Residences in the Hills LLC.

“A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;”

“Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. When the Compliance Officer arrived, E1 was working at the facility. 2. Staff schedules for the previous 12 months were requested for review at 1:00 PM. However, no staff schedules were available for review. 3. In an interview, E1 reported that E1 was the only personnel employed in the home and a staff schedule has not been updated or completed. E1 acknowledged that documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.”

“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 two of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. 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 R1's (accepted August 2024) medical record revealed documentation of R1's freedom from infectious tuberculosis. However, no assessment of risk of prior exposure to infectious tuberculosis or determination if R1 has signs or symptoms of tuberculosis were available for review. 3. A review of R2's (accepted July 2024) medical record revealed documentation of R2's freedom from infectious tuberculosis. However, no assessment of risk of prior exposure to infectious tuberculosis or determination if R2 has signs or symptoms of tuberculosis were available for review. 4. In an interview, E1 reported E1 understood only the test to be required to meet rule. E1 acknowleged R1 and R2 did not provide evidence of freedom from infectious tuberculosis.”

“B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and”

“E. 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 one of the following individuals: 1. The resident, 2. The resident's representative, 3. The resident's legal guardian, or 4. Another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual's behalf.”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative;”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: b. The manager;”

“Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services from November 2024. This service plan stated the following services were needed: -"Eating- Requires total care- Three times daily and as needed with snacks"; -"Oral Care- Requires total care- Twice daily and as needed"; -"Nail Care- Requires total care- Nails checked daily and trimmed as needed"; -"Hair Care- Requires total care- Daily and as needed"; -"Dressing- Requires total care- Twice Daily and as needed"; -"Bathing- Requires total care- twice weekly and as needed"; -"Toileting- Requires total care- Daily as needed"; and -"Transferring- Requires total care- Daily and as needed. However, documentation was not available indicating these services were provided. 2. During an interview, E1 acknowledged R2's medical records did not include documentation of services provided.”

“E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or”

“F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility;”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for two of two residents reviewed. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Review of R1's and R2's service plans for directed care services from November 2024 revealed that R1 and R2 received medication administration. 2. Compliance offer requested R1's and R2's medical record "complete with all required documents" at 1:00PM. 3. A medication administration record (MAR) was not available for R1 and R2, and no other documentation was available of the medication administered to R1 and R2. 4. In an interview, E1 reported that residents are receiving medication, and reported he administers medication per doctor's orders. E1 reported E1 is attempting to setup Synkwise for digital record keeping although has not been able. E1 acknowledged medication administered to R1 and R2 was not documented in R2's medical record.”

“C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and”

“B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility,”

“A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;”

“Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for one of two caregivers reviewed. The deficient practice posed a risk if the individual was not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. Review of E3's personnel record revealed that E3 was hired as a caregiver. 2. Review of the "Employee Work Schedule" for July 2024 reported that E3 worked alone on the following dates and times: -July 1 7am-7pm; -July 2 7am-7pm; -July 3 7am-7pm; -July 6 7am-7pm; -July 7 7am-7pm; -July 8 7am-7pm; -July 15 7am-7pm; and -July 29 7am-7pm. 3. Review of E3's personnel record revealed a caregiver training certificate from Platinum Training Services, LLC dated February 15, 2013 with the ALTP number listed as ALTP0176. However, this ALTP number was not associated with Platinum Training Services, LLC. No other documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers was available. In addition, E3's record did not include documentation showing an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 4. Review of the az.tmuniverse.com website revealed no documentation of a caregiver training certificate for E3. 5. During an interview, when the Compliance Officer pointed out that the certificate in E3's personnel record appeared to be invalid, E2 stated "I don't care."”

“Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E1 and E2 were working at the facility. 2. Review of the provided personnel schedule dated August 2024 revealed that it contained dates and the times of shifts, however, it did not contain the names or initials of staff. 3. Review of the provided personnel schedule dated July 2024 revealed that it contained dates and the times of shifts, however, it did not contain the names or initials of staff on the following days: -July 9-14; -July 16-21; -July 23-28; -July 30-31. 4. In an interview, E1 acknowledged that documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.”

“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 two of two residents sampled. 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 R1's (accepted in 2024) medical record revealed no documentation to indicate R1 provided evidence of freedom from infectious TB. Based on R1's date of admission, this documentation was required. 3. A review of R2's (accepted in 2024) medical record revealed no documentation to indicate R2 provided evidence of freedom from infectious TB. Based on R2's date of admission, this documentation was required. 4. In an interview, E1 reported having the documentation, however, it was not provided for review during 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 two of two residents reviewed. 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 2024) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 2. A review of R2's (admitted in 2024) medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged R1 and R2 did not provide documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.”

“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 documented residency agreement included the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed, for one of two residents reviewed. The deficient practice posed a risk if the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under A.R.S. \'a7 36-3221 was not informed of the terms of residency. Findings include: 1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed. Based on R1's acceptance date, this document was required to be signed. 2. During an interview, E2 stated "the Department should force people to come here and sign it." E1 and E2 acknowledged R1's residency agreement did not include the signature of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, and date signed.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of two residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's medical record revealed a written service plan for directed care services dated August 3, 2024. However, this service plan did not include a signature and date from the resident or representative. 2. Review of R2's medical record revealed a written service plan for directed care services dated August 3, 2024. However, this service plan did not include a signature and date from the resident or representative. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include a signature and date from the resident or representative.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for two of two residents reviewed. The deficient practice posed a health and safety risk if the manager did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's medical record revealed a written service plan for directed care services dated August 3, 2024. However, this service plan did not include a signature and date from the manager. 2. Review of R2's medical record revealed a written service plan for directed care services dated August 3, 2024. However, this service plan did not include a signature and date from the manager. 3. In an interview, E1 acknowledged R1's and R2's service plans did not contain a signature and date from the manager.”

“Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated August 3, 2024. This service plan stated the following services were needed: -"Oral Care- Requires total care- Twice daily and as needed"; -"Hair Care- Requires total care- Daily and as needed"; -"Dressing- Requires total care- Twice Daily and as needed"; -"Bathing- Requires total care- twice weekly and as needed"; and -"Toileting- Requires total care- Daily as needed". However, documentation was not available indicating these services were provided. 2. Review of R2's medical record revealed a current written service plan for directed care services dated August 3, 2024. This service plan stated the following services were needed: -"Oral Care- Requires assistance- Twice daily and as needed"; -"Hair Care- Requires total care- Daily and as needed"; -"Dressing- Requires total care- Daily as needed"; -"Bathing- Requires total care- 2-3 times weekly and as needed"; and -"Toileting- Requires total care- Daily as needed". However, documentation was not available indicating these services were provided. 3. During an interview, E1 acknowledged R1's and R2's medical records did not include documentation of services provided.”

“Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the facility tour with E1, the Compliance Officer observed R2's bedroom did not have a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies accessible to a resident in bed. 2. Review of R2's medical records revealed R2 received directed care services. 3. In an interview, E1 reported that the bell was in the room somewhere, but could not find it, and acknowledged the bell was not accessible to alert employees to a resident's needs or emergencies in a bedroom being used by a resident receiving directed care services.”

“Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the Compliance Officer observed a door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 3. In an interview, E1 and E2 reported the alarm does work, but it was switched off. E1 reported that the device was only switched on at night because it makes too much noise when people go out during the day. 4. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered. Findings include: 1. Review of R2's service plan for directed care services dated August 3, 2024 revealed that R2 received medication administration. 2. Review of R2's medical record revealed the following medication orders dated March 13, 2021: -"Simvastatin 10mg PO QHS"; -"Amlodopine 5mg tab, QHS PO hold for SYS”

“Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents. Findings include: 1. During the facility tour, the Compliance Officer observed the following in an unrefrigerated pantry: -An open bottle of "Sweet Baby Ray's Barbecue sauce"; -An open bottle of "Burman's Tomato Ketchup"; and -An open bottle of "Kroger Sugar Free Original Pancake Syrup". All of these containers stated "Refrigerate after opening". 2. During an interview, E2 acknowledged the foods were stored at room temperature and required refrigeration.”

“Based on record review and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if residents were unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's and R2's medical record revealed no documentation to indicate R1 and R2 were oriented to exits from the assisted living facility. 2. In an interview, E1 acknowledged that R1's and R2's medical records were missing several required documents.”

“Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During the facility tour with E1, the Compliance Officer observed the hot water temperature at 127.4\'b0 F from the faucet in the kitchen. 2. In an interview, E1 reported that it was not possible to keep the water used by residents below 120\'b0 F in the facility building. E1 acknowledged the hot water temperatures were not maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents.”