Dream Street Care LLC.

“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.”

“C. A manager shall ensure that a resident's medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;”

“C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and”

“C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);”

“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”

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

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

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

“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;”

“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.”

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

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

“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;”

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

“A. A manager shall ensure that: 7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;”

“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;”

“B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours:”

“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);”

“Based on documentation review, record review, and interview, for three of four staff reviewed, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. In documentation review, the facility did not have documentation of a fall prevention and fall recovery training program. 2. In record review, the personnel records for E1, E2 and E4, did not include documentation the staff received training on fall prevention and fall recovery. 3. During an interview, E2 acknowledged the facility did not develop and administer a fall prevention and fall recovery training program for all staff.”

“Based on documentation review, observation, interview, and record review, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), when there was a change in the manager, and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A.R.S. \'a7 36-425(I) states "A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer..." 2. In observation, the Compliance Officer observed the facility did not have a manager's certificate posted. 3. A review of Department documentation revealed E5 was reported as the manager from August 1, 2024, through September 27, 2024. 4. During an interview, E1 reported E4 became the manager on November 7, 2024, and had requested a duplicate license from the the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). 5. In record review, E4's personnel record included documentation E4 was hired as the manager on November 7, 2024. 6. A review of the NCIA Board website revealed E4's Assisted Living Manager's certificate was active. O1 reported E4 "did a notice of appointment for [facility] to show... started on 11/7/2024, but indicated the estimated end date of Dec 2024..." A "Notice of Appointment Change," document indicated E4's start date as the manager at the facility was November 7, 2024. 7. During an interview, E1 reported there was a prior manager to E4; however, E1 was hired at the same time as E4, and did not have the information for the prior manager. E1 acknowledged the Department was not notified when there was a change in the manager, as required.”

“Based on documentation review, record review, and interview, for two of three personnel members reviewed, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C) states: 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. Verify the current status of a person's fingerprint clearance card. 2. In record review, E1's personnel record (hired as a caregiver on October 27, 2024) included a fingerprint clearance card dated July 15, 2024; however, did not include documentation the facility made a good faith effort to verify the status of the card, and to contact previous employers to obtain information or recommendations that may be relevant to the caregiver's fitness to work in the facility. 3. In record review, E3's personnel record (hired as a caregiver on October 7, 2024), included a fingerprint clearance card dated September 26, 2022; however, did not include documentation the facility made a good faith effort to verify the status of the card, and to contact previous employers to obtain information or recommendations that may be relevant to the caregiver's fitness to work in the facility. 4. A review of the Department of Public Services website revealed E1 and E3 had a valid fingerprint clearance card. 5. During an interview, E2 reported E1 worked at the facility as the manager designee, and E3 worked on the weekends. E1 acknowledged the personnel records for E1 and E3 did not include the required documentation per A.R.S. \'a7 36-411 (C).”

“Based on observation, documentation review, record review, and interview, for one caregiver record reviewed, 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 Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and provided false and misleading information to the Department. Findings include: 1. In observation, E1 came to the facility during the inspection. 2. In documentation review, the November "Employee Work Schedule," documented E1 worked Monday through Friday from 7:00am - 7:30pm as the only caregiver on duty. 3. In record review, E1's personnel record (hired October 7, 2024, as a caregiver) included a copy of a caregiver certificate dated January 20, 2010, from "Ability Training and Services." 4. A review of the NCIA board website revealed the Ability Training and Services ALTP #173 Training Program had a "Start Date 2011-01-26," and "Expiration Date 2013-01-31." 5. During an interview, E1 reported [E1] was the manager designee, and took the caregiver training program with Ability Training in 2011. E1 reported being unaware the caregiver certificate was dated prior to the date the training program was started.”

“Based on documentation review, observation, record review, and interview, for one assistant caregiver reviewed, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services unsupervised. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-401.A.49. states "Supervision" means "direct overseeing and inspection of the act of accomplishing a function or activity." 2. In observation, the Compliance Officer observed E2 working alone at the facility, with four residents. 3. In documentation review, the staffing schedule for November 2024, did not include documentation E2 worked shifts at the facility. 4. During an interview, E2 reported being an assistant caregiver, and worked day and night shifts Monday through Friday. Alert and oriented residents reported E2 was their primary caregiver day and night. E2 reported E1 also worked at the facility as the manager designee; however, acknowledged E1 was not always at the facility. 5. In record review, the facility did not have a personnel record for E2. 6. During an interview, E1 acknowledged E2 worked at the facility as an assistant caregiver, and worked alone when E1 was not at the facility, including over night shifts. E1 acknowledged an assistant caregiver was required to interact with residents under the supervision of a manager or caregiver.”

“Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a health and safety risk to residents if the facility did not maintain staffing schedules, with documentation of facility staffing coverage for residents, and an identification of the caregivers who provided services. Findings include: 1. In observation, E2 was observed working alone at the facility, with four residents. 2. In documentation review, the staffing schedule for November 2024, did not include documentation E2 worked shifts at the facility. The staffing schedule indicated E1 worked Monday - Friday from 7:00am - 7:30pm, E3 worked Saturday and Sunday from 7:00am - 7:30pm, and E4 worked Saturdays from 11:45am - 6:00pm. The schedule did not include documentation of the caregivers who worked from 7:30pm - 7:00am each day. 3. During an interview, E2 reported being an assistant caregiver, and worked day and night shifts Monday through Friday. Alert and oriented residents reported E2 was their primary caregiver day and night. E2 reported E1 worked at the facility as the manager designee; however, E1 was not always at the facility. 4. In documentation review, a facility policy, titled "Staffing and Record Keeping," documented, "... 10. A work schedule is developed with all volunteers and staff members who provided assisted living services to residents and is maintained at the facility... The work schedule must contain facility name, dates, and a key abbreviation (names of working staff/volunteers, hours scheduled, hours worked, etc.) 11. Back-up personnel must be documented in the work schedule to ensure that there is a manager or caregiver available as back-up to provided... services..." 5. During an interview, E1 acknowledged the facility did not maintain documentation of the caregivers who worked each day, including the hours worked by each.”

“Based on documentation review, record review, and interview, for one of four caregivers reviewed, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. In record review, E3's personnel record did not include documentation of a baseline screening which assessed the risks of prior exposure to TB, and determined if the individual had signs or symptoms of TB. 3. In documentation review, the facility had policies and procedures which covered TB infection control activities, and included baseline screening. 4. During an interview, E1 acknowledged the facility did not implement TB infection control activities, including a baseline screening for E3, to assess risks of prior exposure to TB, and determine if the individuals had signs or symptoms of TB, as required by R9-10-113.”

“Based on observation, interview, record review, and documentation review, the manager failed to ensure at least the manager or a caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a health and safety risk to residents if there was not a qualified manager or caregiver on site with residents present. Findings include: 1. In observation, E2 was observed working alone at the facility, with four residents. E1 came to the facility and assisted with the inspection. 2. During an interview, E2 reported being an assistant caregiver, and worked day and night shifts Monday through Friday. Alert and oriented residents reported E2 was their primary caregiver day and night. E2 reported E1 worked at the facility as the manager designee; however, E1 was not always at the facility. 3. In record review, the facility did not have a personnel record for E2, and no documentation E2 was a caregiver. 4. In record review, E1's personnel record (hired October 7, 2024, as a caregiver) included a copy of a caregiver certificate dated January 20, 2010, from "Ability Training and Services." 5. A review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers website revealed the Ability Training and Services ALTP #173 Training Program had a "Start Date 2011-01-26," and "Expiration Date 2013-01-31." 6. In documentation review, a facility policy, titled, "Staffing and Record Keeping," documented, "... At least the manager or a caregiver is present at the facility when a resident is present... The facility governing authority will assist the facility manager to hire an additional on call caregiver available to cover shifts if the manager or a caregiver assigned to work is not available or not able to provide the required assisted living services to the residents. This caregiver must qualify to be the manager designee..." 7. During an interview, E1 acknowledged the facility was required to have a manager or a (certified) caregiver present at the assisted living facility when a resident was present. E1 acknowledged E1's caregiver certificate appeared to be invalid as it was dated prior to the start date of the caregiver training program and E2 was an assistant caregiver working at the facility alone with residents, without a caregiver certificate. E1 and E2 worked Monday - Friday as the only caregivers providing services for residents.”

“Based on observation, interview, record review, and documentation review, for one of four employees reviewed, the manager failed to have a personnel record for an employee, as required by this Article. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing an employee met the requirements to provide services for the residents. Findings include: 1. In observation, the Compliance Officer observed E2 working alone at the facility, providing assisted living services (unsupervised) for four residents. 2. During an interview, E2 reported being an assistant caregiver, and worked day and night shifts Monday through Friday. Alert and oriented residents reported E2 was their primary caregiver day and night. E2 reported E1 worked at the facility as the manager designee; however, E1 was not always at the facility. 3. In record review, the facility did not have a personnel record for E2. 4. In documentation review, a facility policy, titled, "Staffing and Record Keeping," documented "... The ... manager shall ensure that a personnel record for each employee... includes... individual's name, date of birth, and contact telephone number... starting date of employment... qualifications, including skills and knowledge... education and past experience... completed orientation... documentation of Tuberculosis Screening... Cardiopulmonary resuscitation training, if required... Documentation of compliance with the fingerprinting requirements..." 5. During an interview, E1 reported being unable to locate E2's personnel record, and acknowledged having no personnel record for E2.”

“Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, and the manager. The deficient practice posed a health and safety risk if the resident or resident's representative, and the manager, did not acknowledge the services to be provided for a resident. Findings include: 1. In record review, R1's medical record (received directed care and medication administration services) included a service plan dated October 7, 2024. The service plan was not signed and dated as reviewed by the resident's representative and the manager. 2. During an interview, E1 acknowledged the service plan was not signed and dated by the resident's representative, and the manager.”

“Based on record review, documentation review, and interview, for one resident reviewed, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered. The deficient practice posed a health and safety risk if the resident received medication and the Department was unable to verify an order for the medication. Findings include: 1. In record review, R1's medical record (received personal care and medication administration services) included documentation R1 received Methenam medication twice daily November 1 through 18, 2024. R1's medical record did not include a medication order from a medical practitioner for this medication. 2. In documentation review, a facility policy titled, "Part III - Medication administration...," documented, "1. No medication or treatment is to be administered to the resident without the order and instructions of a physician or medical practitioner..." 3. During an interview, E1 acknowledged R1 received Methenam medication, and R1's medical record did not contain an order from the medical practitioner.”

“Based on documentation review, record review, and interview, for one of two residents reviewed, the manager failed to ensure documentation of medication administration included the the name and signature of the individual administering medication. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident, and the Department was provided false and misleading information. Findings include: 1. In record review, R1's medication administration record (MAR), dated November 2024, included E1's name and signature, and E1's initials indicating R1's medications were administered by E1, everyday on each shift November 1 - 19, 2024. E2's name, signature and initials were not on R1's MAR. 2. In documentation review, a facility policy, titled "Part III - Medication Administration, Records and Monitoring," on page , documented, "... a. Medication administration is not documented until the resident is seen taking them.. 10. The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken..." 3. During an initial interview with E2, E2 reported E1 administered the medications to the residents. An interview with E1 revealed [E1] filled the residents' medisets, E2 administered the medication to the residents, and E1 signed the residents' MAR. During a joint interview, E2 acknowledged E1 filled the medisets, and E2 administered the medications to the residents. E1 and E2 acknowledged the documentation of medication administration was required to include the name and signature of the individual administering medication, and E1's MAR did not include E2's name and signature.”

“Based on documentation review, record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of the flu and pneumonia vaccination. The deficient practice posed a health and safety risk if a resident or representative did not have knowledge of the availability of the vaccination. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." Findings include: 2. In record review, the medical records for R1 and R2 did not include documentation of notification of the resident or representative of the availability of the vaccination for pneumonia. Based on R1's and R2's acceptance date, this documentation was required. 3. During an interview, E1 acknowledged the medical records for R1 and R2 did not include documentation the pneumonia vaccination was made available to the residents, as required.”

“Based on observation, interview, and record review, for one of two residents reviewed, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner (MP), every six months, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident, if a facility retained a resident without the required authorization. Findings include: 1. In observation, the Compliance Officer observed R1 sitting in a chair in R1's bedroom. 2. During an interview, R1 reported being unable to ambulate, even with assistance. E2 reported R1 was unable to ambulate with assistance. 3. In record review, R1's medical record included a signed and dated determination dated July 17, 2023, and January 29, 2024. The record did not include a written determination from R1's MP every six months, as required. 4. During an interview, E1 acknowledged the facility did not obtain a written determination from R1's MP every six months, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services.”

“Based on documentation review, observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which 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. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. The Compliance Officer observed two patio doors exiting to the backyard did not control or alert employees of the egress of a resident. The doors did not have alarms. One door was unlocked, and the other door had a wooden doll rod in the bottom door rail. 3. During an interview, E1 and E2 acknowledged the patio doors did not controlled or alert the employees of the egress of a resident from the facility.”

“Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not document a medication was administered. Findings include: 1. In observation, the Compliance Officer observed R1's medications on site. 2. In record review, R1's medical record included medication orders for "Seroquel 12.5 mg by mouth twice a day, Creon 10 mg po 3 caps 3 times per day before meals, Rasagiline 1 mg po 1T/1 time per day, Trazodone 15mg PO 1T/1 time per day, at night, Senna 8.6 PO 2T/1 time per day, Hold if loose stool, Gabapentin 600 mg PO 1T/1 time per day, at night, Mirtazapine 30mg PO 1T/1 time per day at night, Atropine PO 2 drops under the tongue every 4 hours as needed for drooling, Escitalopram 10 mg PO 1T per day, Acetaminophen 650 mg PO 1T/3 times per day..." 3. In record review, R1's medication administration record (MAR), dated November 2024, did not include documentation R1 received the medications after 1pm on November 19, 2024 through November 21, 2024. 4. During an interview, E1 and E2 reported R1 was administered the medications; however, the medication administration was not documented by the caregiver, as required, November 19 - 21, 2024.”

“Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. The deficient practice posed a risk to the health and safety of residents if the drug reference guide was not available. Findings include: 1. In observation, a drug reference guide was not observed at the facility. 2. During an interview, E1 and E2 reported being unaware if a drug reference guide was availably for use by personnel members, at the facility. No drug reference guide was provided for review.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection with E2, the Compliance Officer observed large closet (locked), which contained resident medications, along with multiple other items; including but not limited to, medical supplies, notebooks, folders, resident records, policies and procedures, bins, etc. 2. During an interview, E1 and E2 acknowledged the medications were not stored in a room, closet, cabinet, or self-contained unit used only for medication storage.”

“Based on record review and interview, for three of four employees reviewed, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance, and provided false or misleading information to the Department. Findings include: 1. In record review, E1's personnel record included documentation E1 received training on recognizing the signs and symptoms of TB. E4's personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. The facility did not have a personnel record for E2. 2. During an interview, E1 reported [E1] did not receive training on recognizing the signs and symptoms of TB, and was unaware of the facility's TB program and TB infection control policies and procedures. E1 acknowledged E2 and E4 did not have training on recognizing the signs and symptoms of TB.”