Santorini Villas Assisted Living, LLC.

“J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (J)(1); and c. The report in subsection (J)(2); 4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.”

“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;”

“C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);”

“B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint;”

“C. A manager shall ensure that a resident's medical record contains: 11. Documentation of assisted living services provided to the resident;”

“C. A manager shall ensure that a resident's medical record contains: 18. Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B);”

“F. A manager of an assisted living home shall ensure that: 4. Except as provided in subsection (G): a. A smoke detector is: i. Installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer; ii. Either battery operated or, if hard-wired into the electrical system of the assisted living home, has a back-up battery; iii. In working order; and iv. Tested at least once a month; and”

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

“A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;”

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

“A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;”

“Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation, initiate an ivestigation of the suspected abuse, neglect, or exploitation, and maintain documentation including all requirements of this rule for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if a resident was not protected from abuse, neglect, or exploitation. Findings include: 1. In an interview, E1 reported being aware of an incident involving R1 on March 16, 2024. E1 stated the incident was not reported by the facility in compliance with A.R.S. \'a7 46-454. 2. A review of facility incident reports revealed a report created for the incident involving R1 on March 16, 2024. However, the report did not indicate the manager or any other employee reported the suspected abuse according to A.R.S. \'a7 46-454. 3. In an interview, E1 acknowledged the incident was not reported as required.”

“Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of four sampled caregivers. The deficient practice posed a risk if the employees were not qualified to provide the required services. Findings include: 1. In an interview, E1 reported E4 and E5 both worked at the facility as caregivers. 2. A review of facility personnel records revealed E4 was hired as a caregiver. However, E4's personnel record contained no documentation of completion of a caregiver training program approved by the NCIA Board. 3. A review of facility personnel records revealed no personnel record, including documentation of completion of a caregiver training program approved by the NCIA Board, was available for review for E5. 4. In an interview, E1 acknowledged there was no documentation available for review at the time of the survey to indicate E4 and E5 completed a caregiver training program approved by the NCIA Board. This is a repeat citation from the compliance inspection conducted on March 9, 2023.”

“Based on record review and interview, the manager failed to ensure a personnel record was established and maintained, for one of four sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility personnel records revealed no personnel record for E5 available for review. 2. In an interview, E1 acknowledged there was no personnel record for E5.”

“Based on documentation review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. A review of Department documentation revealed a reported incident on March 16, 2024. The documentation indicated R1 was restrained in R1's bed by E4. E4 reportedly placed two fall mats between R1's bed and a dresser and tied the mats to the bed with an oxygen cord. 3. A review of facility documentation revealed no documented report of the aforementioned incident. 4. In an interview, E1 and E6 acknowledged R1 was restrained in R1's bed by E4.”

“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 one of three sampled residents. 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 no documentation of assisted living services provided to R2. 2. In an interview, E1 acknowledged R2's medical record contained no documentation of any assisted living services provided to R2.”

“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 required in Arizona Administrative Code (A.A.C.) R9-10-818(B), for one of three sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation route to be used in an emergency. Findings include: 1. A.A.C. R9-10-818(B) states: "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, and 2. The resident's orientation is documented." 2. A review of R2's medical record revealed no documentation of R2's orientation to exits from the assisted living facility. Based on R2's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility. This is a repeat citation from the compliance inspection conducted on March 9, 2023.”

“Based on documentation review and interview, the manager failed to ensure required smoke detectors were tested at least once a month. The deficient practice posed a potential fire hazard. Findings include: 1. A review of facility documentation revealed no documentation to indicate the facility's smoke detectors were tested at least once a month. 2. In an interview, E2 reported smoke detectors were tested each month as required. E2 acknowledged documentation of the testing was not available for review at the time of the survey.”