The Mission at Agua Fria.

“Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for four of eight residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical records revealed a form titled “Physician Report and Admission Orders – Arizona” which was dated and signed by a medical practitioner; however, R2’s determinations did not include whether the individual required continuous medical services or restraints. 2. A review of R3's, R5’s, and R6’s medical records revealed a form titled “Physician Report and Admission Orders – Arizona” dated and signed by a medical practitioner; however, R3's, R5’s and R6’s determinations did not include whether the individual required restraints. 3. In an interview, E1 and E2 acknowledged that the documentation for R2 was missing determinations for both continuous medical services and restraints, and the documentation for R3, R5, and R6 was missing determinations regarding the need for restraints.”

“Based on documentation review, record review and interview, the manager failed to ensure that a behavioral health professional or medical practitioner completed and signed a written determination, 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months thereafter, stating that the resident’s behavioral health needs could be met by the facility and were within the facility’s scope of services, for two of two residents sampled who were receiving behavioral care. The deficient practice posed a health and safety risk by potentially retaining a resident whose needs were not properly assessed or supported by the facility. Findings include:   1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services.   2. In an interview, E2 reported that R5 and R6 received behavioral health services from a third-party provider.   3. A review of R5's medical record revealed a current written service plan for directed care services dated June 2025. This service plan revealed R5 had a diagnosis of Schizophrenia, unspecified, and Moderate intellectual disabilities. In addition, R5's medical record revealed R5 had a behavioral health professional, “COPA Health”, and received administration of psychotropic medications. However, no documentation indicating R5's behavioral health professional or medical practitioner examined R5 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months, signed and dated a determination stating R5's behavioral care needs were being met by the facility, and reviewed the facility's scope of services was available.    4. A review of R6's medical record revealed a current written service plan for personal care services dated May 2025. This service plan revealed R6 had a diagnosis of Bipolar disorder. In addition, R6's medical record revealed R6 had a behavioral health professional, “COPA Health”, and received administration of psychotropic medications. However, no documentation indicating R6's behavioral health professional or medical practitioner examined R6 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months, signed and dated a determination stating R6's behavioral care needs were being met by the facility, and reviewed the facility's scope of services was available.    5. In an interview, E1 and E2 acknowledged that R5's and R6’s behavioral health professional or medical practitioner did not provide a written determination at least 30 days before acceptance or before the resident began receiving behavioral care, and at least once every six months.”

“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 two of eight residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a current written service plan dated November 2025. The service plan indicated R1 received personal care services and medication administration.  2. A review of facility documentation revealed a form titled “Internal Incident Report” involving R1 on April 17, 2025 at 7:32 AM. The report stated “Case manager notified this nurse that she received a report from the hospital that resident had experienced an oxycodone overdose and inquired how that had happened. Upon further investigation, it was discovered by this nurse that resident had received 2 extra doses of oxycodone on 4/11/25. The order states that resident may have 1 tab twice daily as needed. PCP and case manager notified immediately…” 3. A review of R7's medical record revealed a current written service plan dated January 2025. The service plan indicated R7 received personal care services and medication administration.  4. A review of facility documentation revealed a form titled “Internal Incident Report” involving R7 on March 09, 2025 at 10:30 PM. The report stated “It was brought to this RCC attention that this resident was given the wrong medication at the 10PM medication pass. Resident was supposed to receive [R7] Oxycodone and instead [R7] was given [R7] Alprazolam by mistake. As soon as RCC was notified, all parties were contacted including hospice. WD has also been notified. Resident has had no reactions and is doing okay…” 5. In an interview, E1 acknowledged R1’s and R7’s medication was not administered in compliance with the available medication order.”