: "Clean all resident apartments, common areas, and offices of the property to assure that the building is clean at all times, including furnishings, fixtures, ledges, room heating/cooling units, bathroom fixtures (bathtubs, toilets, showers, sinks)".

3. In an interview, E1 confirmed that a toilet in R1's room had feces throughout the interior of the toilet bowl and E1 confirmed that the facility had a policy and procedure section titled "Job Title: Housekeeper". E1 confirmed that this section had a subsection titled "Essential Functions, Duties and Responsibilities". E1 confirmed that this subsection contained the following: "Clean all resident apartments, common areas, and offices of the property to assure that the building is clean at all times, including furnishings, fixtures, ledges, room heating/cooling units, bathroom fixtures (bathtubs, toilets, showers, sinks)".

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. The Compliance Officer observed the following unsecured chemicals in R2's room:

- Clorox Bleach
- Wipe Out! Anibacterial Wipes

2. In an interview, E1 confirmed that the following unsecured chemicals were in R2's room, and that these were stored by the facility:

- Clorox Bleach
- Wipe Out! Anibacterial Wipes

Based on interview and record review, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request.

Findings include:

1. In an interview conducted at approximately 11:20 AM, the Compliance Officer requested the full medical records of R1 and R4, including documentation of assisted living services (ADLs) provided to R1 and R4 between October 2023 and April 2024.

2. In a series of interviews, E2 reported E2 did not know how to access or print the electronic ADLs for the Compliance Officer to review. E2 stated, "I don't [have] any ADLs" and "I don't have any [ADLs] to print." E2 reported E2 would have to contact another individual to access the ADLs.

3. At approximately 4:00 PM, E2 provided the ADLs for R1 and R4.

This is a repeat citation from the complaint inspection conducted on April 10, 2023.

Based on interview, record review, and documentation review, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. The deficient practice posed a risk if an employee was unqualified to provide caregiving services.

Findings include:

1. In an interview, E2 reported E4 was hired as a caregiver.

2. A review of E4's personnel record revealed E4 was hired as a caregiver. However, the review revealed no caregiver certificate. The review further revealed a document titled "ISL Glassford Place Employee Audit" used at least monthly between September 2023 and January 2024. The document contained places to write in the expiration dates and other information for E4's "CPR/1st Aide," "Finger Print Clearance Card," and "Care Giver Certification" among other employee requirements. However, the boxes for E4's "Care Giver Certification" were left blank.

3. A review of facility documentation revealed a series of personnel schedules dated between October 2, 2023, and April 2, 2024. The schedules revealed E4 worked as a caregiver without a caregiver certificate on more than one shift each week between October 2, 2023, and April 2, 2024.

4. A review of the medical records of R1, R3, and R4 revealed E4 provided physical health services to R1, R3, and R4 at least once each month between September 2023 and March 2024.

5. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate issued after August 2013 under E4's name.

6. In an interview, E2 reported E4 went through the caregiver course and took the test twice. E2 reported E4 failed the test the first time but was unsure whether E4 passed the test the second time.

7. In a telephonic interview, when the Compliance Officer asked if E4 had passed the test the second time and now had a valid caregiver certificate, E4 stated, "I do not have one" and "I know I don't have the certification."

8. In an interview, E1 acknowledged E4 was providing physical health services as a caregiver without documentation of completion of a caregiver training program approved by the Department or the NCIA Board.

This is a repeat citation from the complaint inspection conducted on October 18, 2023.

Based on documentation review, interview, and record review, 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 residents were left alone with an individual who was not a certified caregiver.

Findings include:

1. Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(46) states "Supervision" means "direct overseeing and inspection of the act of accomplishing a function or activity."

2. In an interview, E2 reported E4 was hired as a caregiver and E5 and E7 were hired as assistant caregivers.

3. A review of E4's personnel record revealed E4 was hired as a caregiver. However, the review revealed no caregiver certificate.

4. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate after August 2013 for E4, E5, or E7.

5. A review of facility documentation revealed a series of personnel schedules dated between December 2023 and March 2024. The schedules revealed E4 and E7 worked without being under the supervision of a caregiver or manager multiple times between December 2023 and March 2024. The schedules revealed E5 worked without being under the supervision of a caregiver or manager multiple times in February 2024 and March 2024.

6. In an interview, E2 reported E4 went through the caregiver course and took the test twice. E2 reported E4 failed the test the first time but was unsure whether E4 passed the test the second time.

7. In a telephonic interview, when the Compliance Officer asked if E4 had passed the test the second time and now had a valid caregiver certificate, E4 stated, "I do not have one" and "I know I don't have the certification."

8. In an interview, E1 acknowledged E4, E5, and E7 interacted with residents without being under the supervision of a manager or caregiver.

Based on record review and interview, the manager failed to ensure a resident's written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of three 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 R3's medical record revealed R3 was admitted to the facility more than 14 days prior to the date of the inspection. However, the review revealed no service plan.

2. In an interview, E2 confirmed R3's service plan was not completed at the time of the inspection. E1 acknowledged R3's service plan was not completed within 14 calendar days after R3's date of acceptance.

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

Findings include:

1. A review of R4's medical record revealed a current service plan. However, the service plan did not include what level of service R4 was expected to receive.

2. In an interview, E2 acknowledged R4's service plan did not indicate the level of service R4 was expected to receive.

This is a repeat citation from the complaint inspection conducted on October 18, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of three 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 R4's medical record revealed a service plan dated September 27, 2023. The service plan stated R4 was to receive skin breakdown checks "Every day," "Bathing 2 x week," "Eating reminders...Every day," "Grooming reminders...Every day...in am and before bed," "Dressing...Every day," and "Toileting...Every day." The review revealed a series of "Service Checkoff List" documents used as documentation of assisted living services (ADLs) provided to R4 between October 2023 and April 2024. However, the ADLs were missing documentation of the aforementioned services at least once each month between October 2023 and April 2024.

2. In an interview, E2 reported the system to document ADLs was new and facility personnel did not know how to correctly document services provided to residents. E2 reported all services were provided but not always documented.

This is a repeat citation from the complaint inspection conducted on April 10, 2023.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R1's medical record revealed a current service plan which indicated R1 required medication administration services. The review further revealed a series of medication administration records (MARs) dated September 2023 and October 2023. The MARs revealed R1 received medication administration in September 2023 and October 2023. However, the review revealed no signed medication orders for any of the approximately 15 medications administered to R1.

2. In an interview, E2 reported the facility did not have any signed medication orders for R1.

3. A review of R3's medical record revealed a medication order for "Bumetanide Oral Tablet 1 MG (milligram)...Give 1 mg by mouth in the morning" dated March 12, 2024. The review further revealed a MAR dated March 2023 which revealed R3 did not receive "Bumetanide" on March 18-21, 2024, due to the facility "Awaiting Pharmacy Delivery" and "Medication Not Available."

4. In an interview, E1 acknowledged the aforementioned medications were not administered as ordered.

This is a repeat citation from the complaint inspection conducted on April 10, 2023.

Based on documentation review and interview, the health care institution established policies that could have prevented employees from providing appropriate cardiopulmonary resuscitation and first aid. The deficient practice posed a risk if an employee followed facility policies and procedures by choosing not to assist a resident experiencing a medical emergency.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Staffing and First Aid" dated June 14, 2023. The policy and procedure stated: "If a resident is experiencing respiratory or cardiac arrest, EMS 911 or the hospice agency will be called as described below: If a resident who has an advanced directive and/or request regarding resuscitative measures form on file experiences and medical emergency, Community staff shall do one of the following: Immediately telephone 911, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. If the resident is not enrolled in hospice and is experiencing respiratory or cardiac arrest, EMS 911 will be called immediately and: For those staff members in attendance, who are trained in CPR, when a victim or resident who is known to NOT have a DNR, POLST or POST is found not breathing, has no pulse or both, AND after 911 has been called they may choose, but are not required to attempt to start CPR."

2. In an interview, E1 reported a third party was hired to manage the facility and brought its policies and procedures with it. E1 reported the third party managed facilities in other states and must have used a policy and procedure from another state.

Based on record review, documentation review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, for two of five staff members sampled. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the personnel records for E4 and E7 revealed no documentation of fall prevention and fall recovery training.

2. A review of facility documentation revealed an in-service training dated May 24, 2023, covering fall prevention and fall recovery. The documentation contained a list of participants. However, the list did not include the names of E4 and E7.

3. In an interview, E1 reported E4 and E7 did not participate in the May 2023 in-service training. E1 acknowledged the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for three of four personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(1) states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency."

2. A review of facility documentation revealed a policy and procedure titled "New Hire Paperwork" dated January 2021. The policy and procedure stated, "Within the three (3) days of employment, the supervisor/department head or designee should ensure that each new associate receives a copy, properly completes (if applicable) and signs the following documents: Completed reference checks (should be completed prior to any offer of employment)..."

3. A review of the personnel records of E5, E6, and E7 revealed E5 was hired as a medication technician, E6 was hired as a caregiver, and E7 was hired as an assistant caregiver. The review revealed E5, E6, and E7 had previous employment. However, the review revealed no documentation demonstrating the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E5's, E6's, and E7's fitness to work in a residential care institution.

4. In an interview, E2 reported having a letter from one of E6's previous employers.

5. A review of E6's personnel record revealed a letter from one of E6's previous employers. The letter was relevant to E6's fitness to work in a residential care institution. However, the letter was directed to E6. The review revealed no documentation demonstrating the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E6's fitness to work in a residential care institution.

6. In an interview, E1 and E2 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for E5, E6, and E7.

Technical assistance was provided on this rule during the compliance inspection conducted on August 22, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. The deficient practice posed a risk if the employee was unqualified to provide caregiving services.

Findings include:

1. A review of E6's personnel record revealed E6 was hired as a caregiver. The review revealed a training certificate from "ALTP0062" dated July 19, 2006. The certificate stated, "This certificate is awarded to [E6] For successfully completing the training course for SUPERVISORY, PERSONAL, & DIRECTED CARE LEVELS AT QUALITY UNLIMITED ADULT CARE HOME OWNERS ASSOCIATION TRAINING PROGRAM PRESENTED THIS 19TH DAY OF JULY 2006." The certificate included the signature of the instructor.

2. A review of Department documentation revealed the following:
-ALTP0062 was "Peaceful Valley Care Home" and not "Quality Unlimited Adult Care Home Owners Association Training Program" as stated on the certificate;
-"Peaceful Valley Care Home" did not contract out caregiver training services;
-There was no record of an approved training program by the name of "Quality Unlimited Adult Care Home Owners Association Training Program" or any similar name; and
-The trainer who signed the certificate was associated with ALTP0160 "The Meadows of Northern Arizona, Inc." and not ALTP0062 "Peaceful Valley Care Home."

3. A review of the caregiver certification verification website (az.tmuniverse.com) revealed no documentation of E6's completion of a caregiver training program approved by the Department or the NCIA Board.

4. A review of facility documentation revealed a series of personnel schedules dated between October 2, 2023, and October 18, 2023. The schedules revealed E6 administered medication to residents during the day shift on October 6-7 and 13-14, 2023.

5. In an interview, E1 confirmed E6 was hired as a caregiver. E1 and E2 reported believing E6's caregiver certificate was valid because E6 had worked as a caregiver at other assisted living facilities.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed by the caregiver or assistant caregiver before providing assisted living services to a resident, for three of four caregivers or assistant caregivers sampled.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "New Associate Orientation" dated January 2021. The policy and procedure stated, "[T]he Executive Director must ensure that all associates complete the required training/orientation required for the associate's position within the required time frame."

2. A review of the personnel records of E5, E6, and E7 revealed E5 was hired as a medication technician, E6 was hired as a caregiver, and E7 was hired as an assistant caregiver. The review revealed a document in each record titled "Section 2." The document was a title page and stated, "Signed job Description[s]" and "Completed General Orientation[s]." However, the section did not include documentation of the completed orientations of E5, E6, and E7. The review revealed no documentation of the completed orientations of E5, E6, and E7.

3. A review of facility documentation revealed a series of personnel schedules dated between October 2, 2023, and October 18, 2023. The schedules revealed the following:
-E5 worked the overnight shift on October 2-4, 8-10, and 15-17, 2023;
-E6 worked the day shift on October 6-7 and 13-14, 2023; and
-E7 worked the day shift on October 4-8, 10-11, and 13-14, 2023.

4. In an interview, E1 reported there was no orientation documentation for E5, E6, or E7 available for review.

Technical assistance was provided on this rule during the complaint inspection conducted on April 10, 2023.

Based on interview, record review, and documentation review, the manager failed to ensure a caregiver provided valid documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of four caregivers sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E4's personnel record revealed E4 was hired as a medication technician and had a caregiver certificate. The review revealed a "Standard - CPR / AED" certificate from "NationalCPRFoundation" dated March 13, 2022.

2. A review of the NationalCPRFoundation website revealed a page titled "CPR Certification Class." The page stated: "Help Save Lives Today with Your Online CPR Certification Training!...[O]ur online CPR training class allows you to complete a virtual lesson, take a CPR test, and receive your own CPR certification in under an hour without having to leave the comfort of your favorite chair...The CPR Training Test is the final step in your certification journey. Designed to review everything learned through the course modules, the final exam is thorough as well as focused. Consisting of ten multiple choice questions that cover all of the important aspects of CPR and AED, it can be completed in a few minutes and may be taken as many times as necessary before you pass...At National CPR Foundation, those seeking CPR recertification have the option of skipping the course modules and heading straight to the final test."

3. A review of facility documentation revealed a series of personnel schedules dated between October 2, 2023, and October 18, 2023. The schedules revealed E4 worked the overnight shift on October 5-7 and 11-14, 2023.

4. In an interview, E1 reported E4 was hired as a medication technician and had a caregiver certificate. E1 reported not knowing E4's NationalCPRFoundation CPR certification was done online and did not include a demonstration of E4's ability to perform cardiopulmonary resuscitation, as required by Arizona Administrative Code (A.A.C.) R9-10-803(C)(1)(e)(i).

Based on documentation review, interview, and record review, 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 by an assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two residents sampled. The deficient practice posed a risk if residents required services the facility was not authorized or not able to provide.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Resident Pre-Admission Appraisal" dated June 14, 2023. The policy and procedure stated: "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: If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: Includes whether the individual requires: Continuous medical services, Continuous or intermittent nursing services, or Restraints; and Is dated and signed by a: Physician, Registered nurse practitioner, Registered nurse, or Physician assistant."

2. In an interview, E2 stated the documentation required by the aforementioned policy and procedure and this rule was on the "PPOC" (Physician Plan of Care) document.

3. A review of the medical records of R1 and R2 revealed documents titled "PHYSICIAN PLAN OF CARE" dated within 90 calendar days before R1 and R2 were accepted by the facility. The documents stated, "I have examined this individual and found no evidence to support the need for continuous skilled nursing care at this time, and certify that he/she is appropriate for an assisted living residence." However, the documents did not include whether R1 and R2 required continuous medical services or restraints. The review further revealed a document for R2 titled "Verification of Resident Services" dated within 90 calendar days before R2 was accepted by the facility. The document included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

4. In an interview, E1 and E2 acknowledged the PPOC documents for R1 and R2 did not include all information required by this rule. E2 reported E2 had been waiting for a hospice nurse to sign the "Verification of Resident Services" document, but R2 moved out before the document could be signed.

Technical assistance was provided on this rule during the complaint inspection conducted on April 10, 2023.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of two residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated August 23, 2023. However, the service plan did not include what level of service R1 was expected to receive.

2. In an interview, E2 reported the facility recently switched over to a different system to do service plans. E2 reported the level of service R1 was expected to receive was not on the service plan, but was on a different document.

Technical assistance was provided on this rule during the complaint inspection conducted on April 10, 2023.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for two of four personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."

2. A review of the CDC 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. A review of the personnel records for E6 and E7 revealed E6 was hired as a caregiver and E7 was hired as an assistant caregiver. However, the review revealed no documentation to indicate E6 and E7 were assessed for risks of prior exposure to infectious TB or documentation to determine if E6 and E7 had signs or symptoms of TB. The review revealed documentation of a TST for E7 dated as read on August 7, 2023. However, the review revealed no second TST as recommended by the CDC.

4. In an interview, E1 and E2 reported not knowing personnel members needed two-step testing if using a TST. E1 and E2 acknowledged E6 and E7 did not have documentation indicating E6 and E7 were assessed for risks of prior exposure to infectious TB or documentation determining if E6 and E7 had signs or symptoms of TB.

Technical assistance was provided on this rule during the compliance inspection conducted on August 22, 2022.

Based on interview and record review, 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 ensure the facility's compliance.

Findings include:

1. In an interview conducted at 12:45 PM, the Compliance Officer requested the personnel records of E3, E4, E5, and E6.

2. By the end of the inspection at approximately 3:45 PM, the manager failed to provide E3's, E4's, E5's, and E6's respective documented verification of skills and knowledge.

3. In an interview, E3 acknowledged the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services and according to policies and procedures, for four of five applicable personnel. The deficient practice posed a risk if employees were unable to meet a resident's needs.

Findings include:

1. A documentation review revealed no policy and procedure covering verifying and documenting a caregiver's or assistant caregiver's skills and knowledge.

2. In an interview, E1 stated the facility "[didn't] have an actual policy."

3. A documentation review revealed a personnel schedule dated between March 5, 2023, and April 15, 2023. The schedule revealed E3, E4, E5, and E6 worked at least one shift during this period.

4. In an interview, E1 shared with the Compliance Officer the initials used by E3, E4, E5, and E6 respectively. E1 reported initials on resident documents meant the associated service had been provided by the individual who initialed the document.

5. A review of R1's medical records revealed two documents, each titled "Resident Task Sheet" and dated March 2023 and April 2023 respectively. The document for March 2023 revealed the initials of E3, E5, and E6. The document for April 2023 revealed the initials of E3, E4, and E5.

The review further revealed two medication administration records dated March 2023 and April 2023 respectively. The document for March 2023 revealed the initials of E3 and E6. The document for April 2023 revealed the initials of E3 and E6.

6. A review of R2's medical records revealed a document, titled "Resident Task Sheet," dated April 2023. The document revealed the initials of E6.

7. A review of R3's medical records revealed a document, titled "Resident Task Sheet," dated April 2023. The document revealed the initials of E6.

The review further revealed a medication administration record dated April 2023. The document revealed the initials of E3 and E6.

8. A review of R4's medical records revealed two documents, each titled "Resident Task Sheet," dated March 2023 and April 2023 respectively. The document for March 2023 revealed the initials of E6. The document for April 2023 revealed the initials of E3.

The review further revealed a medication administration record dated April 2023. The document revealed the initials of E6.

9. A review of E3's personnel record revealed E3 was hired as a caregiver/medication technician. However, the review revealed no documentation of E3's skills and knowledge.

10. A review of E4's personnel record revealed E4 was hired as a caregiver/medication technician. However, the review revealed no documentation of E4's skills and knowledge.

11. A review of E5's personnel record revealed E5 was hired as a caregiver/medication technician. However, the review revealed no documentation of E5's skills and knowledge.

12. A review of E6's personnel record revealed E6 was hired as a caregiver/medication technician. However, the review revealed no documentation of E6's skills and knowledge.

13. In an interview, E1 reported E3, E4, E5, and E6 were still new and were still going through training. E1 reported E3's, E4's, E5's, and E6's respective documentation of skills and knowledge had been started but not finished, stating, "Right now they're incomplete."

Based on record review and interview, the manager retained an individual whose primary condition for which the individual needed assisted living services was a behavioral health issue, for one of four residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R4's medical record revealed a court order from the Superior Court of Arizona in Yavapai County for temporary guardianship and conservatorship over R4 dated November 22, 2022. The document stated, "[R4] is currently at [a] hospital and [R4] needs to be discharged and [R4] has no living quarters other than a tent trailer that was set up for him . . . as a temporary domicile."

The review revealed a document titled "Wellness Baseline" dated November 29, 2022. Under the "Medical Diagnosis" section, the document listed three of R4's conditions. The first condition listed was "Schizophrenia."

The review revealed a document titled "Physician Plan of Care" dated November 30, 2022. The document stated R4's "Primary Diagnosis [was] Unsafe living conditions due to cognitive dysfunction [and R4's] Secondary Diagnosis [was] H/O Schizophrenia [and] nightmares."

The review revealed a service plan dated December 29, 2022. The service plan stated R4's "Primary Diagnosis [was] Schizophrenia." The service plan revealed R4 required medication administration, "assistance with showering by means of reminders," frequent checks as "[R4] has a history of leaving [and R4's] elopement risk is high," and transportation. The service plan revealed R4 required no other services.

The review further revealed a filing with the Superior Court of Arizona in Yavapai County for continued guardianship over R4 dated January 5, 2023. The document stated R4's "SPECIFIC DIAGNOSIS" was "Schizophrenia, Cognitive Impairment, [and] Hyperlipidemia" and R4's "IMPAIRMENTS" were "(1) Schizophrenia [and] (2) NeuroCognitive Impaiment [ sic ]." The document stated, "[R4] was Hospitalized Previously for leaving Home And driving - crashing [R4's] car. Living out of the Car And Staying in A Parking lot. . . . Most of [R4's] personal Care Needs With Daily reminders such As Telling [R4] Meal time, Shower days, And Medications Need To be given To [R4]. . . . Resident's Safety is At Risk As [R4] May Return to Prior living situation As Prior Stated."

2. In an interview, E7 reported R4 required minimal services. E7 reported R4 only needed assistance with showers and medication.

3. In an interview, E1 acknowledged R4's primary condition for which R4 needed assisted living services was a behavioral health issue. E1 reported not knowing why R4 was admitted to the facility. E1 reported E1 started at this facility after R4 was admitted.

Based on documentation review, record review, and interview, the manager failed to ensure a resident had a written service plan that was signed and dated by the resident or resident's representative when initially developed and when updated, for three of four residents sampled. The deficient practice posed a risk if a resident was unable to exercise the right to participate or have the resident's representative participate in the development of, or decisions concerning, the resident's service plan.

Findings include:

1. A documentation review revealed a policy and procedure titled "Care Plan" dated September 1, 2016. The policy and procedure stated, "The resident or their designated agent should review and sign the Care Plan following completion of an in-person meeting or phone conference. . . . Documentation of a refusal to sign should be noted in the medical record after one week."

2. A review of R1's medical record revealed a service plan dated March 23, 2022. The service plan was signed by R1's representative. However, the service plan was not dated by R1 or R1's representative.

3. A review of R2's medical record revealed a service plan dated February 15, 2023. However, the service plan was not signed or dated by R2 or R2's representative.

4. A review of R3's medical record revealed two service plans dated December 1, 2022, and December 31, 2022, respectively. Neither of the two service plans were signed or dated by R3 or R3's representative.

5. In an interview, E1 acknowledged the manager failed to ensure R1, R2, and R3 had written service plans that were signed and dated by R1, R2, and R3 or R1's, R2's and R3's representative respectively when initially developed and when updated.

Technical assistance was provided on this rule during the compliance inspection conducted on August 22, 2022.

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 four 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 medical record revealed a service plan dated March 23, 2022. Under the "DRESSING AND GROOMING" section, the service plan stated, "[R1] requires physical assistance with dressing. Staff assistance needed for morning routine and evening routine."

The review further revealed a document titled "Resident Task Sheet" dated April 2023. The document revealed R1 was provided "Physical Assistance with dressing and grooming" on the mornings of April 1-2, 2023. However, the document revealed R1 was not provided "Physical Assistance with dressing and grooming" on the evenings or nights of April 1-2, 2023.

2. In an interview, regarding caregivers and assistant caregivers providing dressing and grooming services to R1, E1 stated, "I can guarantee you they did it." E1 reported the caregiver(s) or assistant caregiver(s) must have forgotten to document it.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of four residents sampled. The deficient practice posed a risk of an adverse health condition due to a medication not being administered as ordered and the Department was provided false or misleading information.

Findings include:

1. A documentation review revealed a policy and procedure titled "MEDICATION ADMINISTRATION" dated September 1, 2016. The policy and procedure stated, "If a resident has physician orders for medication it is our responsibility to administer the medication. However, if a delay is anticipated, an order should be obtained to indicate the medication should be given when available."

The review revealed a policy and procedure titled "MEDICATION DOCUMENTATION" dated September 1, 2016. The policy and procedure stated, "If a medication is not taken within the allowed time frame . . . staff will initial the appropriate square [and] circle their initials."

The review revealed a policy and procedure titled "MEDICATION ERROR" dated September 1, 2016. The policy and procedure stated, "Medication errors include but are not limited to . . . Missed dose[s]."

2. A review of R1's medical record revealed a service plan dated March 23, 2022. The service plan revealed R1 required medication administration services.

The review revealed a medication order, dated March 12, 2023, for the following medications:
- "Acetaminophen Oral Capsule 500 MG Take 1000mg (2 caps) by mouth twice a day,"
- "Aspirin Oral Tablet Chewable 81 MG Take 81 mg by mouth daily,"
- "Colace Oral Capsule 100 MG Tale 100 mg (1 cap) by mouth twice daily,"
- "Lactaid Oral Tablet 3000 UNIT Take 3000 units (1 tab) by mouth daily in morning,"
- "Loratadine Oral Tablet 10 MG Take 10 mg (1 tab) by mouth daily,"
- "LORazepam Oral Tablet 0.5 MG Take 0.5mg (1 tab) by mouth 2x/day,"
- "Metoprolol Tartrate Oral Tablet 25 MG Give 12.5mg (\'bd tab) by mouth twice a day,"
- "Senna S Oral Tablet 8.6-50 MG Give 8.5-50mg (1 tab) by mouth once a day,"
- "Sertraline HCL Oral Tablet 25 MG Take 25 mg (1 tab) by mouth daily in the morning," and
- "Timolol Maleate (Once-Daily) Ophthalmic Solution 0.5% (DAILY) Apply 1 drop to both eyes daily."

The review further revealed two medication administration records, dated March 2023 and April 2023 respectively. The document for March 2023 revealed the following:
- R1 did not receive R1's Senna S on March 1-2, 2023, with the "Reason" stating "Not Available - Not given;"
- R1 did not receive R1's Senna S on March 3-4 and 7-11, 2023, with the "Reason" stating "not available;"
- R1 did not receive any of R1's AM medication (acetaminophen, aspirin, Colace, Lactaid, loratadine, metoprolol, Senna S, sertraline, and timolol) on March 21, 2023, with the "Reason" stating "ALL AM MEDS NOT AVAILABLE;"
- R1 did not receive R1's aspirin on March 28, 2023, with the "Reason" stating "Med. Not Available;" and
- R1 did not receive R1's lorazepam on March 28, 2023, with the "Reason" stating "Med. Not Available."

The document for April 2023 revealed the following:
- R1 did not receive R1's aspirin on April 4, 2023, with the "Reason" stating "MED NOT AVAILABLE;"
- R1 did not receive R1's aspirin on April 5, 2023, with the "Reason" stating "Not Available;"
- R1 did not receive R1's aspirin on April 6-7, 2023, with the "Reason" stating "Med. Not Available;" and
- R1 did not receive R1's aspirin on April 10, 2023, with the "Reason" stating "Med Not Available."

3. In an interview, E1 stated the facility "didn't have any," when referring to R1's Senna S from early March 2023. When the Compliance Officer asked how R1 received R1's Senna S on March 5-6, 2023, but not on March 1-4 and 7-11, 2023, due to the facility not having a supply, E1 reported R1's Senna S was documented as administered but was not, in fact, administered on March 5-6, 2023. E1 reported the caregiver must have forgotten to circle the initials and add a note on the back of the medication administration record. E1 reported R1's morning medications were not given on March 21, 2023, due to a pharmacy error. E1 reported the pharmacy did not deliver R1's medications so facility personnel did not have them and could not administer them.

Based on observation and interview, the manager failed to ensure food was free from spoilage, filth, or other contamination and was safe for human consumption. The deficient practice posed a risk to the health and safety of the resident as there was a potential for food borne illnesses.

Findings include:

1. During a tour of the facility on April 10, 2023, the Compliance Officer observed a storage room behind the kitchen. In the storage room, on a shelf, the Compliance Officer observed a clear plastic tub with a label that read "SUGAR." Inside the tub, the Compliance Officer observed the sugar. Crawling around in the sugar, the Compliance Officer observed what appeared to be a gnat or other small insect.

2. In an interview, E2 stated, "You never know what laid an egg in there or something." E2 reported E2 would have to throw out the sugar.

Based on observation and interview, the manager failed to ensure food was protected from potential contamination. The deficient practice posed a risk to the health and safety of the resident as there was a potential for food borne illnesses.

Findings include:

1. During a tour of the facility on April 10, 2023, the Compliance Officer observed a storage room behind the kitchen. In the storage room, on a shelf, the Compliance Officer observed a box of "PERFECT PARBOILED RICE." In the box, the Compliance Officer observed an open bag of rice. The Compliance Officer observed a clear plastic tub with a label that read "FLOUR." The Compliance Officer observed the lid to the tub of sugar was not completely covering the opening of the tub. The Compliance Officer observed a clear plastic tub with no label. The Compliance Officer observed what appeared to be wheat or brownish rice in the tub. The Compliance Officer the lid to the tub was not completely covering the opening of the tub.

2. In an interview, E2 reported not knowing what was in the unlabeled tub. E2 reported E2 had never used its contents.

3. The Compliance Officer observed an open box of potatoes on the ground. Inside the box, the Compliance Officer observed potatoes. The Compliance Officer observed a majority of the potatoes appeared shriveled. The Compliance Officer observed what appeared to be mold, spewing-liquid, and foam on some of the potatoes.

4. In an interview, E2 reported E2 would be throwing away the potatoes that day along with some bananas E2 had already moved out of the storage room.

5. In a standing freezer, the Compliance Officer observed an open bag of what appeared to be sausage patties.

6. In an interview, E2 reported E2 had used the patties that day and had forgotten to seal the bag.