Arizona's Best Assisted Living Home.

“Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section. Findings include: 1 . A review of R2's medical record revealed that documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for one of two residents sampled. Findings include: 1 . A review of R2's medical records revealed documentation of a signed residency agreement. However, the documentation was completed after the individual's acceptance by the assisted living facility. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, for one of two residents sampled. Findings include: 1 . A review of R2's medical records revealed documentation of an orientation to the exits of the facility. However, the documentation was not completed within 24 hours after the resident’s acceptance by the assisted living facility. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a can of "Lysol" disinfectant cleaner located in an unlocked cabinet under the bathroom sink attached to a resident room. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on November 14, 2023.”

“Based on observation and interview, the manager failed to ensure that documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. During a tour of the facility, the Compliance Officers observed a posted personnel schedule dated October 2023. A personnel schedule after October 2023 was not available. 2. In an interview, E1 acknowledged that documentation was not maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.”

“Based on documentation review, record review, and interview, the manager failed to ensure the policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for one of one resident reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Rule review of R9-10-807(G) on or after October 1, 2019 stated: "A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency: a. For nonpayment of fees, charges or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason." Review of subsection (C) stated: "1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails." 2. Review of the facility's policy and procedure revealed a policy titled "Termination of Residency Agreements" reviewed and signed by E1 July 1, 2021. This policy did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual 3. Review of R1's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual. Based on R1's acceptance date, this documentation was required. 4. In an interview, E1 acknowledged the facility's policy and procedure and R1's residency agreement did not include the correct policy and procedure for an assisted living facility to terminate residency.”

“Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During a tour of the facility, the Compliance Officers observed an unlocked closet near the kitchen that contained two bags of prescription medications. 2. During a tour of the facility, the Compliance Officers observed a bottle of Systane Ultra eye drops, a bottle of Systane Balance eye drops, and a bottle of Systane Complete eye drops sitting on R3's night stand. 3. In an interview, R3 reported the caregivers administered the eye drops. 4. In an interview, E1 reported the medications in the closet were employees' medication and acknowledged that medications were not stored in a locked area. This is a repeat deficiency from the compliance inspection conducted on October 25, 2022.”

“Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted in each hallway of each floor of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During a tour of the facility, the Compliance Officers observed that an internal hallway did not have a posted evacuation path. 2. In an interview, E1 acknowledged that an evacuation path was not posted in each hallway.”

“Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. During a tour of the facility, the Compliance Officers observed a hall bathroom with the lock turned around facing the interior hallway. The door was capable of being locked. 2. During a tour of the facility, the Compliance Officers observed a broken grab bar inside a bathroom. 3. In an interview, E1 acknowledged that the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officers observed the facility garage unlocked. The unlocked garage contained two, one-gallon cans of paint and two containers of WD-40 in a cabinet. 2. In an interview, E1 acknowledged that toxic materials were stored unlocked in the garage.”