Brookdale East Mesa.

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of four employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population.   Findings include:   1. A.R.S. § 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..."   2. A review of E4’s personnel record revealed E4 worked as a caregiver and had a hire date of April 14, 2025. The personnel record revealed a fingerprint card issued on September 23, 2021. 3. A review of the Department of Public Safety (DPS) fingerprint clearance card database revealed E4's fingerprint clearance card was invalid.   4. In an interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that service plans were signed by a nurse or medical professional for three of five residents sampled.     Findings include:         1.  Record review established that R1, R3, and R4 all had service plans that were current and had not been signed by a nurse or medical professional. R1, R3, and R4 were all at the directed level of care. R1, R3, and R4 were all receiving medication administration at the time of the inspection.      2.  In an interview, E1 confirmed that R1, R3, and R4 all had service plans that were current and had not been signed by a nurse or medical professional.”

“Based on documentation review and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. \'a7 36-420.04, for one of one applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 31, 2024. The incident report revealed R1 exhibited aggressive behavior which resulted in the facility calling emergency medical services. 2. In an interview, the Compliance Officer requested a copy of the documentation provided to the emergency responders for R1. The Compliance Officer received a Face Sheet, a medication list, and a copy of R1's advance directives. However, the documentation did not include the following required information: -The reason or reasons the emergency responder was requested on behalf of R1; and -A copy of R1's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R1's discharge. 3. In an interview, E1 acknowledged the documentation provided to emergency medical services did not include all information required in A.R.S. \'a7 36-420.04.”

“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 one resident reviewed. 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 R5's medical record revealed written service plans dated December 18, 2023 and March 18, 2024. The service plans indicated R5 received medication administration. 2. A review of R5's medical record revealed a signed medication order dated October 13, 2023 for "Nayzilam 5 milligrams (MG)/0.1 milliliter (ML) Solution as directed nasally as needed [PRN] seizure cluster 30 days." 3. A review of R5's medical record revealed a January 2024 medication administration record (MAR). The MAR stated, "Nayzilam Nasal Solution 5 MG/0.1 ML (Midazolam (Anticonvulsant)) spray in nostril as needed for short term treatment of seizure clusters give one spray in one nostril for seizure cluster." The MAR indicated R5 did not receive the medication in January 2024. 4. A review of Department documentation revealed R5 experienced a seizure on January 17, 2024. 5. In an interview, E2 confirmed R5 did experience a seizure on January 17, 2024. E2 reported R5 did not receive the Nayzilam as prescribed as the staff did not know there was an order for the medication to be administered as needed if R5 experienced a seizure. 6. In an interview, E2 acknowledged R5's medication was not administered in compliance with the medication order. E2 reported the facility has since conducted a training on seizure protocol and the use of PRN medications. 7. This is a repeat deficiency from the compliance and complaint inspection conducted September 27, 2023.”