Amarsi Assisted Living.

“Based on observation, documentation, and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights.      Findings include:       1. During the environmental inspection of the facility, the Compliance Officers observed that the residents who resided in rooms 109, 111, 123, 122, 124, 125, 132, 137, 139, 143, 205, 206, 214, 215, 222, 224, 225, 232, 239, and 252 were infested with roaches.       2. In an interview, R2 reported that the facility has roaches and the roaches are in their rooms.         3. In an interview, R3 reported that the facility has roaches and the roaches are in their rooms.         4. During the environmental inspection of the facility, the Compliance Officers entered the room of R1. Upon entering, R1 started to cry and asked for help. R1 reported the facility had yet to give medication and had been waiting for a very long time for assistance from a caregiver. R1 reported that they had pushed their pendant for assistance, and no one had responded, and it had been a long period of time.     5. The Compliance Officers requested to see the pendant call alert system. Upon reviewing the pendant call alert system, it revealed that several residents had pushed their pendants, and the wait time was up to 68 minutes:   Room 103 - wait time of 39 minutes, Room 124 - wait time of 68 minutes, Room 225 - wait time of 40 minutes, and Room 214 had a wait time of 26 minutes.     6. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.       This is a repeat citation from inspections conducted on June 3, 2025, and July 9, 2025 September 22, 2025.”

“Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication.       Findings include:       1. Upon arriving at the facility, the Compliance Officers observed ambulatory residents at the facility.       2. During the environmental inspection of the facility, the Compliance Officers observed a medication cart in the dining room/kitchen common area, which contained medication for residents at the facility. The medication cabinet was unlocked at the time of inspection.       3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one of three residents sampled. The deficient practice posed a risk if the 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 written service plan dated July 22, 2025. This service plan indicated R1 received medication administration.   2. A review of R1’s October 2025 medication administration record (MAR) revealed “Gabapentin Tablet 600 mg. Give 1 tablet by mouth three times a day for neuropathy.” This medication was administered from October 1, 2025, to October 19, 2025.  3. A review of R1's medical record revealed a medication order dated October 2, 2025, for “Gabapentin Tablet 600 mg. Give 1 tablet by mouth three times a day for neuropathy.”  4. The Compliance Officer (CO) observed R1's medication bubble pack, stated, “Gabapentin Tablet 400 mg. Give 1 tablet by mouth every 6 hours.” The CO observed the following:  The “Gabapentin 400 mg” for 6:00 am administration had nine bubbles popped.  The “Gabapentin 400 mg” for 2:00 pm administration had 19 bubbles popped. The “Gabapentin 400 mg” for 10:00 pm administration had 18 bubbles popped. 5. In an interview, E3 reported that the “Gabapentin 400 mg” was administered to R1.  6. A review of R1’s October 2025 MAR revealed no documentation of “Pregabalin 75 mg.” However, a document titled “Controlled Drug Sign Out Log” revealed “Pregabalin 75 mg” was administered on September 19, 2025, at 7:00 pm; September 20, 2025, at 12:00 pm; September 26, 2025, at 8:25 pm; September 28, 2025, at 8:00 pm; October 7, 2025, at 8:00 am; and October 10, 2025, at 7:00 pm.  7. A review of R1’s medical record revealed a discontinued order for “Pregabalin 75 mg” dated September 19, 2025.  8. The CO observed R1's medication bubble pack, stated, “Pregabalin 75 mg Capsule. Take 1 capsule by mouth every 8 hours.” 9. In an interview, E3 reported that the “Pregabalin 75 mg” was administered after being discontinued.  10. In an exit interview, the findings were reviewed with E3 and E4, and no additional information was provided.  11. This is a repeat deficiency from the inspections conducted on March 28, 2023, November 13, 2023, September 2, 2025, and September 22, 2025.”

“Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident.   Findings include:     1. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility.      2. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches.     3. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.”     4. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed.     5. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility.     6. During the environmental inspection of the facility, the Compliance Officer observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills     7. During the environmental inspection of the facility, the Compliance Officer observed in R12’s residential unit, a section of the flooring was missing, which could be a trip hazard for a resident or other individual. A bottle of laundry detergent “Xtra.” Also, medications which were unlocked were “DG Health Cold/Hot Roll On, 2.5 oz”       8. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.     This is a repeat citation from an inspection conducted on July 9, 2025.”

“Based on interview, documentation review, and observation, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights.      Findings include:     1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches.     2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.”     3. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress.     4. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat.     5. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility.      6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.     This is a repeat citation from an inspection conducted on June 3, 2025, and July 9, 2025.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents.     Findings Include: 1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs".   2. During the facility's environmental inspection, the Compliance Officer observed that R2’s residential unit near the bed had loose debris and litter on the floor, including a red bag, an empty bottle, and discarded cigarette packaging. Electrical cords are also loosely spread across the floor, presenting a tripping hazard.     3. In an interview, R2 reported that housekeeping had not been to R2’s residential unit in over two and a half weeks.     4. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress.     5. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat.       6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the inspection conducted on June 3, 2025, and July 9, 2025.”

“Based on observation, record review, and interview, for two of two residents sampled, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. During the environmental inspection, R4's medications were observed at the facility, and included "OXYCODONE HCL 20 MG TABLET.” 2. A record review of R4's medical record revealed a service plan for personal care and medication administration services. A review of R4's medication order revealed "OXYCODONE HCL 20 MG TABLET Take 1 tablet by mouth every 4 hours for chronic pain.” A review of R4's electronic medication administration record (eMAR) included documentation that R4 received the OXYCODONE HCL 20 MG medication daily from July 2025 to September 18, 2025. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R4's medical record did not include documentation of an active malignancy or an end-of-life condition.   3. During the environmental inspection, R7's medications were observed at the facility, and included "TRAMADOL HCL 50 MG TABLET" medication. 4. A record review of R7's medical record revealed a service plan for personal care and medication administration services. A review of R7's medication order revealed "TRAMADOL HCL 50 MG TABLET Take 1/2 tablet by mouth three times daily (Indications for use: Pain)." A review of R7's eMAR included documentation that R7 received the TRAMADOL HCL 50 medication daily from August 2025 to September 18, 2025. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R7's medical record did not include documentation of an active malignancy or an end-of-life condition. 5. In an interview, E11 reported that the facility implemented documentation of the resident’s need for the opioid before administration and the monitoring of its effect after administration, beginning on September 19, 2025, and acknowledged that before this date, the facility had not documented the resident’s need for the opioid before administration or the monitoring of the effect after administration. 6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspection conducted September 26, 2022, November 13, 2023,”

“Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident.   Findings include:     1. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility.      2. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches.     3. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.”     4. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed.     5. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility.     6. During the environmental inspection of the facility, the Compliance Officers observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills.     7. During the environmental inspection of the facility, the Compliance Officers observed that in R12’s residential unit, a section of the flooring was missing, creating a potential trip hazard for residents or other individuals. Additionally, a bottle of laundry detergent labeled ‘Xtra’ and an unlocked medication, ‘DG Health Cold/Hot Roll-On, 2.5 oz,’ were observed in the room.”      8. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.     This is a repeat citation from an inspection conducted on July 9, 2025.”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver had the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. This deficient practice posed a health and safety risk to R2 due to unmet medical and skin care needs. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August 2025, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented a diagnosis of "Psoriasis." A review of the service plan stated, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." 5. In an interview, the Compliance Officers reported that R2’s needs were not met, as the assigned staff did not demonstrate the necessary qualifications, skills, and knowledge to properly address and manage R2’s medical and skin care needs.”

“Based on record review and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for seven of ten employees reviewed. The deficient practice posed a TB exposure risk to residents.     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. A review of the Centers for Disease Control and Prevention 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 E2's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E2 had signs or symptoms of TB done on or before the date of hire. Based on E2's hire date, this documentation was required.     4. A review of E3's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E3 had signs or symptoms of TB done on or before the date of hire. Based on E3's hire date, this documentation was required.     5. A review of E4's personnel records revealed a negative TB skin test that was less than 12 months old, however, no documentation of a second negative TB skin test was available for review. Also, a review of E4's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E4 had signs or symptoms of TB done on or before the date of hire. Based on E4's hire date, this documentation was required.    6. A review of E5's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E5 had signs or symptoms of TB done on or before the date of hire. Based on E5's hire date, this documentation was required.   7. A review of E6's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E6 had signs or symptoms of TB done on or before the date of hire. Based on E6's hire date, this documentation was required.     8. A review of E7's personnel records revealed no first or second negative TB skin test that was less than 12 months old. Also, a review of E7's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E7 had signs or symptoms of TB done on or before the date of hire. Based on E7's hire date, this documentation was required.       9. A review of E8's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E8 had signs or symptoms of TB done on or before the date of hire. Based on E8's hire date, this documentation was required.       10. In an exit interview, the findings were reviewed with E10, E11 and E12, and no additional information was provided.     The is a repeat deficiency from the inspection conducted on October 18, 2024.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility, which included the manager's signature and date signed, for two of nine residents sampled.   Findings include: 1. A review of R1’s medical record revealed a residency agreement that included the manager’s signature and date; however, it was signed and dated three days later by the manager or designee. 2. A review of R4’s medical record revealed a residency agreement that included the manager’s signature and date; however, it was signed and dated fifteen days later by the manager or designee. 3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.”

“Based on observation, record review, and interview, the manager failed to ensure a written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of nine residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August 2025, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented a diagnosis of "Psoriasis." A review of the service plan stated, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." However, although R2’s diagnosis of psoriasis was documented in the medical record, the service plan did not include a description of the condition, including its physical effects or related care needs. The lack of documentation describing R2’s psoriasis and the necessary skin maintenance services to address the condition indicates that the service plan was incomplete and did not accurately reflect the resident’s current medical and physical care needs. 5. In an interview, E11 acknowledged the residents' service plans did not include a description of the residents' medical or health problems, as required. This is a repeat deficiency from the inspection conducted on November 27, 2024.”

“Based on observation, record review, and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident sampled who had a significant change in condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." However, the service plan was not updated to indicate this significant change.   5. In an interview, E11 acknowledged R2's service plan was not updated after a significant change of condition.  This is a repeat deficiency from the inspection conducted on October 2, 2023,”

“Based on interview, documentation review, and observation, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights.      Findings include:     1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches.     2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.”     3. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress.     4. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat.     5. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility.      6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.     This is a repeat citation from an inspections conducted on June 3, 2025 and July 9, 2025.”

“Based on observation and interview, the facility maintains residents' medical records electronically, and the manager failed to ensure that safeguards existed to prevent unauthorized access.     Findings include:     1. During an environmental inspection, the Compliance Officers observed a laptop left unattended on a medication cart in the common dining area with no staff present. The laptop was open to a list of resident records and was accessible without safeguards. The device was located in a shared area where residents, visitors, and other guests of the facility were present.     2. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.”

“Based on observation, record review, and interview, for one of nine residents sampled, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a health and safety risk to residents if staff were unaware of the skin maintenance services needed by a resident. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." 5. In an interview, E11 acknowledged that R2’s service plan did not include documentation of the skin maintenance services provided to prevent and treat bruises, injuries, pressure sores, and infections, nor did it include services specific to treating R2’s psoriasis.”

“Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of nine residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.   Findings include:   1. A review of R4's record revealed a current service plan for personal care services dated June 2025. This service plan indicated R4 received medication administration. A review of R4's signed medication orders revealed "CLONIDINE HCL 0.2 MG TABLET Take 1 tablet by mouth every 8 hours. Hold for SBP less than 100. (Related Diagnoses: ESSENTIAL (PRIMARY) HYPERTENSION (I10)."   2. A review of R4's electronic medication administration record (eMAR) revealed that "CLONIDINE HCL 0.2 MG TABLET Take 1 tablet by mouth every 8 hours. Hold for SBP less than 100. " was administered September 15, 2025, to present. However, R4’s MAR did not include documentation of the resident’s systolic blood pressure (SBP) reading before each administration of the medication. 3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspections conducted on March 28, 2023, November 13, 2023, and September 2, 2025.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents.     Findings Include:     1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs".     2. During the facility's environmental inspection, the Compliance Officer observed that R2’s residential unit near the bed had loose debris and litter on the floor, including a red bag, an empty bottle, and discarded cigarette packaging. Electrical cords are also loosely spread across the floor, presenting a tripping hazard.     3. In an interview, R2 reported that housekeeping had not been to R2’s residential unit in over two and a half weeks.   4. A review of R2’s service plan stated” Housekeeping and Laundry Services Weekly and PRN.” A review of the activities of daily living (ADL) sheet dated September 2025 revealed "Intervention / Task HOUSEKEEPING: Pick up trash and check apartment daily to prevent clutter, make bed if needed. Time Qshift (0600-1400) (1400-2200) (1400-2200)." However, the room did not appear to be clean.   5. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress.     6. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat.       7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.       This is a repeat deficiency from the complaint investigation conducted on April 23, 2025, June 3, 2025, and July 9, 2025.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury.     Findings include:     1. During the environmental inspection of the facility, the Compliance Officer observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills     2. During the environmental inspection of the facility, the Compliance Officer observed in R12’s residential unit, a section of the flooring was missing, which could be a trip hazard for a resident or other individual. A bottle of laundry detergent “Xtra.” Also, medications which were unlocked were “DG Health Cold/Hot Roll On, 2.5 oz”     3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspection conducted on July 10, 2023, July 24, 2023 and  January 30, 2025.”

“Based on observation and interview, the manager failed to ensure a pest control program was implemented and effective. The deficient practice posed a potential risk to infection control by exposing residents to unsanitary conditions due to cockroach infestation that could lead to the spread of pathogens and compromise resident health and safety. Findings include: 1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches.     2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.”     3. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed.     4. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility.     5. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided”

“Based on observation, record review, and interview, the manager failed to ensure that each sleeping area had clean linen for the resident. The deficient practice posed a risk to the health and safety of residents.   Findings include:     1. During the environmental inspection of the facility, the Compliance Officers observed that R2's bed sheet was draped over the headboard of R2’s bed. The bed sheet was stained, which looked like a brown substance.     2. A review of R2’s service plan stated” Housekeeping and Laundry Services Weekly and PRN.”     3. In an interview, R2 reported that housekeeping had not gone to R2’s resident unit for over two and a half weeks.     4. During the environmental inspection of the facility, the Compliance Officers observed that R10's bed had no bed sheet, and the bed was stained, which looked like a brown stain.     5. During the environmental inspection of the facility, the Compliance Officers observed that R11's bed had no bed sheet, and the bed was stained, which looked like a brown stain.     6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record correctly for 5 of 5 residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was provided false and misleading information. Findings include: 1. The Compliance Officers were provided service plans and activities of daily living (ADL) at 11:00 am. Activities of daily living showed lunch scheduled at 12:30 pm. 2. A review of R1's service plan revealed a section titled Nutrition/Eating that showed three daily meals and snacks would be provided. 3. A review of R1's ALDs revealed a section title, Meal Attendance for September, which showed that breakfast and lunch were provided at 6:08 am on September 2nd. 4. A review of R2's service plan revealed a section titled Nutrition/Eating that showed three daily meals and snacks would be provided. 5. A review of R2's ADLs revealed a section title, Meal Attendance for September, which showed that breakfast and lunch were provided at 6:14 am on September 2nd. 6. A review of R3's service plan revealed a section titled Nutrition/Eating that showed three daily meals and snacks would be provided. 7. A review of R3's ADLs revealed a section title, Meal Attendance for September, which showed that breakfast and lunch were provided at 6:34 am on September 2nd. 8. A review of R4's service plan revealed a section titled Nutrition/Eating that showed Meal delivery as needed. 9. A review of R4's ADLs revealed a section title, Meal Attendance for September, which showed that breakfast and lunch were provided at 6:56 am on September 2nd. 10. A review of R5's service plan revealed a section titled Nutrition/Eating that showed three daily meals and snacks would be provided. 11. A review of R5's ADLs revealed a section title, Meal Attendance for September, which showed that breakfast and lunch were provided at 6:23 am on September 2nd. 12. In an interview, E1 acknowledged that ADLs for R1, R2, R3, R4, and R5 showed lunch being provided before being served, and the initials belong to the same caregiver. 13. This is a repeat deficiency from the complaint inspection conducted on September 26, 2022, the compliance and complaint inspection conducted on March 28, 2023, the compliance and complaint inspection conducted on October 18, 2024, and the complaint inspection conducted on November 27, 2024.”

“Based on record review and interview, the manager failed to follow procedures for assisting a resident in procuring medication. Findings include: 1. R9-10-817.A.1.e.: A manager shall ensure that:  Policies and procedures for medication services include: Procedures for assisting a resident in procuring medication; and 2. A review of R4's medical record revealed medication orders showing various medications, including Febuxostat 40 mg Tab Take 1 tablet by mouth once daily and Omeprazole DR 20 mg, Take 1 capsule by mouth once daily. 3. A review of R4's medication administration record for August 2025 revealed Febuxostat and Omeprazole as not being administered on the following dates, with administration notes: Febuxostat : 27th- note - will reach out to pharmacy/hospice, not arrived yet 28th - note - pharmacy 30th - note - med unavailable 31st - note - none. Omerprazole : 27th - note - will reach out to pharmacy/hospice 28th - note - pharmacy 30th - note - Unavailable 31st - note - will reach out to pharmacy/hospice 4. In an interview, R4 reported they were in pain and had not been provided medication. 5. In an interview, E1 acknowledged that medication was not administered to the resident, and medication was not procured for the resident.”

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record correctly. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R4's medical record revealed a service plan dated August 28, 2025, and showing R4 required medication administration. The section titled "Medication/Pharmacy" stated: "Medication Administration. This may include: Storing Residents' Medication, Reading of Medication Label if Requested, Opening Container of Medication, Pouring and Placing Medication into Container or Resident's Hand, and Observing While Resident takes medication, or may be administered to the final destination." 2. A review of R4's medical record revealed medication orders showing various medications, including: Febuxostat 40 mg Tab, Take 1 tablet by mouth once daily Omeprazole DR 20 mg, Take 1 capsule by mouth once daily 3. A review of R4's medication administration record for August 2025 revealed Febuxostat and Omeprazole being administered on the 29th. However, it showed as not being administered on the following dates, with administration notes: Febuxostat : 27th- note - will reach out to pharmacy/hospice, not arrived yet 28th - note - pharmacy 30th - note - med unavailable 31st - note - none Omeprazole : 27th - note - will reach out to pharmacy/hospice 28th - note - pharmacy 30th - note - Unavailable 31st - note - will reach out to pharmacy/hospice 5. In an interview, R4 reported they were in pain and had not been provided medication. 6. In an interview, E1 reported that they must have found some pills; medication should have been available after the 29th. 7. This is a repeat deficiency from the complaint inspections conducted on March 4, 2024, November 13, 2023, and June 15, 2023, and the complaint investigation and compliance inspection conducted on March 28, 2023.”

“Based on record review and interview, the manager failed to ensure before or within five working days after a resident's acceptance by an assisted living facility, a manager shall obtain on the documented agreement required in subsection (D), the signature of the resident, the resident's representative, or the resident's legal guardian for one out of five residents reviewed. Findings include: 1. A review of R5's medical record revealed a residency agreement. This document did not include a signature of the resident, the resident's representative, or the resident's legal guardian. 2. In an interview, E2 and E6 reported R5 refused to sign the residency agreement. 3. In an exit interview, the findings were reviewed with E2 and E6 and no additional information was provided”

“Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident.   Findings include:   1. During an environmental inspection of R1's room the Compliance Officers observed live roaches crawling on R1’s bed, pillows, curtains, dressers, walls, floor, and lamp shade. R1 was in the bed at the time with the roaches. E1 was called into the room and observed the roaches moving across the room.   2. In an exit interview, the findings were reviewed with E1 no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of injury and violated a resident's rights.      Findings Include:     1. During an environmental inspection of R1's room, the Compliance Officers observed live roaches crawling on R1’s bed, pillows, curtains, dressers, walls, floor, and lamp shade. R1 was in the bed at the time with the roaches. E1 was called into the room and observed the roaches moving across the room. The room     2. In an interview, E2 acknowledged R1 was not treated with dignity, respect, and consideration.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents.     Findings Include:     1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs".     2. A review of facility documentation revealed a log sheet titled “Problem area/ Rooms log book” for reporting pest issues. R1's room had been reported 8 times.      3. During an environmental inspection of R1's room, the Compliance Officers observed live roaches crawling on R1’s bed, pillows, curtains, dressers, walls, floor, and lamp shade. R1 was in the bed at the time with the roaches. E1 was called into the room and observed the roaches moving across the room.     4. In an interview, E1 acknowledged R1’s room contained roaches on the bed, pillows, curtains, dressers, walls, floor, and lamp shade. This is a repeat deficiency from the complaint investigation conducted on June 3, 2025.”

“Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. Findings include: 1. During an environmental inspection of R1's room, the Compliance Officers observed dead roaches next to the bed and bathroom. E2 and E3 were called into the room, and all observed a roach moving across the room. There was also dirty laundry on top of the hamper and in the bathtub. 2. During an environmental inspection of R2's room, the Compliance Officers observed urine all over the bathroom floor. There was a strong smell of urine in the room. 3. In an interview, R1 reported the facility had been informed of the roaches in the room. 4. In an interview, R2 also stated the facility does not have enough caregivers to provide them with care. 5. In an interview, E2 acknowledged residents were not treated with dignity, respect, and consideration.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings Include: 1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs". 2. During an environmental inspection of R1's room, the Compliance Officers observed dead roaches next to the bed and bathroom. E2 and E3 were called into the room, and all observed a roach moving across the room. There was also dirty laundry on top of the hamper and in the bathtub. 3. During an environmental inspection of R2's room, the Compliance Officers observed dry urine on the bathroom floor. 4. In an interview, E2 acknowledged that R1's and R2's rooms were not cleaned. E2 also acknowledged there was no housekeeping log. This is a repeat deficiency from the complaint investigation conducted on April 23, 2025.”

“Based on observation and interview, for two of two resident rooms observed, the manager failed to ensure the facility premises were cleaned and disinfected. The deficient practice posed a health risk to residents if the environment was not kept clean.   Findings include:   1. Upon entry to the facility, the Compliance Officer observed an odor of urine. During an environmental inspection, the Compliance Officer observed the odor came from R4's bedroom. Soiled linens were observed in an uncovered laundry basket, and on the floor of the room. An uncovered garbage can was observed to contain gloves and briefs. 2. In an interview, E4 observed R4's room and acknowledged the odor, the soiled linen, and the uncovered garbage can. 3. The Compliance Officer observed R1's unit had a strong odor of feces. A large amount of water was observed on the floor around the toilet in R1's bathroom. 4. During an interview, the housekeeper reported R1's bathroom had feces on or around the toilet, and the water was used to clean the area. E1 and E2 acknowledged the facility premises were not maintained in a clean manner.”

“A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;”

“Based on documentation review, record review, and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a potential risk to the health and safety of residents. Findings include:”

“Based on record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of three residents sampled. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of Department documentation revealed Emergency Medical Services (EMS) was requested for a lift assist for R2 on November 17, 2024. According to O2's intake narrative, "Staff on scene would not lift uninjured R2 back into bed. Staff states "we are a no lift facility." Staff says they do not have enough staff working to perform lift assists. R2 was an average sized... Engine 925 found R2 sitting on the floor..." 2. A review of facility documentation revealed an incident report dated November 17, 2024. The report stated; "Call for help. Walked Resident on floor. EMS called to assist only to lift Resident. Called all parties and no injuries." 3. During an interview, R2 reported a fall on November 17, 2024. Due to R2's condition, staff members E3, E4, and E5 were unable to safely assist R2 from the floor to the bed. EMS was contacted and responded to provide lift assistance only. 4. In an interview, E3 reported that staff members E3, E4, and E5 were unable to safely transfer R2 from the floor to the bed. As a result, they contacted EMS for lift assistance. 5. In an interview, E2 and E3 acknowledged the facility failed to provide appropriate first aid to R2 who had fallen and appeared to be uninjured.”

“Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice prevented the facility's personnel from ensuring the health and safety of the resident as R1 left the facility and the personnel members were unaware that R1 did not return. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. A review of R1's medical record revealed a service plan for personal care services dated May 2024. The initial intake documents from Phoenix Mountain Post-Acute stated "PT is legally blind but can maneuver around on their own as needed," however, R1's current service plan did not indicate R1 was legally blind. 3. A review of the facility's policy and procedure titled "Resident General/Specific Location" stated, "PROCEDURE Assisted Living: 3. If the resident Sign's Out of the Facility & does not return by the end of the day, the Facility will attempt to contact: a. The resident b. The resident's POA/Decision-Maker c. The local hospital(s)". 4. A review of facility documentation revealed a Sign In & Sign Out form (Resident Sign in Log). The form indicated R1 signed out of the facility on November 14, 2024 at 2:30pm. However, there was no documented return time, and R1 had not signed back into the facility. 5. A review of Department documentation revealed that R1 was located by Emergency Medical Services (EMS) personnel at a transit stop around 9:25am on November 15, 2024. According to the EMS intake narrative, R1 slept at a transit stop and upon return, the facility had no idea R1 was missing for 24 hours. 6. A review of R1's medical record revealed no documentation that the resident was missing on November 14, 2024 or that the facility attempted to contact the resident, the resident's POA/Decision-Maker or the local hospital(s) as required in the policy. 7. In an interview, R1 reported being blind and becoming disoriented on the above incident date, subsequently staying overnight at a transit stop. While unable to specify exact duration of absence, R1 reported spending the night away from the facility. 8. In an interview, E1 and E2 reported R1 frequently went out of the facility and returned safely. In addition, E1 reported that the facility front doors were locked after 8pm and opened at 8am by facility personnel. E1 and E2 acknowledged R1 had not signed back in at the facility during the incident on November 14, 2024, the facility was unaware that R1 was missing, and facility personnel did not follow the above-mentioned policy.”

“Based on record review and interview, the manager failed to ensure a written service plan included a current summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated May 2024. The service plan stated "Diagnoses; Diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris." A review of R1's initial intake documents from Phoenix Mountain Post-Acute reported R1 was legally blind (Cortical blindness), however, R1's current service plan did not indicate R1 was legally blind. 2. In an interview, R1 reported to the Compliance Officer and E2 that R1 was blind. 3. In an interview, E2 acknowledged R1's service plan did not include a current summary of R1's medical or health problems.”

“Based on documentation review, record review and interview, the manager failed to ensure the caregiver accurately documented the services provided in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a Sign In & Sign Out form (Resident Sign in Log). The form indicated R1 signed out of the facility on November 14, 2024 at 2:30pm. However, there was no documented return time, and R1 had not signed back into the facility. 2. A review of Department documentation revealed that R1 was located by Emergency Medical Services (EMS) personnel at a transit stop around 9:25am on November 15, 2024. According to the EMS intake narrative, R1 slept at a transit stop and upon return, the facility had no idea R1 was missing for 24 hours. 3. A review of R1's medical record revealed a service plan for personal care services dated May 2024. The service plan indicated R1 received assistance with activities of daily living (ADL). 4. A review of R1's November 2024 ADL sheet documented R1 received "two times bed safety check/assistance per night" on November 15, 2024 at 5:32am by E6. 5. In an interview, R1 reported being blind and becoming disoriented on the above incident date, subsequently staying overnight at a transit stop. While unable to specify exact duration of absence, R1 reported spending the night away from the facility. 6. In an interview, E1 and E2 acknowledged R1's ADL sheet was documented as completed for the night shift. However, the facility was unable to account for or provide documentation of R1's whereabouts during that time period. This is a repeat deficiency from the compliance/complaint inspection conducted March 28, 2023 and October 18, 2024.”

“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. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents. 3. During the environmental tour, the Compliance Officer observed multiple doors leading to a large courtyard which a resident could exit to a location at least 30 feet away from the facility. The doors leading out to the courtyard from the facility did not control or alert employees to the egress of a resident to the outside area. 4. In an interview, E1 and E2 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated May 2024. This service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed signed medication orders for the following medications: - Atorvastatin 80 MG 1-tab PO QHS; - Fenofibrate 48 MG 1-tab PO QHS; - Metformin HCL 500 MG 2-tabs PO BID; - Metoprolol Tart 25 MG 1- tab PO BID; and - Trazodone 50 MG 1-tab PO QHS. 3. A review of R1's medical record revealed a November 2024 Medication Administration Record (MAR) and R1's aforementioned medications were documented as administered on November 14, 2024 at 7:00pm and 8:00pm. 4. A review of facility documentation revealed a Sign In & Sign Out form (Resident Sign in Log). The form indicated R1 signed out of the facility on November 14, 2024 at 2:30pm. However, there was no documented return time, and R1 had not signed back into the facility. 5. A review of Department documentation revealed that R1 was located by Emergency Medical Services (EMS) personnel at a transit stop around 9:25am on November 15, 2024. According to the EMS intake narrative, R1 slept at a transit stop and upon return, the facility had no idea R1 was missing for 24 hours. 6. In an interview, R1 reported being blind and becoming disoriented on the above incident date, subsequently staying overnight at a transit stop. While unable to specify exact duration of absence, R1 reported spending the night away from the facility. 7. In an interview, E3 reported E3 provided the night medication to R1. 8. In an interview, E1 and E2 acknowledged R1's MAR included documentation the medications were administered. However, the facility was unable to account for or provide documentation of R1's whereabouts during that time period.”

“Based on record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1's personnel record revealed no documentation of training in fall prevention and fall recovery. 2. In an interview, E1 acknowledged E1 did not have fall training and fall recovery training available for review.”

“Based on record review and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of four employees reviewed. The deficient practice posed a TB exposure risk to residents. 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. Review of the Centers for Disease Control and Prevention 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 E2's personnel record revealed a negative TB skin test before the date of hire. However the second negative skin test was dated after the date of hire. A further review of E2's record revealed no documentation of the signs and symptoms screening done on or before the date of hire. Based on E2's hire date, this documentation was required. 4. A review of E3's personnel record revealed a chest x-ray. However, documentation was not available indicating E3 had a previous positive TB skin test or blood test and without such documentation a chest x-ray is not acceptable as documentation of freedom from TB. A further review of E2's record revealed no documentation of the signs and symptoms screening done on or before the date of hire. Based on E3's hire date, this documentation was required. 5. In an interview, E1 acknowledged E2 and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure the manager provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of four employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E1's personnel record revealed E1 worked as the facility manager and had a hire date of March 1, 2022. The personnel record revealed a first aid and CPR card with an expiration date of March 3, 2024. There was no other documentation of first aid and CPR training in E1's record. 2. During an interview, E1 acknowledged E1's documented first aid and CPR training expired.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record for two of six 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 R2's medical record revealed a service plan dated May 24, 2024. The service plan revealed R2 received personal care service which included, "Bathing: Stand by assistance with bathing twice weekly; Monitor skin for redness, openings, or abnormality ..." 2. A review of R2's medical record revealed an Activities of Daily Living (ADL) log dated October 2024. The ADL log included "Stand by assistance with bathing twice weekly" and revealed the stand by assistance with bathing was provided on the following days: - October 2, 2024; - October 5, 2024; - October 9, 2024; and - October 16, 2024. However, on October 12, 2024 the service was left blank on the ADL log. 3. A review of R6's medical record revealed an ADL log dated October 2024. The ADL log included the following service, "Visual check completed each shift to ensure that the residents either observed safely on campus or not expected on campus at that time ..." 4. A review of R6's ADL log revealed R6 did not receive a visual check on the following days and times which were left blank: - October 12, 2024 at 6am and 2 pm; and - October 13, 2024 at 2 pm. 5. A review of R6's medical record revealed a service plan dated September 24, 2024. The service plan revealed R6 received personal care services which included, "Housekeeping" and "Mobility: Encourage non-slip socks in room". 6. A review of R6's ADL log included the following service dated October 2024, "HOUSEKEEPING: Pick up trash and check apartment daily to prevent clutter. Daily bed making" and revealed R6 did not receive housekeeping service on the following days and shifts which were left blank: - October 12, 2024 AM and PM shift; and - October 13, 2024 PM shift. 7. A review of R6's ADL log included the following service dated October 2024, "Encourage non-slip socks in room" and revealed R6 did not receive "Encourage non-slip socks in room" on the following days and shifts which were left blank: - October 12, 2024 AM and PM; and - October 13, 2024 PM. 8. In an interview, E1 acknowledged the services were provided. However the services were not documented on R2's and R6's ADL logs. This is a repeat deficiency from the compliance/complaint inspection conducted March 28, 2023.”

“Based on record review and interview, the manager failed to ensure at the time of admission, a resident or resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (C), for one of six residents sampled. The deficient practice posed a risk as individuals were not informed of the resident requirements. Findings include: 1. Review of R3's medical record revealed no documentation showing the resident or resident's representative received a copy of the requirements in subsection (B). Based on R3's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available showing the resident or resident's representative received a copy of the requirements in subsection (B).”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for one of six residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R3's medical record revealed no documented residency agreement dated before or at the time of R3's acceptance into the facility. 2. In an interview, E1 acknowledged there was no documented residency agreement dated before or at the time of R3's acceptance into the facility at the time of the inspection.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of six sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R3's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection. 2. In an interview, E1 acknowledged R3's medical record did not contain documentation of R3's orientation to exits from the assisted living facility at the time of the inspection.”

“Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three 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 R1's (admitted in 2023) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 reported the requested documentation was not available for review. This is a repeat deficiency from the complaint investigation conducted January 23, 2024.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, for five of five residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Medical Records Subject: Resident Records Contents." The policy stated "...9. Documentation of freedom from pulmonary tuberculosis (as mandated by state regulations)." 2. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed no documented evidence of freedom from infectious TB. 3. In an interview, E1 reported R1, R2, R3, R4, and R5 did have documentation of freedom from infectious TB, but the documentation was not available for review at the time of the inspection.”

“Based on record review and interview, 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 the assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for five of five residents sampled. The deficient practice posed a risk if staff were unable to meet the needs of residents. Findings include: 1. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed no documentation dated within 90 calendar days before R1, R2, R3, R4, and R5 were accepted by the assisted living facility to include whether R1, R2, R3, R4, or R5 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's medical records did not contain the required documentation. 3. In an interview, O1 reported believing the facility did not require this doumentation if the resident was ambulatory.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for five of five 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, R2's, R3's, R4's, and R5's medical records revealed no documentation of assisted living services provided to the residents. 2. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's medical records contained no documentation of any assisted living services provided to the residents.”

“Based on record review and interview, the manager failed to ensure compliance with A.R.S. \'a7 36-411(A), for one of four employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population Findings include: 1. A review of E2's record (hired in July 2023) revealed a fingerprint clearance card status request dated August 8, 2023. The fingerprint clearance card status request showed E2's fingerprint card was not valid. 2. In an interview, E1 acknowledged E2's fingerprint clearance was not valid and was working under supervision of another personnel member. However, a good cause letter was not provided for review.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of four residents sampled; and failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of four residents sampled. The deficient practice posed a risk if R3 experience a change in condition due to improper medication administration. Findings include: 1. A review of R3's medical record revealed a medication order dated June 14, 2023 for "Gabapentin 600 mg tablet. Give 1200 mg by mouth three times day for Neuropathy." 2. A review of R3's medical record revealed a medication administration record (MAR) for November 2023. The MAR revealed "Gabapentin 600 mg" was not documented as administered on the following dates and times: -November 8, 2023 at 1900 hour -November 9, 2023 at 1300 hour 3. A review of R3's medical record revealed a medication order dated January 18, 2023 for "Atorvastatin Calcium Oral tablet 80 mg give 80 mg by mouth at bedtime for HLD." 4. A review of R3's medical record revealed a MAR for November 2023. The MAR revealed "Atorvastatin Calcium Oral tablet 80 mg" was not documented as administered on the following date and time: -November 8, 2023 at 2000 hour 5. A review of R3's medical record revealed a medication order dated October 4, 2023 for "Ammonium Lactate External Cream 12% Apply to RLE topically every day shift for Skin integrity." 6. A review of R3's medical record revealed a MAR for November 2023. The MAR revealed "Atorvastatin Calcium Oral tablet 80 mg" was not documented as administered on the following date and time: -November 8, 2023 at 1900 hour 7. A review of R3's medical record revealed a medication order dated October 4, 2023 for "Alogliptin Benzoate Oral tablet 25 mg. Give 25 mg by mouth one time a day for DM2." 8. A review of R3's medical record revealed a MAR for November 2023. The MAR revealed "Alogliptin 25 mg tab" was not documented as administered on the following date and time: -November 1-4, 2023 at 700 hour 9. In an interview, E1 reported E1 was unable to confirm if R3 was administered medication in compliance with the medication orders, or if R3 did receive medication administration and personnel members did not document R3 received medication administration.”

“Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of one resident who had an accident, emergency, or injury resulting in the resident needing medical services. Finding include: 1. A review of documentation revealed an incident report dated November 5, 2023. The incident report revealed R1 needed emergency medical services on November 5, 2023. However, the incident report did not indicate if R1's emergency contact and primary care provider were notified. 2. In an interview, E1 acknowledged R1's emergency contact and primary care provider were notified of the November 2023 accident, emergency, or injury.”

“Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered, and the effect of the opioid administered for a prescribed opioid was provided, for one of four residents sampled. Findings include: 1. A review of documentation revealed a policy and procedure titled "Opioid Medication Administration" dated February 15, 2023. The policy stated "5. Prior to administering the opioid medication, the Caregiver or Licensed Nurse will request the resident identify the pain they are experiencing. This will be entered into the eMAR as the resident described. 6. One or two hours after receiving the opioid medication, staff will return to the resident and ask them to identify their current pain. This will be entered into the eMAR as the resident described." 2. A review of R3's medical record revealed a service plan for personal care services (dated in October 2023). The service plan revealed R3 received medication administration. 3. A review of R3's medical record revealed a medication order (dated October 17, 2023) for "Oxycodone-Acetaminophen oral tablet 5/325 mg (Oxycodone-Acetaminophen) give 1 tablet by mouth three times a day for chronic pain." 4. A review of R3's medical record revealed a medication administration record (MAR) dated November 2023. The MAR indicated R3 received Oxycodone-Acetaminophen on November 4-13, 2023. However, the MAR did not document an identification of R3's need for the opioid before the opioid was administered, and the effect of the opioid administered. 5. In an interview, E1 acknowledged R3's pain level was not documented.”

“Based on documentation review, record review, and interview, the manager failed to establish and document policies and procedures to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk as the established and documented policies and procedures were not sufficient to protect the health and safety of residents. Findings include: 1. A review of documentation revealed a complaint was received by the Department on September 2, 2023. The complaint alleged a resident (later identified as R3) was found in their electric wheelchair on the side of the road, was later sent to the hospital, and was found to have a temperature of 108\'b0F upon arrival to the hospital. 2. A review of facility documentation revealed an incident report (dated August 31, 2023). The report stated "Resident was out of the facility and did not tell anyone of [R3's] where about [sic]. [R3's sibling] stated Resident was found unresponsive and slumped over in [R3's] electric wc [wheelchair] on the side of the road on 8/31/23 at approx. 1700. A good Samaritan called 911 and the paramedics took resident to the hospital. Residents core temp was at 108 upon arrival to the ER." 3. A review of facility documentation revealed a policy and procedure titled "Signing In & Out as Assisted Living Residents" (date unavailable). The policy and procedure stated "It is our policy to request that all Assisted Living residents sign in & out prior when coming & going throughout there [sic] day-today [sic] activities as a resident of this campus. However, it is a violation of a resident's rights to demand compliance with this request. ... 1. The campus has a sign in & out binder located at or near the front desk. 2. All residents are encouraged to sign in & out to ensure that the campus is aware of their location when they leave the campus. 3. The Campus strongly encourages resident compliance with this process but cannot mandate compliance as this a violation of their rights in a residential setting." However, the policy and procedure did not include methods to be aware of resident's specific or general whereabouts as the facility's policies and procedures stated the facility could not "demand" or "mandate" compliance with their policy and procedure to protect the health and safety of a resident. 4. A review of facility documentation revealed a document titled "Resident Sign-Out Log" (dated for August 2023-September 2023). However, documentation to indicate R3 had signed in or signed out was not available for review. 5. A review of R3's medical record revealed a service plan for personal care services (dated in June 2023). The service plan stated the following service was to be provided to R3: "Two Times Bed Safety Check / Assistance per Night." However, the service plan did not include methods to be aware of R3's specific or general whereabouts during the day time hours as the facility's policies and procedures stated the facility could not "demand" or "mandate" compliance with their policy and procedure to protect the health and safety of a resident. 6. A review of R3's medical record revealed activities of daily living (ADL) sheets for August 2023 and September 2023. However, "Two Times Bed Safety Check / Assistance per Night" was not documented as provided in August 2023 and September 2023. 7. A review of R3's medical record revealed documentation of progress notes. The progress notes stated the following: -September 1, 2023: "residents [sibling] called to inform me of residents condition. [R3's sibling] stated they have resident on a ventilator and is still unresponsive"; and -September 1, 2023: "Hospital thinks resident may have has [sic] a stroke and then became heat exhausted." 8. In an interview, E7 reported R3 was always in and out of the facility. 9. In an interview, E10 reported the facility cannot enforce residents to use the sign in and sign out log. E10 reported if a resident does not return to the facility, the resident's representative will be notified. 10. In a joint interview, the findings were reviewed with E1, E7, E8, and E9, and no additional comments or statements were provided regarding the findings.”

“Based on documentation review and interview, the manager, who had a reasonable basis to believe abuse had occurred, failed to ensure an assisted living facility's manager, caregiver, or assistant caregiver documented the report in subsection (J)(2). Findings include: A.R.S. \'a7 46-454 Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. 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 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...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures. 1. A review of facility documentation revealed an incident report for R1 (dated August 31, 2023). The report stated "Resident states [R1] thinks another resident stole [R1's] wallet and kept knocking on [resident's] (later identified as R5) door and then the other resident got mad and came out and punch [R1] in the jaw ... Police were notified on 9/1/23." However, documentation of the report made to the police was not available for review. 2. A review of facility documentation revealed an incident report for R5 (dated August 31, 2023). The report stated "Staff stated another ... [R1] kept knocking on this resident door; claiming [R5] stole [R1's] wallet. Resident states another ... resident kept banging on [R5's] door all night long and [R5] got mad and punched [R1] in the jaw. ... Glendale police were called ..." However, documentation of the report made to the police was not available for review. 3. In an interview, E7 reported E7 would have to check for documentation of the report made to the police. 4. In a joint interview, the findings were reviewed with E1, E7, E8, and E9, and no additional comments or statements were provided regarding the findings.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for two of five residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R1's medical record revealed documentation of a progress note (dated September 26, 2023). The progress note stated "LATE ENTRY ... INITIAL PSYCH EVAL ... Patient arrived to our facility on [date]. Patient admits to some worsening feelings of depression as of late ... Mental Health Functional Status: Patient requires assistance with ADLs ... CARE PLAN ... Staff continues to attempt nonpharmacologic interventions prior to the administration or psychotropic medications. Psychotropic medications are administered when nonpharmacologic interventions are ineffective." 2. A review of R1's medical record revealed a service plan (dated in June 2023) for personal care services. The service plan revealed R1 was independent in activities of daily living (ADLs) with a stand-by assistance in bathing. However, an updated service plan updated, within 14 calendar days after R1's psychiatric evaluation, was not available for review. 3. In an interview, E7 reported an updated service plan updated, within 14 calendar days after R1's psychiatric evaluation, was not available for review. 4. A review of R5's medical record revealed documentation of a progress note (dated August 8, 2023). The progress note stated "LATE ENTRY ... FOLLOW UP PSYCH EVAL ... Psychiatry has been consulted due to the patient's history or depression, recent drug overdose, and for medication management. ... patient states mood has been up and down. ... CARE PLAN ... Staff continues to attempt nonpharmacologic interventions prior to the administration or psychotropic medications. Psychotropic medications are administered when nonpharmacologic interventions are ineffective." 5. A review of R5's medical record revealed a service plan (dated in June 2023) for personal care services. The service plan revealed R5 was independent in activities of daily living (ADLs) with a safety check twice a night. However, an updated service plan updated, within 14 calendar days after R5's psychiatric evaluation, was not available for review. 6. In an interview, E7 reported an updated service plan updated, within 14 calendar days after R5's psychiatric evaluation, was not available for review. 7. In an interview, E1 reported R5 was determined to not be appropriate to receive assisted living services. 8. In a joint interview, the findings were reviewed with E1, E7, E8, and E9, and no additional comments or statements were provided regarding the findings.”

“Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistance caregiver documented the action taken to prevent the accident, emergency, or injury from occurring in the future, for three of three residents who required medical services after an accident, emergency, or injury. The deficient practice posed a risk as the facility did not document preventative measures to protect the health and safety of residents. Findings include: 1. A review of facility documentation revealed an incident report (dated September 3, 2023). The report stated "Resident called for help and caregivers helped [R1] off the ground. Resident states [R1] lost [R1's] balance and fell backwards and his [R1's] head on the cement. ... called 911 and the paramedics took [R1] to .... Hospital." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 2. In an interview, E7 reported R1's fall was an isolated incident. E7 reported R1 was monitored for three days. 3. A review of facility documentation revealed an incident report (dated September 15, 2023). The report stated "Resident states [R2] was trying to get up and out of bed, [R2] lost [R2's] balance and hit [R2's] head on the table and wont [sic] stop bleeding ... Resident Taken to Hospital Y." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 4. In an interview, E9 reported R2 has been receiving physical therapy since before the fall on September 15, 2023. E9 reported this was the action taken to prevent the accident, emergency, or injury from occurring in the future because receiving physical therapy was preventive. 5. In an interview, E9 reported R2 continued to receive physical therapy after R2's fall. 6. A review of facility documentation revealed an incident report (dated August 31, 2023). The report stated "Resident was out of the facility and did not tell anyone of [R3's] where about [sic]. [R3's sibling] stated Resident was found unresponsive and slumped over in [R3's] electric wc [wheelchair] on the side of the road on 8/31/23 at approx. 1700. A good Samaritan called 911 and the paramedics took resident to the hospital. Residents core temp was at 108 upon arrival to the ER." However, documentation of any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review. 7. In an interview, E1 acknowledged actions taken to prevent the accident, emergency, or injury from occurring in the future were not documented. This deficiency was previously cited on March 23, 2023.”