Quail Park of Oro Valley.

“Based on record review and interview, for three of six sampled residents, the assisted living home failed to maintain a standardized form for each resident which included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. The deficient practice posed a risk if staff were unable to relay critical information to emergency responders in a timely manner. Findings include: A review of R1's medical record revealed an emergency responder document was available for review and included all required sections. However, the HIPAA release required by A.R.S. § 36-420.04(A)(8) was for a different assisted living facility and allowed only assessment information to be released. A review of R2's medical record revealed an emergency responder document was available for review. However, a HIPAA release required by A.R.S. § 36-420.04(A)(8) was not included with the emergency responder form and was not available for review. A review of R3's medical record revealed an emergency responder document was available for review and included all required sections. However, the HIPAA release required by A.R.S. § 36-420.04(A)(8) did not allow discharge information to be released. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the assisted living center failed to maintain a copy of documentation provided to an emergency responder for two years after the date of an emergency, for three of three sampled residents for whom an emergency responder had been contacted on their behalf by the facility. ARS 36-420.04(A-B) states: "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives. B. The assisted living center or assisted living home must notify the resident's authorized representative that the resident was transported to a hospital and provide the name and location of the hospital." Findings include: A review of R3's medical record revealed emergency responders had been called on R3's behalf on February 23, 2026. However, a copy of the document provided to the emergency responders was not available for review. A review of R4's medical record revealed emergency responders had been called on R4's behalf on March 15, 2026. However, a copy of the document provided to the emergency responders was not available for review. A review of R5's medical record revealed emergency responders had been called on R5's behalf on March 9, 2026. However, a copy of the document provided to the emergency responders was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan was updated no later than 14 calendar days after a significant change in the resident's functional condition, for one of six sampled residents. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: A review of R3's medical record revealed an incident report, dated February 28, 2026. The incident report stated, "The med tech was doing medication administration, the resident took all [R3's] pills at once as [R3] always does, shortly after the resident started to choke. It was observed the resident's face started to turn red and could not cough up what [R3] was choking on, the care staff had to perform the Heimlich on the resident. The care staff was able to dislodge the pill from the resident airway. After a few moments of the resident coughing and catching [R3's] breath, the med tech took the resident vitals, took B/P 3x times and got an error, then on the 4th B/P 206/107 Pulse: 79, O2: 98, Temp 97.1, after a few moments retook B/P: 187/100 at 8:59 AM and then 175/96 at 9 AM. The med tech called MCD at 8:58 AM to inform her of the incident and called POA at 8:45 AM (sic) to inform [POA] of the incident, stated if O2 was good and [R3] is talking no EMS needed. The med tech will administer pills one by one on the next pass to ensure this incident does not happen again." A review of R3's medical record revealed a service plan, last updated February 22, 2026, for directed care services including medication administration. However, the service plan did not include the strategy of administering pills one at a time to prevent choking, and had not been updated within 14 calendar days after February 28, 2026. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 14, 2023.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record for one of six sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan, and false or misleading information was provided to the Department. Findings include: A review of R4's medical record revealed a service plan, dated February 12, 2026, for personal care services, which detailed the services the facility would provide to R4, including: "Bathing: [R4] requires 1 person assistance for bathing/showering twice weekly; minimal assistance with transfers in/out with CG steadying, for safety r/t generalized weakness;" "Safety Checks: Care associates will observe [R4] every 4 hours for safety/needs..." "Fall Prevention: MONITORING: Remind [R4] to use assistive devices appropriately as needed, monitor for signs of depression...observe/cue orientation, supervise behaviors, provide supportive environment, Observe/report [R4's] ability to cope with personal loss/trauma r/t medical condition. Daily supervision of mediation as per provider orders r/t ETOH." A review of R4's medical record revealed a progress note, dated March 15, 2026, at 22:49, which stated, "At appx 1100, the resident had called for assistance...staff observed the resident laying face down on the floor....EMS was called... Vitals were out of parameter according to EMS and [R4] was transported to [an area hospital]." A review of R4's medical record revealed a progress note, dated March 19, 2026, at 08:26, which stated, "3/18/26 1700: Returned to community from [an area hospital], accompanied by [a representative.] Awake, alert, oriented, and wearing the cervical collar...." A review of R4's medical record revealed a document titled "Documentation Survey Report v2," (ADL) dated March 2026. The ADL documented the services provided to R4 during the month of March 2026 and included the following entries: For the service "Bathing" on March 17, 2026, at 20:46, the service was marked: "Shower Completed: 1 - Yes." However, R4 was at the hospital on this day and a bath could not have been provided as indicated. For the service "Assurance Checks: Observe [R4] for safety/needs every 4 hours," the task had been marked as completed on March 16 at 17:45 and 20:45, and on March 17 at 20:45. However, R4 was at the hospital and these safety checks could not have been performed as indicated. For the service "Monitoring: Remind [R4] to use assistive device...," the task had been marked as completed on March 16, at 21:31 and on March 17 at 01:53. However, R4 was at the hospital and monitoring could not have been performed as indicated. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 14, 2023, the on-site compliance and complaint inspection conducted on March 1, 2024, the on-site compliance and complaint inspection conducted on April 15, 2025, the on-site complaint inspection conducted on August 8, 2025, and the on-site complaint inspection conducted on January 6, 2026.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. Findings include: A review of R1's medical record revealed a service plan, dated February 7, 2026, for directed care services. The service plan indicated R1 was "an elopement risk r/t dementia, but does not wander." A review of the facility's policies and procedures revealed a policy titled "Elopement Policy - Assessing Risk, Drills, and Handling an Elopement," last revised November 29, 2023. This policy stated: "Memory care residents need not be assessed as they have already been determined to be appropriate for a secured area. Residents should be monitored for exit-seeking behaviors and additional interventions should be implemented, as well as updating the Individual Service Plan." "The community will verify that alarmed exit doors are working properly each shift..." "Routine checks should be documented on the nursing Medication Administration Record (MAR) or the Task Administration Record (TAR) and nursing will sign off on placement and functionality each shift." A review of the facility's policies and procedures revealed a policy titled "Preventing unsafe wandering or exit seeking Arizona only." This policy stated: "Never provide alarm or secure entry codes to family members, visitors, or others. Only associates should have access to alarm/entry codes. Codes should be monitored and changed as necessary." A review of the facility's policies and procedures revealed a policy titled "Systems to Accommodate Visitors, Associates, and Residents Who do not require controlled egress Arizona Only." This policy stated: "Communities who do not use Wanderguard, accommodate visitors and resident who do not require Directed Level Care in and out of the secured neighborhood by escorting visitors and residents through the secured doors." "Associated are trained to enter and exit secured neighborhoods with provided access via assigned entry code or fob with an awareness of securing entry for residents who reside in a secured neighborhood." A review of facility documentation revealed an incident report dated January 31, 2026. The incident report stated, "On Saturday, January 31, 2026, at approximately 1315, while case associates were completing assurance checks, care associates became aware that resident [R1] was not in the anticipated location. [R1] was observed at lunch and was escorted to [R1's] room at approximately 12:25 pm....While care associates were attempting to locate the resident, it was noted that an alarm was not functioning as expected. At the time of the incident, the community was experiencing increased traffic related to another resident moving out. The main egress door was open intermittently to accommodate move-out activity, resulting in higher-than-usual foot traffic in the area. The resident was located...at approximately 1400... .3 miles from the facility.... EMS was called to complete a wellness assessment.... R1 was discharged from [an area hospital] and returned to the community at approximately 1930, no resulting injuries or changes in cognition noted. Resident was discharged with a diagnosis of dehydration....E4 was notified at 1448 of the elopement and presented to the community at 1548 to assess the status of the alarm that was observed to not be functioning as expected....All systems were validated as operational." A review of facility alarm records revealed two main-egress alarms at 12:21 PM and 12:47 PM. However, during a telephonic interview with E4, both alarms were found to be evidence of system functionality, and because both alarms were cleared in 0.1 minutes, they indicated a person who knew and entered the correct door code was present at the door at the time of the alarm. In an interview, E1 reported the exact method and route of egress by R1 was still undetermined. In an interview, E3 reported additional safeguards to prevent the most likely scenarios were being considered, such as additional checks or systems to fully ensure every member of a group leaving the secured area is a visitor. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for two of five 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 R3's medical record revealed a service plan, dated September 19, 2025, for personal care services, which detailed the services the facility would provide to R3, including: - “Focus: Safety checks – assurance checks will be completed every 4 hours for safety related to fall risk. Desired outcome: [R3] general and specific whereabouts and well being will be verified. Actions/Support Actions: Assurance checks will be completed every 4 hours for safety related to fall risk.” 2. A review of R3's medical record revealed a document titled "Documentation Survey Report v2," dated November 2025. The report documented the services provided to R3 on each day in November 2025. The report documented the following: • “Assurance Checks: Assurance checks will be completed every 4 hours for safety related to fall risk” were scheduled on the “Day (6a-2p)…” shift and the “Evening (2p-10p)…” shift and had been marked as completed one time per shift.  However, documentation of assurance checks on the overnight shift were not available for review. 3. A review of R5’s medical record revealed a service plan, dated May 19, 2025, for personal care services, which detailed the services the facility would provide to R5, including: - “Socialization…Care associated will remind/encourage/supervise attending social events for cognitive and social stimulation”; - “Continence: Care associate will remind resident to go to bath room as needed….”; - “Bathing: Care associates will check skin with bath/shower and report any open areas, bruises, injuries, or signs of infection for example, swelling redness, pain , odor, pus like drainage to nurse. Care associated will provide set up bathing supplies per resident bathing schedule. Care associates will provide stand by assistance for safety during shower”; - “Eating/Meals/Hydration: Care associates will cue resident for meals and encourage independence in dining. Eating: The resident requires assistance for eating, reminding to go to meals.”; - “Level of awareness: Care associate to take resident for a walk.”; - “Vision: Ensure glasses are on and that the glasses are clean.”; - “Hearing: Care associates will remind resident to wear hearing aid(s).”; - “Care associate will provide laundry services 2 times weekly with showers.”; - “Dentures: Care associate will provide assistance with the resident’s dentures including cleaning and storing each morning, each evening, and as needed.”; and - “Assurance Checks: observe resident for safety/needs one time per shift.” 4. A review of R5’s medical record revealed a service plan, dated July 24, 2025, for directed care services, which detailed the services the facility would provide to R5, including: - “Vision: Care associate will monitor if glasses are clean, intact and in good working order.  Ensure glasses are on and that the glasses are clean.” 5. A review of R5’s medical record revealed a document titled “Documentation Survey Report v2,” dated June 2025. The report documented the services provided to R5 on each day in June 2025. However, the report documented the following: - The report did not include documentation of assisting R5 with socialization or walks; - The report did not include documentation of assisting R5 with R5’s glasses; and - The report did not include documentation of assisting R5 with R5’s hearing aids. 6. A review of R5’s medical record revealed a document titled “Documentation Survey Report v2,” dated July 2025. The report documented the services provided to R5 on each day in July 2025. However, the report documented the following: - The report did not include documentation of assisting R5 with socialization or walks; - The report did not include documentation of assisting R5 with R5’s glasses;  - The report did not include documentation of assisting R5 with R5’s hearing aids between July 1, 2025 and July 23, 2025; and - The report did not include documentation of any services provided to R5 between July 12, 2025 and July 23, 2025 except the provision of snacks, which were provided on every day in July 2025. 7. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025, and the on-site complaint inspection conducted on August 8, 2025.”

“Based on record review, documentation review, and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed potential dangers to residents who were unsupervised. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 6, 2025, for directed care services. The service plan included the following services: "strategies to ensure personal safety include frequent rounds for awareness of the resident's general or specific whereabouts and instruction on utilizing call pendant as appropriate...," and, "Mid-Day preferences...After lunch, prefers to rest and enjoys sitting outside and watching birds." 2. A review of the facility's policies and procedures revealed a policy titled, "General or Specific Whereabouts of Residents - AZ Only," last revised February 14, 2024, which stated, "...memory care residents need not be assessed for elopement risk as they have already been determined to be appropriate for a secured area...Associates should continuously monitor residents for knowledge of their general or specific whereabouts and exit-seeking strategies." 3. A review of facility incident reports revealed an incident report dated August 5, 2025 at 02:45. The incident report stated, "staff doing rounds and safety checks, observe [R1] is not in [R1's] room, staff located [R1] sitting outside by the patio. Observe [R1's] arms are red, [R1's] head and [R1's] back. staff escorted [R1] inside, checked vitals...[R1] is able to verbalize [R1] is not in pain..." and, "Immediate Action Taken: First aid provided, staff hydrated [R1] with lots of fluids intake, applied cold wash cloth on [R1's] head, back and [R1's] arms..." 4. A review of R1's medical record revealed a progress note, dated August 6, 2025 at 22:04. The progress note stated, "...hospice nursing on site to assess wounds as well. The blisters are thought to be related to [R1] receiving prolonged sun exposure on the 5th. The blisters were discovered on the 6th in the AM. Please note that per [E9], that [R1] may have a medical condition known at bulbous pemphigoid. It was noted in [R1's] admission H and P notes, although was never transcribed to [R1's] Watermark EMR...." 5. A review of R1's medical record revealed a progress note, dated August 7, 2025 at 11:07. The progress note stated, "...[E3] accompanied [Hospice nurse] to assess [R1]. [Hospice nurse] removed bandages, assessed, measured and documented wound. [Hospice Nurse] observed that the previous blisters were now open wounds. [E3] and [Hospice nurse] discussed the change in condition..." 6. In an interview, E2 reported the doors to the patio area from the memory care dining room are alarmed and were found to be functioning, however, E2 acknowledged the incident report indicated the memory care staff were not aware R1 was outside. E2 reported based on interviews with staff regarding when R1 left their room and ate, R1 was not outside more than 30 minutes. E2 reported the facility has now locked the patio doors based on the time of day and outside temperature. 7. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program or documentation of employment as a manager or caregiver of an unclassified residential care institution or adult foster care home before November 1, 1998, for one of four sampled caregivers. The deficient practice posed a risk if an individual was not qualified to provide the required services. R9-10-806.A.1.a-b states: A. A manager shall ensure that:: 1. A caregiver: a. Is 18 years of age or older; and 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; ii. For supervisory care services, employment as a manager or caregiver of a supervisory care home before November 1, 1998; iii. For supervisory care services or personal care services, employment as a manager or caregiver of a supportive residential living center before November 1, 1998; or iv. For supervisory care services, personal care services, or directed services, one of the following: (1) A nursing care institution administrator’s license issued by the Board of Examiners; (2) A nurse’s license issued to the individual under A.R.S. Title 32, Chapter 15; (3) Documentation of employment as a manager or caregiver of an unclassified residential care institution before November 1, 1998; or (4) Documentation of sponsorship of or employment as a caregiver in an adult foster care home before November 1, 1998; Findings include: 1. A review of E5's personnel record revealed E5 had been hired as a caregiver on April 18, 2025. 2. A review of E5's personnel record revealed a caregiver certificate issued by "ALTP0019" on September 19, 1996. 3. A review of E5's personnel record revealed documentation of verification of E5's caregiver certificate, which stated ALTP0019 had been an authorized caregiver training program starting on February 10, 1999, and ending on August 2, 2013. 4. A review of E5's personnel record revealed a work history which covered employment between January 2013 and April 2025. 5. A review of E5's personnel record revealed a caregiver certificate issued by an approved training program or documentation of employment as a manager or caregiver of an unclassified residential care institution or adult foster care home, before November 1, 1998, was not available for review. 6. In an exit interview with E1, E2, E3, E4, the findings were reviewed and no additional information as provided.”

“Based on record review and interview, the manager failed to ensure, for one of four sampled residents, a service plan included the level of service the resident was expected to receive. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 30, 2025. However, the service plan did not state the level of care R2 was expected to receive. 2. In an interview, E3 reported R2 was in the memory care unit and received directed care services. 3. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan, when initially developed and when updated, was signed by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of four sampled residents. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R4's medical record revealed a service plan, updated June 25, 2025, and printed during the on-site inspection. However, the service plan did not include any signatures. 2. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025, and from the on-site monitoring inspection conducted on July 6, 2025.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for one of four sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan, and false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 6, 2025, for directed care services, which detailed the services the facility would provide to R1.. 2. A review of R1's medical record revealed a progress note, dated August 6, 2025 at 9:51 PM. The progress note stated R1 was sent to the hospital on August 6, 2025 at 21:15 (9:15 PM). 3. A review of R1's medical record revealed a progress note, dated August 7, 2025 at 12:35 PM. The progress note stated R1 returned to the facility at 8:55 AM. 4. A review of R1's medical record revealed a document titled, "Documentation Survey Report v2," (ADL) dated August 2025. The ADL documented the services provided to R1 on each day in August 2025. The ADL documented the following: On August 6, 2025 at 23:33 (11:33 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist resident to/from bathroom per schedule. Assist with hygiene and incontinence supplies." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 6, 2025 at 23:35 (11:35 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist to/from bathroom 1 Naya to assist [R1] with toileting task. Report increasing difficulty with toileting task to MCD and RCD." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 6, 2025 at 23:36 (11:36 PM), a caregiver on the 2200-0600 shift documented providing R1 with, "Continence: Assist with continence supplies." However, this entry was false or misleading, as R1 was at the hospital during this time period; On August 7, 2025 at 00:01 (12:01 AM), a caregiver on the 2200-0600 shift documented providing R1 with, "Assurance Checks: Observe resident for safety/needs every 4 hours." However, this entry was false or misleading, as R1 was at the hospital during this time period; and On August 7, 2025 at 04:03 (4:03 AM), a caregiver on the 2200-0600 shift documented providing R1 with, "Assurance Checks: Observe resident for safety/needs every 4 hours." However, this entry was false or misleading, as R1 was at the hospital during this time period. 5. In an exit interview with E1, E2, E3, E4, the findings were reviewed and no additional information as provided. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025.”

“Based on record review and interview, for one of four sampled residents, the manager failed to ensure a service plan for a resident receiving directed care services included documentation of the resident's weight and of coordination of communications with the resident’s representative, family members, and, if applicable, other individuals identified in the resident’s service plan. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 30, 2025. However, the service plan did not state R2's level of care and did not include documentation of R2's weight or coordination of communications with R2's responsible party and family members. 2. In an interview, E3 reported R2 was in the memory care unit and receiving directed care services. 3. In an exit interview with E1, E2, E3, and E4, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for three of nine residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a current service plan, signed by a nurse. However, the service plan had not been signed by the resident or resident's representative, or the manager. 2. A review of R2’s, R6's, and R7’s medical records revealed each resident had a current service plan. However, for each resident, the service plans provided for review did not include any signatures.  3. In an interview, E1, E2, E3, and E4 acknowledged the service plans provided for R1, R2, R6, and R7 were not signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan. This is an uncorrected deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of nine residents sampled receiving medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order, and if false or misleading information was provided to the Department.   Findings include:   1. A review of R6's medical record revealed a signed medication order dated May 16, 2025. The medication order stated the following:  “Add: Lomotil 2.5MG capsule Take 1 tablet by mouth four times daily until diarrhea subsides Depakote 125MG capsule sprinkles Take 2 capsule by mouth two times daily Discontinue: Depakote 125MG capsule sprinkles Take 1 capsule by mouth twice daily." 2. A review of R6's medical record revealed a verbal order, dated May 26, 2025, signed by a registered nurse, which stated, "Routine Visit. Switched Lomotil to PRN now that diarrhea has subsided."    3. A review of R6's medical record revealed a medication administration record (MAR), dated May 2025, which included the following: - Lomotil had been marked as administered at 0700, 1100, 1600 and 1900 starting at 1900 on May 16, 2025 through 0700 on May 23, 2025. - Lomotil had been held with the code, "9" (See nurses note) starting at 1100 on May 23, 2025 through 1900 on May 24, 2025; - Lomotil had been marked as administered at 0700 on May 25, 2025; - Lomotil had been held with the code, "9" at 1100 on May 25, 2025; - Lomotil had been marked as administered starting at 1600 on May 25, 2025 through 1900 on May 26, 2025; - Lomotil had been held with the code, "9" at 0700 and 1100 on May 27, 2025' - Lomotil had been marked as administered starting at 1600 on May 27, 2026 through 0700 on May 28, 2025; - Lomotil had been marked held with the code, "9" starting at 1100 on May 28, 2025 through 1100 on May 30, 2025; and - Lomotil had been marked as administered starting at 1600 on May 30, 3025 through 1900 on May 31, 2025. 4. A review of R6's medical record revealed medication hold notes as follows: - On May 23, 2025 at 10:20, Lomotil was held with the note, "The resident has not had diarrhea in the last 2 days"; - On May 24, 2025 at 07:29, Lomotil was held with the note, "Resident has not had loose bm in 2 days"; and - On May 24, 2025 at 12:06, Lomotil was held with the note, "Resident has not had loose bm in 3 days." 5. A review of R6's medical record revealed a controlled substance log for Lomotil. The controlled substance log indicated on May 30, 2025, one tablet had been signed out at 4:00 PM. However, the MAR indicated the medication had been administered at 1600 and 1900 on May 30, 2025, indicating the MAR was false and misleading for the 05/30/2025 entry at 1900. 6. A review of R6's medical record revealed a medication administration record (MAR), dated June 2025, which included the following: - Lomotil had been marked as administered at 0700, 1100, 1600 and 1900 starting at 0700 on June 1, 2025 through 0700 on June 2, 2025. - Lomotil had been held with the code, "9" (See nurses note) at 1100 on June 2, 2025; - Lomotil had been marked as administered starting at 1600 on June 2, 2025 through 1100 on June 3, 2025; - Lomotil had been held with the code, "9" starting at 1600 on June 3, 2025 through 1100 on June 4, 2025; - Lomotil had been marked as administered on June 4, 2025 at 1600 and at 1900; - Lomotil had been held with the code, "9" on June 5, 2025 at 0700 and 1100; - Lomotil had been held with the code, "5" on June 5, 2025 at 1600; - Lomotil had not left blank on the MAR on June 5, 2025 at 1900; and - Lomotil had been held with the code, "9" at 0700 and 1100 on June 6, 2025. 7. A review of R6's medical record revealed a controlled substance log for Lomotil. The log indicated the last tablet was signed out on June 3, 2025. However, the MAR indicated the medication had been administered on June 4, 2025 at 1600 and 1900, indicating the MAR was false or misleading for both entries. 8. In an interview, E1, E2, E3, and E4 acknowledged the medication administered to R6 had not been accurately documented in the provided records. This is an uncorrected deficiency from the on-site compliance and complaint inspection conducted on April 15, 2025.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of seven personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.      A.R.S. § 36-411 states:   "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.   B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.   C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to:   1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.   2. Verify the current status of a person's fingerprint clearance card.   3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee.   4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee.   5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459.   D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.   E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.   F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.   G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.   H. For the purposes of this section:   1. "Direct supportive services":   (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:   (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.   (ii) Assistance with self-administration of medication.   (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.   (iv) Transportation services, including van services.   (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.   2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.   3. "Home health services" has the same meaning prescribed in section 36-151."     Findings include:   1. A review of E5’s personnel record revealed E5 worked for a staffing agency at the facility as a caregiver starting in July 2024.   2. A review of E5’s personnel record revealed documentation of verification E5 was not on the Adult Protective Services (APS) registry prior to E5’s employment was not available for review. E5’s personnel record contained an APS registry check, however, the first and last names had been switched in the registry search, and E5’s last name had been misspelled.   3. A review of E6’s personnel record revealed E6 worked for a staffing agency at the facility as a caregiver starting in August 2024.   4. A review of E6’s personnel record revealed documentation of verification E6 was not on the Adult Protective Services (APS) registry prior to E6’s employment was not available for review. E6’s personnel record contained an APS registry check, however, the first and last names had been switched in the registry search.   5. A review of E6’s personnel record revealed a fingerprint clearance card issued on April 19, 2023. However, an employment record was not available for review. Documentation of E6’s employment between April 19, 2023 and August 2024 was not available for review, a time period of more than six months during which E6 was not documented to have been employed by any employer.   6. a review of E6’s personnel record revealed two forms titled, “Applicant Reference Check.” However, both forms were marked as personal references and the person contacted was listed as a friend.  Documentation of good faith efforts to contact E6’s prior employers was not available for review.   7. A review of E7’s personnel record revealed E7 had been hired as a caregiver in April 2025.   8. A review of E7’s personnel record revealed a fingerprint clearance card issued on May 21, 2021.   9. A review of E7’s personnel record revealed an employment record extending back past the date E7’s fingerprint clearance card had been issued. However, E7’s employment record indicated E7 had been unemployed between November 2021 and February 2023, a time period of more than six months during which E7 was not documented to have been employed by any employer.   10. A review of E9’s personnel record revealed E9 had been hired as a caregiver in November 2024.   11. A review of E9’s personnel record revealed a fingerprint clearance card issued on October 25, 2021.   12. A review of E9’s personnel record revealed an employment record extending back past the date E9’s fingerprint clearance card had been issued. However, E9’s employment record indicated E9 had been unemployed between April 2024 and E9’s hire date, a time period of more than six months during which E9 was not documented to have been employed by any employer.   13. In an interview, E1, E2, E3, and E4 acknowledged the personnel records provided for E5, E6, E7 and E9 did not include documentation of compliance with all sections of ARS § 36-411. This is a repeat deficiency from the on-site complaint inspection conducted on September 14, 2022, the on-site compliance inspection conducted on March 14, 2023, and from the on-site compliance and complaint inspection on March 1, 2024.”

“Based on record review and interview, the manager accepted an individual who required continuous nursing services. Findings include: A review of R4's medical record revealed a form titled, "Determination for Admission, AZ Only." The form had been signed and dated by a medical provider four days prior to R4's date of acceptance. This form stated, "2. Does this person require continuous nursing service? (i.e. skilled nursing, RN/LPN 24/7)," and had been marked, "Yes." In an interview, E2 reported R4 had not required continuous nursing services and R4's medical provider had not completed the form accurately prior to R4's acceptance. In an interview, E1, E2, E3, and E4 acknowledged the form, required per R9-10-807.B, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, had indicated R4 did require continuous nursing services at the time of acceptance, however, the facility had accepted R4 anyway, as they did not agree with this assessment.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for three of seven residents sampled. Findings include: 1. A review of R2’s, R3's, and R5’s medical records revealed each resident had a current service plan. However, for each resident, the service plans provided for review did not include any signatures.  2. In an interview, E1, E2, E3, and E4 acknowledged the service plans provided for R2, R3, and R5 were not signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for four of seven 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, and R7’s medical records revealed each resident had a current service plan describing the services which would be provided to each resident.   2. A review of R1’s, R2’s, and R3’s medical records revealed electronic documentation titled, “Documentation Survey Report,” (ADL) which documented the services provided to each resident on each day in March 2025 and April 2025. However, the ADLs included multiple gaps and omissions, for each resident, where required services had not been documented to have been provided.   3. A review of R7’s medical record revealed ADL’s dated December 2024 and January 2025 documenting the services provided to R7. However, the ADLs included multiple gaps and omissions, where required services had not been documented to have been provided.   4.   In an interview, E1, E2, E3, and E4 acknowledged the services provided to each resident had not been accurately documented on the provided ADL forms.   This is a repeat deficiency from the on-site complaint inspection conducted on March 3, 2022, the on-site compliance inspection conducted on March 14, 2023, and the on-site compliance and complaint inspection conducted on March 1, 2024.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to a resident, for one of seven sampled residents. Findings include: A review of R6's medical record revealed a medication administration record (MAR) dated November 2024. The MAR indicated R6 was being administered the following medications, 'Lactulose, Haloperidol, Lorazepam, and Morphine. A review of R6's medical record revealed medication orders were not available for review. In an interview, E1, E2, E3 and E4 acknowledged the medical record provided for R6 had not included medical records.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of seven residents sampled receiving medication administration.   Findings include:   1. A review of R2's medical record revealed a signed medication order dated April 9, 2025. The medication order stated the following:  “Add: Lorazepam 1MG tablet, Take 1 tablet by mouth three times daily scheduled and every 4 hours as needed Discontinue: Lorazepam 0.5MG Tablet, Take one tablet by mouth three times a day Lorazepam 0.5 MG Tablet, Take one tablet by mouth every 6 hours as needed.”    2. A review of R2's medical record revealed a medication administration record (MAR), dated April 2025, which included the following: - “Lorazepam, 0.5MG Tablet…three times daily” had been marked as administered on April 9, 2025 at 0700, 1300, and 1900; - “Lorazepam, 1.0MG Tablet,” had been marked as administered on April 9, 2025 at 1600; - “Lorazepam, 0.5MG Tablet,” had been marked as administered on April 10, 2025 at 1900; - “Lorazepam, 1.0MG Tablet,” had been marked as administered on April 10, 2025 at 0700, 1100, and 1600; - “Lorazepam 0.5 MG tablet…every 6 hours as needed,” had not been administered in April 2025; and - “Lorazepam 1.0 MG tablet…every 4 hours as needed,” had not been administered in April 2025;   3. A review of R2’s medical record revealed a document titled, “Controlled Substance Declining Inventory record,” for the medication, “Lorazepam 0.5 MG.” The log documented the following: - On 04/09/2025 at 0923, 1 dose was given; - On 04/09/2025 at 1245, 1 dose was given; - On 04/09/2025 at 1725, 1 dose was given; - On 04/09/2025 at 2004, 1 dose was given; and - On 04/10/2025 at 7 AM, 1 dose was given.   4. A review of R2’s medical record revealed a “Controlled Substance Declining Inventory Record,” for the medication, “Lorazepam 1.0MG.” The log documented the following: - On 04/09/2025, no entries had been made; - On 04/10/2025 at 758 [AM], 1 amount was given; - On 04/10/2025 at 334 [AM], 1 amount was given; - On 04/11/2025 at 1134, 1 amount was given., however, an original mark in the date field had been obscured and was not legible.   5. A review of R5’s medical record revealed a MAR, dated March 2025, which revealed the following: - On March 7, 2025 at 1300, “Aspirin 81 MG, co Q10 50 MG Softgel, Fish Oil 1200MG Softgel, Folic Acid 1 MG tablet, and L-Lysine 500Mg tablet had been left blank; and - On March 15, 2025 at 1900, “Diflunisal 500 MG, Donepezil HCL 5 MG, and Gabapentin 300 MG had been left blank.   6. In an interview, E1, E2, E3, and E4 acknowledged the medication administered to R2 and R5 had not been accurately documented in the provided records.”

“Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.      Findings include:     1.     During an environmental inspection of the facility, in R3’s bedroom, the compliance officer observed a hygiene supply drawer in the attached bathroom had a lock, however, the lock appeared loose and the Compliance Officer was able to open the cabinet without the key. Inside the drawer, the Compliance Officer observed a tube of Diclofenac Gel. 2.    During an environmental inspection of the facility, in R5’s bedroom, the compliance officer observed a medicine cabinet in the attached bathroom did not have a lock. Inside the cabinet, the Compliance officer observed containers of “Acyclovir,” and “Acetaminophen.” 3.    A review of R3’s medical record revealed a service plan for directed care services including medication administration for all medications. 4.    A review of R5’s medical record revealed a service plan for personal care services including medication administration for all medications. 5.    In an interview, E1, E2, E3, and E4 acknowledged medications stored by the assisted living facility had not been stored in a separate locked area.”

“Based on record review, document review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services for one of seven personnel sampled. The deficient practice posed a health and safety risk to residents if E5 was unable to meet the needs of residents. Findings include: 1. A review of E5's personnel record (hire date 2024) revealed no documented evidence E5's skills and knowledge were observed and verified before E5 provided physical health services. 2. In an interview, E1 acknowledged E5 had worked regular shifts as a caregiver since there date of hire. E1 agreed verification of E5's skills and knowledge prior to providing physical health services had not been documented.”

“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 and documented in the resident's medical record. 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 service plan which indicated R1 received medication administration. Further review revealed a medication order, dated June 11, 2024, for "Torsemide 20 mg tablet, take 1 tablet by oral route once daily." A review of R1's medication administration record (MAR) for July 2024 revealed evidence of documentation indicating R1 was being administered "Torsemide 20 mg tablet" twice daily at 8:00 a.m. and 7:00 p.m. 2. In an interview, E1 acknowledged R1 acknowledged R1 was not being administered medication as ordered.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for six of seven caregivers sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. A.R.S. \'a7 36-411 states, "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service. E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked. F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card. G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety. H. For the purposes of this section: 1. "Direct supportive services": (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including: (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair. (ii) Assistance with self-administration of medication. (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room. (iv) Transportation services, including van services. (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution. 2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised. 3. "Home health services" has the same meaning prescribed in section 36-151." Findings include: 1. A review of E3's personnel record revealed E3 had been hired as a housekeeper more than 20 working days prior to the on-site inspection. However, E3's personnel record did not include documentation E3 had a fingerprint clearance card or had applied for a fingerprint clearance card within 20 working days of employment. 2. A review of E4's personnel record revealed E4 had been hired as an assistant caregiver in November of 2023. E4's personnel record contained an employment record listing multiple previous employers. However, E4's personnel record contained documented, good faith attempts to contact only one previous employer. 3. A review of E5's personnel record revealed E5 had been hired as a caregiver in July of 2023. E5's personnel record contained an employment record listing multiple previous employers. However E5's personnel record contained documented, good faith, efforts to contact only one previous employer. A second documented reference check indicated the person spoken to was a peer, not an employer. 4. A review of E6's personnel record revealed E6 had been hired as a caregiver in November of 2023. E6's personal record contained an employment record listing multiple previous employers. However, E5's personnel record did not contain documented, good faith, efforts to contact previous employers. All documented reference checks indicated the person spoken to was a peer, not an employer. 5. A review of E8's personnel record revealed E8 has been hired as a caregiver in December of 2023. E8's personnel record included a valid fingerprint clearance card issued in 2018. E8's personnel record included an employment history listing previous employers. However, E8's employment history indicated E8 was unemployed for a period of longer than six months since E8's current fingerprint clearance card had been issued. E8's personnel record did not include documentation E8 had submitted a completed application to the Department of Public Safety after the gap in employment. 6. A review of E9's personnel record revealed E9 had been hired as a caregiver in January of 2024. However, documented, good faith attempts to contact previous employers was not provided for review. 7. In an interview, E1 and E2 acknowledged the personnel records provided for review did not document compliance with all subsections of A.R.S. \'a7 36-411. This is a repeat deficiency from the on-site complaint inspection conducted on September 14, 2022 and from the on-site compliance inspection conducted on March 14, 2023.”

“Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for two of five caregivers and assistant caregivers sampled. 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 (TB), 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, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E4's personnel record revealed E4 had been hired as an assistant caregiver in November of 2023. 4. A review of E4's personnel record revealed documentation two negative TST, however, documentation of a baseline screening questionnaire to include assessing risks of prior exposure to TB and determining if E4 had signs or symptoms of TB, was not available for review. 5. A review of E9's personnel record revealed E9 was hired as a caregiver in January of 2024. 6. A review of E9's personnel record revealed a doctor's note which stated, based on a historical X-ray, E9 had no signs or symptoms of active TB. However, the Doctor's note did not include documentation of a positive test for TB. However, baseline screening to include assessing risks of prior exposure to TB and documentation of the E9's freedom from infectious TB, such as a two-step TST or TB Blood test, were not available for review. 7. In an interview, E1 and E2 acknowledged E4 and E9 had not provided documentation of freedom from infectious TB as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of eight residents sampled. 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 R2's medical record revealed a negative Mantoux skin test (TST). However, a baseline screening questionnaire documenting an assessment of risks of prior exposure to TB and documenting signs and symptoms of TB, was not available for review. Based on R2's date of admission, this documentation was required. 3. A review of R4's medical record revealed a baseline screening to include a questionnaire documenting an assessment of risks of prior exposure to TB and documenting signs and symptoms of TB, and documentation of R4's freedom from TB, were not available for review. Based on R4's date of admission, this documentation was required. 4. A review of R5's medical record revealed a negative Mantoux skin test (TST). However, a baseline screening questionnaire was not available for review. Based on R5's date of admission, this documentation was required. 5. A review of R7's medical record revealed a negative Mantoux skin test (TST). However, a baseline screening questionnaire was not available for review. Based on R7's date of admission, this documentation was required. 6. A review of R8's medical record revealed a baseline screening questionnaire, and documentation of R8's freedom from TB, were not available for review. Based on R8's date of admission, this documentation was required. 7. In an interview, E1 and E2 acknowledged complete documentation of baseline screening as specified in R9-10-113(A)(2)(a) had not been provided for R2, R4, R6, R7, and R8.”

“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 and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for three of eight residents sampled. Findings include: 1. A review of R1's, R2's, and R4's medical records revealed a physician's determination for admission for each resident was not provided for review. 2. In an interview, E1 and E2 acknowledged R1's, R2's, and R4's initial admission determinations had not been provided for review.”

“Based on observation, record review, and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for two of eight residents sampled. Findings include: A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R2's medical record revealed a service plan, dated September 23, 2023. However, the service plan did not state the level of service R2 was expected to receive. 2. A review of R6's medical record revealed a service plan, dated September 20, 2023. However, the service plan did not state the level of service R6 was expected to receive. 3. In an interview, E1 and E2 acknowledged the service plans provided for review had not identified if each resident was expected to receive Supervisory care services, Personal Care services, or Directed care services.”

“Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, and included medication administration or assistance in the self-administration of medications, for three of eight sampled residents. Findings include: 1. A review of R5's, R7's and R8's medical records revealed each resident had a current service plan and required some assistance with bathing or showering. However, the service plans did not specify the frequency or amount of showers which would be provided to each resident. 2. In an interview, E1 and E2 acknowledged the service plans provided for R5, R7, and R8 did not accurately include the type, amount, and frequency of assisted living services being provided to each resident.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, when initially developed and when updated, for seven of eight residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's, R2's, R3's, R4's, and R6's medical records revealed each resident had a current service plan. However, the service plans were printed directly off of the facility's electronic health record at the time of the request and did not include all required signatures. 2. A review of R7's and R8's medical records revealed each resident had a current service plan. However, the service plans were not signed by the manager. 3. In an interview, E1 acknowledged the service plans provided for R1, R2, R3, R5, R6, R7, and R8 had not been signed and dated by the resident or their representative, the manager, or a nurse when initially developed and when updated. This is a repeat deficiency from the on-site compliance inspection conducted on March 3, 2022, the on-site compliance inspection conducted on March 14, 2023, and the on-site complaint inspection conducted on December 21, 2023.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for seven of eight 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, R5's, R7's, and R8's medical records revealed each resident had a current service plan which included services needed by each resident. 2. A review of R1's, R2's, R3's, R4's, R5's, R7's and R8's medical record revealed documentation of services provided to each resident on each shift. However, the documentation included multiple omissions for each resident where provided services had not been documented. 3. In an interview, E1 and E2 acknowledged the services provided to each resident were not accurately documented in each resident's medical record. This is a repeat deficiency from the on-site complaint inspection conducted on March 3, 2022 and the on-site compliance inspection conducted on March 14, 2023.”

“Based on record review and interview, the manager failed to ensure a resident was provided a diet that met the resident's nutritional needs as specified in the resident's service plan, for four of eight sampled residents. Findings include: 1. A review of R4's, R5's, R7's and R8's medical records revealed each resident had a current service plan. However, the service plans did not state what diet each resident would be provided. 2. In an interview, E1 and E2 acknowledged the service plans for R4, R5, R7, and R8 did not specify the diet required by each resident.”

“Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked three shifts per day, from 6 AM to 2 PM, from 2 PM to 10 PM, and from 10 PM to 6 AM. 2. A review of facility documentation revealed disaster drills during the previous 12 months had been conducted and documented as follows: - February 1, 2024, no shift or time noted; - October 1, 2023 on the 6 AM to 2 PM shift; - August 16, 2023 on the 2 PM to 10 PM shift; - July 2, 2023 on the 2 PM to 10 PM shift; and - May 30, 2023 on the 6 AM to 2 PM shift. 3. In an interview, E1 and E2 acknowledged documentation of disaster drills conducted every three months on each shift had not been provided for review.”

“Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the hot water temperature measured at 125.4\'b0 F in a resident bathroom in the memory care unit, measured 122.1\'b0 F in a second resident bathroom, and measured 122.2\'b0 F in a third resident bathroom. 2. In an interview, E1 and E2 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers and stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a kitchen area in the memory care dining room. The kitchen area was separated from the dining room by a swinging half door which was closed by a slide-latch. Inside the kitchen area, the Compliance Officer observed a cabinet next to the refrigerator. The cabinet had a lock, however, the cabinet was found to have been left unlocked at the time of the inspection. Inside the cabinet, the Compliance Officer observed a spray can of, "ZEP Stainless Steel cleaner and polish," a spray can of, "Boardwalk Stainless Steel Cleaner," and a spray bottle of, "Keystone Peroxide Disinfectant and Glass Cleaner RTU." 2. In an interview, E1 and E2 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.”

“Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. This deficient practice posed a risk as organized instruction and information related to resident care and safety had not been implemented. Findings include: 1. A review of the facility's policies and procedures revealed a policy, dated June 22, 2023, titled, "Administering CPR, First Aid, Fall Prevention Training, Fall Recovery Training AZ only, in accordance with A.R.S. 46-420 (sic)." This policy stated, "All associates will complete one hour of competency training in fall prevention and fall recovery upon hire and annually thereafter. This education will be captured in the learning center as an in-service (AZ-RM-I203)." 2. A review of the facility's policies and procedures revealed a policy, dated August 29, 2022, titled, "Fall Reduction Program." This policy stated the following: - "Associate that have not been trained and deemed competent in lifting or transferring a resident by a qualified instructor shall not engage in such activity until the training has been complete (sic) and the associate demonstrates safe lifting and training techniques to the qualified instructor. This includes the qualified instructor documenting the training and skill completion in Watermark's Learning Center software"; - "III.A. Notify Physician if injury is noted, verbal notification immediately including assessment findings, if non-injury-verbal, notify as soon as practicable or based on previous directions, if any, provided by the Physician"; - "III.B. Notify Responsible Part if injury is noted, verbal notification as soon as resident is stabilized, if non-injury, notify as soon as practicable or based on previous directions, if any, provided by the Responsible Party"; - "III.C. All residents that fall and hit their head should be sent out for evaluation, unless they are on Hospice Care and the Hospice provider should be notified and they will make the decision with the family as to whether the community should send the resident to the hospital for evaluation." 3. A review of E4's, E5's, and E6's personnel records revealed documentation of fall prevention and fall recovery training was not available for review. 4. A review of E9's personnel record revealed documentation of fall prevention training, however, the required in-service "AZ-RM-I203" was not available for review. 5. A review of R1's medical record revealed an incident report dated July 2, 2023 at 2:04 AM. The incident report stated, "Medtech heard, 'help' started going down the hall and open [R1] door, [R1] was face down in the livingroom. Medtech asked [R1] if [R1] hit [R1's] head, [R1] stated no just bump [R1] mouth and bit [R1] upper lip. Resident stated [R1] was going to turn off the TV and [R1] shoe came off and tripped on [R1's] other foot causing[R1] to lose [R1's] balance and fall, 'I did not hit my head.' Medtech looked [R1] over moved [R1] arms legs not skin tears and took vitals." The incident report stated an injury observed at the time of the incident was a "bruise" on "4)Face." The incident report indicated R1's physician was notified at 3:30 AM, and indicated R1's, "POA Care" was notified at 6:11 AM. Under a section titled, "Immediate Action Taken," the incident report stated, "Resident [Responsible Party] took [R1] to the hospital for evaluation and treatment." However, this section of the incident report was misleading as this action was not taken immediately. The incident report documented a head injury, however, notifications were not documented to have been made immediately and the facility did not send the resident to the hospital as required per policy. 6. In an interview, E1, E2, and E3 acknowledged the facility's fall prevention and fall recovery training program had not been fully implemented. This is a repeat deficiency from the on-site complaint inspection conducted on September 14, 2022 and from the on-site compliance inspection conducted on March 14, 2023.”

“Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation training for applicable employees to include the method and content of cardiopulmonary resuscitation training, to include a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of three sampled caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy and procedure dated March 30, 2020, covering cardiopulmonary resuscitation (CPR) training, titled ,"Associate & Volunteer Training and Personnel Files, Arizona Only." The policy and procedure stated, "B Procedures: Each file will contain the following:...3. Documentation of:...Prior to delivery of care to the residents, the Business Office Manager will verify ... current training in CPR specific to adults from one of the following organizations: 1) American Red Cross; 2) American Heart Association; or 3) National Safety Council, (with hands on demonstration of techniques)." 2. A review of E6's personnel record revealed E6 was hired through a staffing agency as a caregiver. 3. A review of E6's personnel record revealed a CPR card from "NationalCPRFoundation", an online only CPR provider. 4. In an interview, E1, E3, and E3 acknowledged E6 had worked as a caregiver and E6's CPR training had not included a demonstration of E6's ability to perform CPR. This is a repeat deficiency from the on-site compliance inspection conducted on March 14, 2023.”

“Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained to include all required documentation, for four of six personnel records reviewed. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of E4's personnel file revealed E4 was hired through a staffing agency to work for the facility as a caregiver. However, the personnel file did not include the following required items: - A starting date of employment; - Contact information; - Documentation of verification skills and knowledge; - Documentation of completed orientation; - Documentation of compliance with the requirements in A.R.S. \'a7 36-11(C) to include documented, good faith attempts to contact prior employers and verification of the current status of the fingerprint clearance card; - Documentation of evidence of freedom from infectious tuberculosis, as the personnel file included only a single skin test; and - Documentation of certification as a caregiver. 2. A review of E5's personnel file revealed E5 was hired through a staffing agency to work for the facility as a caregiver. However, the personnel file did not include the following required items: - Contact information; - Documentation of verification skills and knowledge; - Documentation of completed orientation; - Documentation of compliance with the requirements in A.R.S. \'a7 36-11(C) to include documented, good faith attempts to contact prior employers and verification of the current status of the fingerprint clearance card; and - Documentation of evidence of freedom from infectious tuberculosis, as the personnel file included only a single skin test. 3. A review of E6's personnel file revealed E6 was hired through a staffing agency to work for the facility as a caregiver. However, the personnel file did not include the following required items: - A starting date of employment; - Contact information; - Documentation of verification skills and knowledge; - Documentation of completed orientation; - Documentation of compliance with the requirements in A.R.S. \'a7 36-11(C) to include documented, good faith attempts to contact prior employers and verification of the current status of the fingerprint clearance card; and - Documentation of evidence of freedom from infectious tuberculosis, as the personnel file included only a single skin test. 4. A review of E9's personnel file revealed E9 was hired as a caregiver in May of 2023. However, the personnel file did not include documentation of completed orientation. 5. In an interview, E1, E2, and E3 acknowledged the personnel records provided for review had not included all required documentation.”

“Based on record review and interview, the manger failed to ensure, for three of seven residents sampled, each resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments or the level of service the resident was expected to receive. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated January 12, 2023. However, the service plan did not state the level of care R1 was expected to receive. 2. A review of R4's medical record revealed a service plan dated September 12, 2023. However, the service plan did not state the level of care R4 was expected to receive. 3. A review of R7's medical record revealed a service plan dated August 27, 2023. However, the service plan did not state the level of care R7 was expected to receive. Additionally, the service plan indicated R7 required assistance with all activities of daily living but did not include a description of the R7's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. R7's service plan stated, "No Medical Diagnoses Found." 4. In an interview, E1, E2, and E3 acknowledged the service plans provided for R1, R4, and R7 did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments and did not include the level of service each resident was expected to receive. This is a repeat deficiency from the on-site compliance inspection conducted on March 14, 2023.”

“Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for two of three sampled residents receiving directed care services. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated August 24, 2023. However, the required service plan update dated on or before November 25, 2023 was dated November 29, 2023. 2. A review of R6's medical record revealed a written service plan for directed care services, dated August 27, 2023. However, the required service plan update dated on or before November 27, 2023 was dated December 11, 2023. 3. In an interview, E1, E2, and E3 acknowledged R2 and R6 received directed care services and each resident's service plans had not been updated at least once every three months.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, when initially developed and when updated, for three of seven residents sampled. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 29, 2023, for directed care services. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan when the service plan was updated. The service plan had been signed the day of the on-site inspection. 2. A review of R6's medical record revealed a service plan, dated October 31, 2023, for directed care services. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan. 3. A review of R7's medical record revealed a service plan, dated December 11, 2023, for directed care services. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan when the service plan was updated. The service plan had been signed the day of the on-site inspection. 4. In an interview, E1, E2, and E3 acknowledged the service plans provided for R2, R6, and R7 had not been signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan when initially developed and when updated. This is a repeat deficiency from the on-site compliance inspection conducted on March 3, 2022 and from the on-site compliance inspection conducted on March 14, 2023”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of seven sampled residents. The deficient practice posed a risk if a 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 September 11, 2023, which included medication administration and required monthly monitoring of vitals to include blood pressure. 2. A review of R4's medical record revealed an electronically signed prescription, dated August 3, 2023, for, "Lisinopril 10 MG Oral Tablet, Take 1 tablet by mouth every 12 hours." The prescription had been initialed by the facility on October 17, 2023. 3. A review of R4's medical record revealed a fax from R4's primary care physician, dated September 6, 2023. The fax was a response to a fax R4's pharmacy had sent to R4's primary care physician and stated, "The patient identified below is requesting a refill for the prescription indicated; however, there are no authorized refills remaining.....Lisinopril 10 MG tablet, Take 1 tablet by mouth every 12 hours." The fax had a hand written note stated, "Patient needs appt." The facility had initialed the fax on September 8, 2023 with the note, "Resident advised." 4. A review of R4's medical record revealed an electronic Medication Administration Record (eMAR) dated October 2023. The eMAR indicated the following: - R4 had received, "Lisinopril 10 MG Tablet, take 1 tablet orally two times a day," at 0700 and at 1900 on each day between October 1, 2023 and October 17, 2023 at ordered; - R4 had not received Lisinopril on October 18, 2023, October 19, 2023, or October 20, 2023. However, the MAR did not include any notation to indicate the reason the medication had not been administered; - R4 had received, "Lisinopril 10 MG tablet, take 1 tablet one time a day for high blood pressure," at 0800 on each day between October 21, 2023 and October 30, 2023. However, the second ordered daily dosage of Lisinopril had not been administered to R4; and - R4 had not received Lisinopril on October 31, 2023. The eMAR included the notation, "MU" to indicate, "Medication Unavailable." 5. A review of R4's medical record revealed an eMAR dated November 2023. The eMAR indicated the following: - R4 was scheduled to receive, "Lisinopril 10 MG tablet, take 1 tablet orally one time a day for high blood pressure." on each day in November 2023. However, this was not the ordered frequency of every 12 hours. Additionally, the medication had been marked as unavailable on November 1,2,3,7,8,11,13,20,21,22,23,and November 24, 2023, and had been marked as administered on November 5,6,9,10,12,14,15,16,17,18,19,25,26,27,28, and November 29, 2023. the eMAR was misleading because medication had been marked as administered when the medication was not available. 6. A review of R4's medical record revealed an eMAR dated December 2023. The eMAR indicated the following: - R4 was scheduled to receive, "Lisinopril 10 MG tablet, take 1 tablet orally one time a day for high blood pressure." on each day in December 2023. However, this was not the ordered frequency of every 12 hours. Additionally, the medication had been marked as unavailable on December 1,2,3,4,5,6,7,9,10,11,12,13,14,15,17,19, and December 20, 2023, and had been marked as administered on December 8,16,18, and December 21, 2023, the day of the on-site inspection. the eMAR was misleading because medication had been marked as administered when the medication was not available. 7. In an interview, E3 reported the medication had been sent to a different pharmacy. E3 provided a fax from R4's primary care physician dated the day of the on-site inspection. 8. A review of the fax from R4's primary care physician revealed a note dated December 21, 2023 at 1:56 PM which stated, "Watermark called the records line requesting [R4's] prescription for Lisinopril go to [a pharmacy] and not [a different pharmacy]. [R4] had not been taking it for awhile. Not sure how long [R4's] been out of the medication." 9. A review of R4's medical record revealed documentation of R4's blood pressure for October, November, and December was not available for review. 9. In an interview, E1, E2, and E3 acknowledged documentation had not been provided to show medication had been administered to R4 in compliance with a medication order. This is a repeat deficiency from the on-site compliance inspection conducted on January 21, 2021, from the on-site complaint inspection conducted on March 3, 2022, and from the on-site compliance inspection conducted on March 14, 2023.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R2's medical record revealed an incident report dated July 16, 2023 at 21:00. The incident report stated, "[R2] was very upset and acting usual (sic) then [R2] fell and hit [R2's] left eyes (sic), and cut it open." The incident report stated, "Called EMT. They took vitals, stopped bleeding - helped [R2] to [R2's] room. However, the incident report indicated R2's physician was notified of the incident on July 17, 2023 at 08:00. 2. In an interview, E1, E2, and E3 acknowledged the provided incident report indicated emergency medical services were contacted due to R2's accidental injury and the incident report indicated R2's physician was not immediately notified of the accident.”