Casa del Rey Assisted Living Care Home LLC.

“Based on record review and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2’s medical record revealed a current service plan dated May 6, 2025. This service plan indicated R2 received medication administration. 2. Review of R2’s medical record revealed a signed medication order dated July 11, 2025, that stated, “Cetirizine 10 MG BID” (twice a day). 3. Review of R2’s medical record revealed the medication administration record (MAR) for the month of August 2025. This MAR revealed Cetirizine 10 MG was administered once a day from August 1st to present.  4. In an interview, E1 reported that Cetirizine 10 MG was administered once a day. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on July 11, 2023.”

“Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s medical record revealed a current service plan dated July 21, 2025. This service plan indicated R1 received medication administration. 2. Review of R1’s medical record revealed signed medication orders dated June 27, 2025. These orders stated, “Donepezil 10 MG two tablets PO HS” and “Gabapentin 300 MG one tablet PO QD”. 3. Review of R1’s medical record revealed R1’s medication administration record (MAR) for August 2025. This MAR showed Donepezil 10 MG was not documented as administered on the 14th and Gabapentin 300 MG was not documented as administered on the 12th, 13th, and 14th. 4. In an interview, E1 reported E1 administered the medications, however E1 did not document it. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on July 11, 2023.”

“Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed medical records for all residents were stored in an office room in the back of the facility. However, the office was not locked and provided access to the door leading to the backyard from this office room. The Compliance Officer observed medical records scattered all over the office room. The Compliance Officer also observed two ambulatory residents walking through this office room to the backyard several times. 3. In an interview, E2 and E3 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use. 4. In an telephonic interview, E1 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed four ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the front door leading to the street from the facility. However, the door was not secured and the door chime was not functioning. 4. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility. 5. In an telephonic interview, E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed four ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 4. During the environmental tour, the Compliance Officer observed a gate in the back yard leading to the front yard. The gate was locked and did not allow an exit to a location at least 30 feet away from the facility. This gate was not equipped with a device that alerted caregivers of the egress of a resident. 5. In an interview, E2 and E3 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility. 6. In an telephonic interview, E1 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.”

“Based on observation, documentation review, and interview, the manager failed to ensure pets were licensed consistent with local ordinances. Findings include: 1. The Compliance Officer observed O1 freely roaming in the facility. 2. A review of facility documentation for O1 revealed no documented evidence to indicate O1 was licensed consistent with local ordinances. 3. In an interview, E3 reported being unable to provide documentation of a pet license for O1. 4. In an telephonic interview, E1 reported being unable to provide documentation of a pet license for O1.”

“Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies. Findings include: 1. The Compliance Officer observed O1 freely roaming in the facility. 2. A review of facility documentation for O1 revealed no documented evidence to indicate a current rabies vaccination for O1. 3. In an interview, E3 reported being unable to provide documentation of a current rabies vaccination for O1. 4. In an telephonic interview, E1 reported being unable to provide documentation of a current rabies vaccination for O1.”