DAVIS PLACE

INSP-0136330

Complete

Date: 7/22/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-09-02

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint(s) 00136387, 00136346, and 00136337 conducted on July 22, 2025:

Deficiencies Found: 7

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 and

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of four 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 pursuant to 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's, E2's, E3’s, and E4's 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, E1 acknowledged that good faith efforts were not made to verify that each employee was not on the adult protective services registry.

Temporary Solution:

Immediate Correction/ Temporary correction The Executive Director conducted an immediate
audit of all current staff files to confirm APS Registry verification was completed and properly
documented. - Any missing or incomplete verifications were addressed immediately by completing and
filing the APS Registry results in the personnel file. - This audit was completed on

Permanent Solution:

- A revised New Hire Checklist was implemented to include APS Registry
verification prior to allowing any new employee to begin work. - The verification will be conducted by the
Executive Director or designee by accessing the APS Registry at the time of hire. - Verification results
will be printed or saved electronically and placed in the employee’s personnel file.

Person Responsible:

Executive Director/Business office Manager

Deficiency #2

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 documentation review, record review, and interview, the manager failed to ensure that a personnel record for a caregiver included current documentation of first aid (FA) and cardiopulmonary resuscitation (CPR) training for three of three caregivers reviewed. 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 facility documentation staff schedules for May 2025 through July 2025 revealed E2 and E4 worked numerous shifts throughout the month. 2. A review of E1's personnel record revealed CPR certification; however, no FA. 3. A review of E2's personnel record revealed E2 was hired in July 2024 until July 18, 2025. E2’s personnel record revealed no FA. E2’s personnel record also revealed CPR in the personnel record; however, the CPR had expired on May 17, 2025. (E2 worked from July 2024 until July 18, 2025.) 4. A review of E4's personnel record revealed no current documentation of FA and CPR training. (E4 worked from May 2025 until July 22, 2025.) 5. In an interview, E1 reported that E2 worked from July 2024 until July 18, 2025. E1 reported that E4 worked from May 2025 until July 22, 2025. 6. In an interview, E1 acknowledged that E1 had no FA. E1 acknowledged E2 had no FA, and E2’s CPR had expired on May 17, 2025. E1 also acknowledged E4 had no CPR or FA. This is a repeat citation from an inspection conducted on June 13, 2024.

Temporary Solution:

Audits done immediately of Staff records for CPR/First Aid Certification. All staff files checked and Copies of CPR/First aid Certificate's copied and placed in file. No staff have performed care services without CPR/First aid.

Permanent Solution:

Nurse/ Business Office Assistant, To Audit Monthly Via spread cheat alerts and Tickler with alerts to upcoming CPR/First aid needed when needed in a timely manner. Chart Audits for staff records for CPR/First Aid Certifications. Check offs are in front of staff charts as well.

Person Responsible:

Nurse

Deficiency #3

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 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 the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for one of four caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E2's personnel record revealed no documented verification of E2's skills and knowledge. 2. In an interview, E1 acknowledged that E2’s personnel record did not include documented verification of skills and knowledge at the time of the inspection.

Temporary Solution:

Prior to giving care, the Nurse did an audit on all care staff to ensure all skills are checked off and placed in their appropriate employee files. with 4 employees being taken off schedule until skills checked off list was finished checked off and placed in files. Nurse to do immediate chart auding to verify all staff have been trained appropriately according to level of care. Training to be done immediately.

Permanent Solution:

Nurse to ensure all staff upon new hire and prior staff have appropriate training skills check off list in their files with appropriate training check offs in place. Nurse will do skills and knowledge check offs with new hires to be put ibn their appropriate charts.

Person Responsible:

Nurse

Deficiency #4

Rule/Regulation Violated:

R9-10-808.A.3.f. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 3. Includes the following: f. For a resident who will be storing medication in the resident’s bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan included how medication would be stored and controlled, for one resident reviewed who stored medication in the bedroom. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's record revealed a service plan dated February 19, 2025. This service plan stated "Self Admin..." However, this service plan did not indicate how the medication would be stored and controlled. 2. In an interview, E1 reported R1 manages R1's own medications and acknowledged that R1's service plan did not indicate how the medications would be stored and controlled.

Temporary Solution:

Nurse to ensure residents are trained and meds are stored according to required policy. Double lock in place at all times.

Permanent Solution:

Residents to be trained and educated according to policy and procedures of building. All new residents to have check off in place upon move in as well as the residents that are already in place, must be educated and signed off on. All residents service plans are in place with the required policy in place for storing and locking meds by double lock and storage of said medications and according to state and company policy.

Person Responsible:

Nurse

Deficiency #5

Rule/Regulation Violated:

R9-10-814.F.1. Personal Care Services F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;

Evidence/Findings:

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 three of seven sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of a resident. Findings include: 1. A review of R3's medical record revealed a current service plan for personal care services dated April 17, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. A review of R6's medical record revealed a current service plan for personal care services dated April 17, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. A review of R7's medical record revealed a current service plan for personal care services dated January 08, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 4. In an interview, E1 acknowledged that R3's, R6's, and R7's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Temporary Solution:

Nurse to check care plan and implement audits for skin care and precautions. Training of staff. with signatures on training and placed in employee charts.

Permanent Solution:

Nurse to include in care plan skin integrity and checks/monitoring in place to prevent skin injuries, tears and bruising, pressure sores. Nurse and care staff to do skin checks upon showering and when care is given. Regular training in place on preventing injuries to skin. Changes in skin are to be reported to nurse immediately. All staff trained in reporting skin issues.

Person Responsible:

Nurse

Deficiency #6

Rule/Regulation Violated:

R9-10-814.F.2. Personal Care Services F. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 2. Offering sufficient fluids to maintain hydration;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services, included offering sufficient fluids to maintain hydration, for two of seven residents sampled who received personal care services. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated February 19, 2025. However, the service plan did not include offering sufficient fluids to maintain hydration. 2. A review of R5's medical record revealed a service plan for personal care services dated April 23, 2025. However, the service plan did not include offering sufficient fluids to maintain hydration. 3. In an interview, E1 acknowledged R1's and R5's service plans for personal care services did not include offering sufficient fluids to maintain hydration.

Temporary Solution:

Nurse to audit all residents care plans to ensure all have hydration in place for monitoring. Hydration station placed at entrance to dining room.

Permanent Solution:

Nurse to add Hydration to each care plan and new residents care plans to include hydration is being offered, and location of hydration station. Staff to offer fluids, water, juice, supplements with hydration to residents when care is given, when in hallways in residents apartments, and outside in courtyard or sitting watching TV. fluids to be offered at all meals and snacks Hydration stations to be in place at the entrance to dining room. As well as outside in courtyard in inclement weather.

Person Responsible:

Nurse/Care staff/Community Life enhancement Coordinator

Deficiency #7

Rule/Regulation Violated:

R9-10-820.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 that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 132.9º F in R6’s room. 2. In an interview, E1 acknowledged that the hot water temperatures were not maintained between 95º F and 120º F in the area used by the resident.

Temporary Solution:

testing done in building immediately to ensure temperatures are kept in accordance with policy.

Permanent Solution:

Maintenance Director to do and weekly water temperature checks throughout building with random resident's rooms are checked.

Person Responsible:

Alexander Urbach Maintenance Director

INSP-0132067

Complete

Date: 5/19/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-16

Summary:

The following deficiency was found during the on-site investigation of complaint 00131086 conducted on May 19, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services 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; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

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 the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the inspection of the facility, the Compliance Officer observed R1 at the front desk located at the front of the facility. The Compliance Officer and E2 walked R1 back to R1’s room. During the inspection, O1 entered the facility with R1 through a secured door. O1 reported O1 had tracked R1 by R1’s phone when O1 noticed R1 was not in R1’s room via a camera that was placed in R1’s room to monitor R1 by O1. O1 reported R1 was about half a mile away from the facility when O1 located R1. R1 had scrapes on the right knee and left palm of R1’s hand. R1 was provided first aid by a caregiver to clean the wounds. 2. In an interview, E2 reported the facility front door alert had not alerted to notified staff of R1's egress from the facility. E2 acknowledged the staff was unaware of R1’s egress due to the front door alerts not sounding when R1 opened the front door of the facility.

Temporary Solution:

Door Transmitter added to Front Entrance door. Transmitter on door alerts staff via pagers. To be monitored by Maintenance Director via Tels weekly, Monthly with documentation.

Permanent Solution:

New 1,200-pound Magnetic lock installed with audible alarm and transmission to pager system, rewiring of keypad and main panel. As well as Tels monitoring systems on Weekly and Monthly basis, with documentation.

Person Responsible:

Alexander Urbach Maintenance Director

INSP-0094776

Complete

Date: 6/13/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-07-09

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint AZ00211239 conducted on June 13, 2024.

Deficiencies Found: 19

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 record review and interview the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.

Findings include:
1. Review of the record for E1 (hired November 1, 2023), failed to reveal documentation that fall prevention and fall recovery training had been administered.
2. This is an uncorrected deficiency from the survey conducted on June 15, 2024.
3. During an interview, E2 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Deficiency #2

Rule/Regulation Violated:

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

Evidence/Findings:

Based on record review and interview, the governing authority failed to ensure that three of five sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety (DPS), or an application for a fingerprint clearance card completed, within 20 working days of employment.

Findings include:
1. The record for E5 (start date October 29, 2022) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the DPS.
2. The record for E2 (start date November 8, 2023) contained a DPS fingerprint clearance card, however, there was no documentation present in the record reflecting that DPS was contacted to verify that the fingerprint clearance card remained valid.
3. Review of the DPS web site revealed that the card was valid.
4. The record for E1 (start date November 1, 2023) contained a DPS fingerprint clearance card, however, there was no documentation present in the record reflecting that DPS was contacted to verify that the fingerprint clearance card remained valid.
5. Review of the DPS web site revealed that the card was valid.
6. During an interview, E2 acknowledged the required documentation was not in the records.

Deficiency #3

Rule/Regulation Violated:

A manager shall ensure that:
2. A documented report is submitted to the governing authority that includes:
b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that quality management reports included changes made or actions taken as a result of the identification of a concern about the delivery of services related to resident care.

Findings include:
1. Review of the monthly facility quality management reports revealed that the reports did not include changes made or actions taken as a result of the identification of a concern about the delivery of services related to resident care.
2. During an interview, E2 acknowledged the required documentation was not included in the facility quality management documentation.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Deficiency #4

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A caregiver:
b. Provides documentation of:
i. 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;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of five sample employee records for staff who were providing caregiver services, contained 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.

Findings include:
1. The record for E5 (hired October 29, 2022) did not contain documentation reflecting that the employee had completed a caregiver training program.
2. During an interview, E2 acknowledged the required documentation was not available for review.

Deficiency #5

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 that three of five sample personnel records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Findings include:
1. The record for E1 (Manager, hired November 1, 2023) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review.
2. The record for E5 (Assistant Caregiver, hired October 29, 2022) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review.
3. The record for E3 (Caregiver, hired March 13, 2023) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record.
4. During an interview, E2 acknowledged that the required documentation was not available for review.

Deficiency #6

Rule/Regulation Violated:

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 and interview, the manager failed to ensure for two of five sample records, that before providing services to a resident, a manager or caregiver provided documentation of first aid training certification.

Findings include:
1. The record for E1 (hired November 1, 2023) failed to reveal documentation of first aid certification.
2. The record for E4 (hired November 21, 2018), revealed documentation of first aid certification that expired on June 15, 2021.
3. During an interview, E2 acknowledged that the manager and caregiver provided services to residents without documentation of first aid training certification.

Deficiency #7

Rule/Regulation Violated:

E. A manager shall ensure that:
2. A calendar of planned activities is:
b. Posted in a location that is easily seen by residents,

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that a calendar of planned activities is conspicuously posted for residents to see.

Findings include:
1. The posted activity calendar was dated May, 2024.
2. During an interview, E2 acknowledged that a current activity calendar was not conspicuously posted.

Deficiency #8

Rule/Regulation Violated:

E. A manager shall ensure that:
2. A calendar of planned activities is:
d. Maintained for at least 12 months after the last scheduled activity;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a calendar of planned activities was maintained for 12 months after the last scheduled activity.

Findings include:
1. The following activity calendars were not available for review: July 1, 2023 - December 31, 2023.
2. During an interview, E2 stated, "We've been running activities I just don't have the documentation."
3. During an interview, E2 acknowledged the required documentation was not available for review.

Deficiency #9

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

Findings include:
1. No menu was observed posted in the facility.
2. During an interview, E2 acknowledged that no menu was posted in the facility.

Deficiency #10

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A food menu:
e. Is maintained for at least 60 calendar days after the last day included in the food menu;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a food menu is maintained for at least 60 calendar days after the last date noted on the menu.

Findings include:
1. Two months of menus were requested. No menus were available for review.
2. During an interview, E2 stated, "I don't have that."
3. During an interview, E2 acknowledged the required documentation was not available for review.

Deficiency #11

Rule/Regulation Violated:

B. If the assisted living facility offers therapeutic diets, a manager shall ensure that:
1. A current therapeutic diet manual is available for use by employees, and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a current therapeutic diet manual was available for use by employees when the assisted living facility offered therapeutic diets.

Findings include:
1. During an interview, E2 indicated that the facility offered therapeutic diets and that R6 was currently on a therapeutic diet.
2. The record for R6 contained a physician's order indicating the resident required a diabetic diet.
3. The facility therapeutic diet manual was the Becky Dorner Diet manual with a copyright date of 2008. Internet review of the manual's web site revealed that there was a more current edition available for use.
4. During an interview, E2 acknowledged a current therapeutic diet manual was not available for use by employees.

Deficiency #12

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months.

Findings include:
1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months.
2. During an interview, E2 acknowledged that the required documentation was not available for review.

Deficiency #13

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Facility documentation failed to reflect that disaster drills had been conducted.
2. During an interview, E2 acknowledged that no documentation of employee disaster drills was available for review.

Deficiency #14

Rule/Regulation Violated:

A. A manager shall ensure that:
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months.

Findings include:
1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided failed to reveal that resident evacuation drills had been conducted. No other evacuation drill documentation was available for review.
2. During an interview, E2 acknowledged the requested documentation was not available for review.

Deficiency #15

Rule/Regulation Violated:

A. A manager shall ensure that:
1. The premises and equipment used at the assisted living facility are:
a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that the premises were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.

Findings include:
1. Observation of the carpeting located in the main hallway between the dining room and kitchen doorway was observed to be heavily soiled. The soiled area was approximately 5' by 3' in diameter and had a dark gray to black appearance.
2. Review of the facility policies and procedures indicated the premises will be maintained in a clean condition.
3. During an interview, E2 acknowledged that the premises was not maintained in a clean condition according to policies and procedures.

Deficiency #16

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
b. Licensed consistent with local ordinances; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the dog that was allowed in the facility, was licensed consistent with local ordinances.

Findings include:
1. Review of the file for a dog allowed in the facility (O3), failed to reflect documentation indicating that the dog was licensed.
2. During a telephone interview with the local authority it was determined that the dog required a license.
3. During an interview, E2 acknowledged that facility documentation failed to indicate the dog had a current license.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Deficiency #17

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
c. For a dog or cat, vaccinated against rabies;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that three of three pets that resided at the facility, were vaccinated against rabies.

Findings include:
1. The record for a dog allowed in the facility (O3) contained no documentation indicating that the dog had been vaccinated against rabies.
2. The record for a cat allowed in the facility (O2) contained no documentation indicating that the cat had been vaccinated against rabies.
3. The record for a cat allowed in the facility (O1) contained no documentation indicating that the cat had been vaccinated against rabies.
4. During an interview, E2 acknowledged the documentation available for review failed to reflect the pets were currently vaccinated against rabies.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Deficiency #18

Rule/Regulation Violated:

R9-10-113. Tuberculosis Screening
A. 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:
c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution.

Findings include:
1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
4. Review of the record for E4 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
5. Review of the record for E5 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
6. During an interview, E2 acknowledged that the required documentation was not available.

Deficiency #19

Rule/Regulation Violated:

R9-10-113. Tuberculosis Screening
A. 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:
d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis.

Findings include:
1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis.
2. During an interview, E2 acknowledged that the required documentation was not available for review.

INSP-0094775

Complete

Date: 4/8/2024

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2024-05-09

Summary:

The following deficiencies were found during the investigation of complaints AZ00208697, AZ00208693, and AZ00199977 conducted on April 8, 2024:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.

Findings include:
1. Review of facility documentation failed to reveal that the health care institution had developed a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.
2. Review of the record for E1 (hired November 1, 2023), failed to reveal documentation of fall prevention and fall recovery training.
3. Review of the record for E2 (hired November 8, 2023), failed to reveal documentation of fall prevention and fall recovery training.
4. Review of the record for E3 (hired September 16, 2021), failed to reveal documentation of fall prevention and fall recovery training.
5. During an interview, E2 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on record review and interview the manager failed to ensure that a record for one of three employees included all the information required in sub-sections a. through c. of this rule.

Findings include:
1. During an interview, E2 indicated that E1 was employed as the manager of the facility.
2. No personnel record for E1 was available for review.
3. During an interview, E2 stated "(E1) started at the facility as the manager on November 1, 2023."
4. During an interview, E2 acknowledged the required documentation was not available for review.

Deficiency #3

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
b. The level of service the resident is expected to receive;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of two sample resident records contained a service plan that included the level of service the resident is expected to receive.

Findings include:
1. The record for R1 contained a current service plan that did not include the level of service the resident was receiving.
2. During an interview, E2 stated, "The resident is personal care."
3. During an interview, E2 acknowledged the resident record did not contain the required information.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Deficiency #4

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview the manager failed to ensure for two of two sample service plans, a resident had a written service plan that when initially developed and when updated, is signed and dated by: The resident or resident's representative; The manager; The nurse or medical practitioner who reviewed the service plan.

Findings include:
1. Review of the record for R1 (receiving medication administration, personal care services), revealed that the following service plans were not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan: August 22, 2023, September 21, 2023, and February 23, 2024.
2. Review of the record for R2 (receiving medication administration, personal care services), revealed that the following service plans were not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan: August 22, 2023, September 26, 2023, October 8, 2023 and March 5, 2024.
3. During an interview E2 acknowledged the required documentation was not available for review.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

INSP-0094773

Complete

Date: 6/15/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-06-30

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint #AZ00195553 conducted on June 15, 2023.

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

D. A manager shall ensure that the following are conspicuously posted:
4. The location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection can be found, was conspicuously posted.

Findings include:
1. Inspection of the facility failed to reveal the posting indicating the location at which a copy of the most recent Department inspection report can be found.
2. During an interview, E1 acknowledged the required documentation was not conspicuously posted.

Deficiency #2

Rule/Regulation Violated:

A manager shall ensure that:
2. A documented report is submitted to the governing authority that includes:
a. An identification of each concern about the delivery of services related to resident care, and
b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

Evidence/Findings:

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "monthly" basis.
2. No quality management reports were available for review.
3. During an interview, E2 stated, "I don't have that."

Deficiency #3

Rule/Regulation Violated:

A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis:
1. Before or within seven calendar days after the resident's date of occupancy, and
2. As specified in R9-10-113.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy.

Findings include:
1. The record for R3 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E1 acknowledged that the record did not contain evidence of freedom from TB before or within seven calendar days after the resident's date of occupancy.

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained a service plan that included the level of service the resident is expected to receive.

Findings include:
1. The record for R3 contained a service plan dated December 29, 2022 that did not include the level of service the resident was receiving.
2. During an interview, E2 stated, "The resident is Supervisory care."
3. During an interview, E1 acknowledged the resident record did not contain the required information.

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Based on record review and interview the manager failed to ensure for three of three sample service plans, a resident had a written service plan that when initially developed and when updated, is signed and dated by: The resident or resident's representative; The manager; If required, the nurse or medical practitioner who reviewed the service plan.

Findings include:
1. Review of the record for R1 (receiving medication administration, nursing services, personal care services), revealed that the service plan dated April 23, 2023 was not signed and dated by the resident or their representative.
2. Review of the record for R2 (receiving medication administration, personal care services), revealed that the service plan dated April 23, 2023 was not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan.
3. Review of the record for R3 (receiving supervisory care services), revealed that the service plan dated December 29, 2022 was not signed and dated by the resident or their representative or the manager.
4. During an interview E1 acknowledged the required documentation was not available for review.

Deficiency #6

Rule/Regulation Violated:

B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Evidence/Findings:

Based on record review and interview for one of two sample personal care resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident reside in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs can be met by the facility as per their scope of services.

Findings include:
1. During an interview, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs can be met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Deficiency #7

Rule/Regulation Violated:

D. A manager shall ensure that:
1. A current drug reference guide is available for use by personnel members, and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members.

Findings include:
1. The drug reference guide available for review was the Nursing Drug Handbook, copyright date 2022.
2. The Internet web site for the drug reference guide revealed that a more current edition was available for distribution.
3. During an interview, E2 stated, "That's the most current one I have."

Deficiency #8

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
b. Licensed consistent with local ordinances; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that one of two pets that were allowed in the facility, were licensed consistent with local ordinances.

Findings include
1. Review of documentation for O3, a dog allowed in the facility, failed to reflect that the dog was licensed.
2. During a telephone interview with the local authority it was determined that the dog required a license.
3. During an interview, E1 acknowledged that facility documentation failed to indicate the dog had a current license.

Deficiency #9

Rule/Regulation Violated:

A. A manager shall ensure that:
14. If pets or animals are allowed in the assisted living facility, pets or animals are:
c. For a dog or cat, vaccinated against rabies;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that four of five pets that reside at the facility, were vaccinated against rabies.

Findings include:
1. Review of documentation for O2, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies.
2. Review of documentation for O3, a dog that resides in the facility, failed to indicate that the dog was vaccinated against rabies.
3. Review of documentation for O4, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies.
4. Review of documentation for O5, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies.
5. During an interview, E1 acknowledged the documentation available for review failed to reflect the pets were currently vaccinated against rabies.

Facility Information

Inspection History

INSP-0157569

Summary:

INSP-0136330

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0132067

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0094776

Summary:

Deficiencies Found: 19

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: