Reflections at Fellowship Square Mesa.

“Based on documentation review and interview, the manager failed to ensure that a policy and procedure were established and documented for inventorying controlled substances.  Findings include:  1. A review of the facility’s policies and procedures revealed a policy titled “Controlled Substance.” The policy contained sections on storing and dispensing controlled substances. The policy did not include inventorying controlled substances. 2. In an interview, E1 acknowledged that the policy did not include inventorying controlled substances.  3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of the four employees sampled. The deficient practice posed a potential 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) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used."  3. A review of E3's personnel record revealed E3’s hire date of July 24, 2023. In addition, the following was revealed:  No documentation of TB risk assessment.  No documentation of TB signs and screening.  4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of four 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 R3's medical record revealed the following:  No documentation of TB risk assessment.  No documentation of TB signs and screening.  Based on R3's admission date, this documentation was required. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review, documentation review, and interview, before or at the time of an individual's acceptance by an assisted living facility, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included the policy for refunding fees, charges, or deposits for three of four residents sampled. Findings include: 1.  A review of R1’s, R2's, and R3’s medical records revealed no policy for refunding fees, charges, or deposits in the residency agreement.  2.  In an interview, E4 acknowledged that there was no policy for refunding fees, charges, or deposits in the residency agreement.  3.  In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for four of four residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include:  1. A review of R1's medical record revealed a current written service plan dated September 10, 2025, which indicated R1 received directed care services. R1’s service plan did not include the frequency of assistance with dressing, bathing or showering, grooming, incontinence care, and medication administration. 2. A review of R2's medical record revealed a current written service plan dated October 9, 2025, which indicated R2 received directed care services. R2’s service plan did not include the frequency of assistance with dressing, bathing or showering, grooming, incontinence care, and medication administration. 3. A review of R3's medical record revealed a current written service plan dated October 9, 2025, which indicated R3 received directed care services. R3’s service plan did not include the frequency of assistance with dressing, bathing or showering, grooming, incontinence care, and medication administration. 4. A review of R4's medical record revealed a current written service plan dated November 6, 2023, which indicated R4 received directed care services. R4’s service plan did not include the frequency of assistance with dressing, bathing or showering, grooming, incontinence care, and medication administration. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included cognitive stimulation and activities to maximize functioning, for four of four residents sampled. Findings include:  1. A review of R1's medical record revealed a current written service plan dated September 10, 2025, which indicated R1 received directed care services. R1’s service plan did not include cognitive stimulation and activities to maximize functioning.  2. A review of R2's medical record revealed a current written service plan dated October 9, 2025, which indicated R2 received directed care services. R2’s service plan did not include cognitive stimulation and activities to maximize functioning.  3. A review of R3's medical record revealed a current written service plan dated October 9, 2025, which indicated R3 received directed care services. R3’s service plan did not include cognitive stimulation and activities to maximize functioning.  4. A review of R4's medical record revealed a current written service plan dated November 6, 2023, which indicated R4 received directed care services. R4’s service plan did not include cognitive stimulation and activities to maximize functioning.  5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“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 four 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 R2's medical record revealed a signed medication order, dated March 18, 2025, which included “Carvedilol 12.5 mg Tablet - Oral - 1 tablet - 2 times daily - HTN. Hold for SBP less than 100 or HR less than 60.” 2. A review of R2's medication administration records (MAR), for October - November 2025, revealed R2 was administered Carvedilol 12.5 mg on the following dates and times: October 1, 2025, at 8:00 am  October 2, 2025, at 8:00 am  October 6, 2025, at 8:00 pm  October 7, 2025, at 8:00 am and 8:00 pm  October 14, 2025, at 8:00 pm  October 15, 2025, at 8:00 am  October 22, 2025, at 8:00 am  October 29, 2025, at 8:00 am  October 30, 2025, at 8:00 pm  November 4, 2025, at 8:00 am  November 8, 2025, at 8:00 am  November 18, 2025, at 8:00 pm  However, R2's heart rate (HR) did not indicate administration of Carvedilol 12.5 mg. 3. In an interview, E4 acknowledged that the “Carvedilol 12.5 mg” was administered when it should have been held.  4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record for three of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's, R2's, R3's and R4's medical records revealed an April 2024 activities of daily living (ADL) document. This ADL document revealed R1, R2, R3 and R4 required 2 hour "Checks" to be completed along with "Bathroom and Wellness Checks". However, documentation revealed that these services were not performed at 12:00pm and 2:00pm on April 27, 2024. 2. Review of R4's ADL document revealed: -"Housekeeping Safety Sweeps" were required but were not marked as completed on April 27, 2024 at 2:00pm. -"Meal Log: Percentage of Snack/Beverage" was required but not marked as completed on April 27, 2024 at 2:00pm. -"Meal Log: Percentage of Meal Eaten" was required but not marked as completed on April 27, 2024 from 11:00am to 12:30pm. -"Meal Reminders/Escorts: Meals Reminders/Escorts" was required but not marked as completed on April 27, 2024 at 11:30am. -"Meals: Meals Provide Set And Heat Up Meals" was required but not marked as completed on April 27, 2024 at 11:00am. 3. Review of R2's ADL document revealed: -"Meal Log: Percentage Of Meal Eaten" was required but not marked as completed on April 27, 2024 at 11:00am to 12:30pm. -"Meal Log: Percentage Of Snack/Beverage" was required but not marked as completed on April 27, 2024 at 2:00pm. -"Meal Reminders/Escorts: Meals Reminders/Escorts" was required but not marked as completed on April 27, 2024 at 11:30am. -"Housekeeping Safety Safety Sweeps" was required but not marked as completed on April 27, 2024 at 2:00pm. 4. Review of R3's ADL document revealed: -"Housekeeping: Safety Sweeps" was required but not marked as completed on April 27, 2024 at 2:00pm. -"Meal Log: Percentage Of Meal Eaten" was required but not marked as completed on April 27, 2024 at 11:00am to 12:30pm. -"Meal Log: Percentage Of Snack/Beverage" was required but not marked as completed on April 27, 2024 at 2:00pm. -"Meal Reminders/Escorts: Meals Reminders/Escorts" was required but not marked as completed on April 27, 2024 at 11:30am. -"Meals: Meals Provide Set And Heat Up Meals" was required but not marked as completed on April 27, 2024 at 11:00am. 5. A review of R1's ADL document reveal: - "2 Hour Checks" was required but not marked as completed on April 27, 2024 at 12:00pm and 2pm. - "Bathroom and Wellness Checks" was required but not marked as completed on April 27, 2024 at 12:00pm and 2pm. 6. Documentation revealed a section of the facilities policies and procedures titled "Scope of Services". A subsection of this section included: -"Meals provided daily with assistance at mealtimes". - "Toileting assistance and incontinence care". 6. In an interview, E1 acknowledged that R1's, R2's, R3's, and R4's ADL documents did not include documentation of the above services and that R1, R2, R3 and R4 were at the directed level of care.”