Ridge at the Stratford.

“Based on documentation review, record review, and interview, the manager failed to ensure that personnel records included documentation of training and education related to recognizing the signs and symptoms of tuberculosis (TB) infection, as required by R9-10-113, for three of three personnel sampled.   Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E4’s personnel records revealed no initial TB training (hired September 2024). Based on E4’s date of hire, this documentation was required. 3. A review of E3's and E4's personnel records revealed no documentation of annual TB training. Based on E3's and E4's hire dates, this documentation was required. 4. In an interview, E2 reported that E2 had been completing TB training since E2 started employment and was not sure whether TB training was completed by staff before E2’s start date. 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. Technical assistance was provided on this Rule during the inspections conducted on February 1, 2025, and February 12, 2024. This is a repeat deficiency from the inspection conducted on July 29, 2024.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training for one of three employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents. Findings include: 1. A review of E5’s personnel record revealed that E5 was hired as a caregiver in February 2023. E5’s first aid training and CPR card expired on October 11, 2023; however, a new first aid training and CPR card was not issued until December 4, 2023. The personnel record did not reveal any indication that E5 was not providing assisted living services during the period from October 11, 2023, through December 4, 2023, during which E5 did not have a valid first aid training and CPR card. 2. In an interview, E6 reported that caregivers were required to have current CPR and First Aid certification completed before providing assisted living services to residents. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident was expected to receive, for one of one residents sampled who received directed care services. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R4's medical record revealed a current service plan dated October 2025. The service plan did not include the level of service R4 received.  2. In an interview, E2 reported R4 received directed care services. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. This is a repeat deficiency from the inspections conducted on March 27, 2024, and April 18, 2024.”

“Based on documentation review, observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services, or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. The deficient practice posed a risk to the physical health and safety of a resident.     Findings include:   1. A review of Department records revealed the facility was licensed to provide directed care services. The facility license was split into 48 Directed Care Services and 122 Personal Care Services. 2. During the environmental inspection of the facility with E1, the Compliance Officers observed that directed care residents were housed in a separate secured unit from the main building. At the time of the inspection, only one staff member was present in the directed care unit, assisting approximately 20 residents. Further review revealed that neither the residents nor their rooms were equipped with a call bell, intercom, or any other mechanical means for residents to alert staff in the event of a need or emergency. 3. In an interview, E1 acknowledged that the directed care residents’ bedrooms did not have a bell, intercom, or any other mechanical means available to alert employees to a resident’s needs or emergencies. 4. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.”

“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 two residents sampled receiving directed care services.   Findings include: 1. A review of R1's medical record revealed a written service plan for directed care services, dated January 18, 2025. However, there were no further required service plan updates available for review. 2. A review of R2's medical record revealed a written service plan for directed care services, dated January 18, 2025. However, there were no further required service plan updates available for review. 3. In an interview, E1 acknowledged that R1’s and R2's service plans were not updated every three months as required. This is an uncorrected deficiency from the complaint investigation conducted on July 29, 2024, and the compliance inspection and complaint investigation conducted on May 20, 2025.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a service plan dated January, 2025. The service plan reported the following: - "daily rounds and safety checks - check in on once each night and provide assistance as needed. 2. Review of R1's medical record revealed an ADL record for the month of May 2025. There was no documentation of the nightly checks as indicated in the service plan. 3. In an interview, E1 acknowledged that the caregiver did not document the services provided in R1's medical record.  This is a repeat deficiency from the compliance inspections and complaint investigations conducted on March 16, 2023, and February 12, 2024, and the complaint investigations conducted on September 19, 2023, February 16, 2024, and March 27, 2024.”

“Based on record review and interview, the manager failed to ensure the service plan for two of two sampled residents receiving directed care services included coordination of communications with the resident's representative, family members, or other individuals identified in the resident's service plan.   Findings include:   1. A review of R1's medical record revealed a service plan January, 2025. R1's service plan did not include coordination of communication with R1's representative, family members, or other individual identified in R1's service plan. 2. A review of R2's medical record revealed a service plan January, 2025. R2's service plan did not include coordination of communication with R2's representative, family members, or other individual identified in R2's service plan.   3. In an interview, E1 acknowledged R1 and R2's service did not include coordination of communication with the representative, family members, or other individual identified in R1 and R2's service plan.”

“Based on record review and interview, the manager failed to ensure that one resident's service plan was updated at least once every three months.   Findings include:   1.  Documentation review established that R1 was at the directed level of care.   2.  Documentation review established that R1 had a service plan that was dated January 19, 2025. The date of the inspection was May 20, 2025.   3.  In an interview, E1 confirmed that R1 was at the directed level of care and that the last time R1’s service plan was updated was January 19, 2025. This is an uncorrected deficiency from the complaint investigation conducted on July 29, 2024.”

“Based on documentation review, record review, and interview, for one of three residents reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to a resident who was not administered a medication, as prescribed. Findings include: 1. In record review, R1's medical record (received directed care and medication administration services) included documentation of a medication order, for Permethrin 5% cream, "apply topically once for scabies on all skin from head to toe except around the eyes on day 1, day 2, day 8, day 9, and day 15, for scabies infection." 2. In record review, R1's medication administration record (MAR) included documentation R1 received the medication on July 24, July 25, (day 1, and day 2), August 1, (day 9), and August 8, 2024 (day 16). There was no documentation R1 received the medication on July 31, (day 8) or August 7, 2024 (day 15), as ordered. 3. During in interview, E1 and E2 acknowledged R1's MAR did not include documentation R1 was administered the Permethrin medication as ordered.”

“Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i), for two of five sampled personnel members. The deficient practice posed a potential TB infection risk to residents. Findings include: 1. A.A.C. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)..." 2. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." The web page indicated two-step testing involves an initial TST, and if negative, a second TST administered one to three weeks after the initial TST. 3. A review of E3's personnel records (hired in 2023) revealed no documentation of completed initial TSTs for employee. 4. A review of E5's personnel records (hired in 2023) revealed no documentation of completed initial TSTs for employee. 5. In an interview, E1 acknowledged no documentation of evidence of freedom from infectious TB, as specified in A.A.C. R9-10-113(B)(1)(a)(i), for E3 or E5 was available for review.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months, for one of two residents sampled who received directed care services. 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 R2's medical record revealed a service plan dated March 19, 2024, for directed care services. No more recent service plan for R2 was available for review at the time of the inspection. 2. In an interview, E1 acknowledged there was no updated service plan for R2 available for review at the time of the inspection.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan, for two of four sampled residents. Findings include: 1. A review of R3's medical record revealed a service plan dated November 3, 2023. R3's service plan reflected R3 required assistance with bathing every Tuesday and Friday in the morning, escort to meals twice daily, dressing twice daily, oral care twice daily, nighttime checks twice nightly, bedmaking twice daily, housekeeping weekly on Tuesday and Thursday, and assistance with ambulation morning, noon, and night. 2. A review of R3's medical record revealed a document titled "Service Checkoff List" dated May 2024. The document reflected the following services were not provided as required: -Bathing on Friday, May 3, 2024, and May 10, 2024; -Dressing, grooming, morning meal escort, oral care, and toileting on May 3, 2024, and May 13, 2024; and -Nighttime checks and toileting on May 8-11, 2024. 3. A review of R4's medical record revealed a service plan dated May 2, 2024. R4's service plan reflected R4 required assistance with bathing every Monday and Thursday, meal escorts twice daily, dressing twice daily, grooming twice daily, oral care twice daily, housekeeping every Thursday, and toileting twice daily. 4. A review of R4's medical record revealed a document titled "Service Checkoff List" dated May 2024. The document reflected the following services were not provided as required: -Toileting on May 5-6, 2024, and the morning of May 12, 2024; -Transfer assistance on the morning of May 12, 2024; -Total assistance with ambulation on May 5-6, 2024, and May 12, 2024; -Dressing on May 4-6, 2024, and May 16, 2024; -Grooming on May 4-6, 2024, and May 12, 2024; -Oral care on May 5, 2024, and May 12, 2024; and -Nighttime safety check on May 5-6, 2024. 5. In an interview, E1 reviewed R3's and R4's medical records and acknowledged there was no other documentation to reflect the aforementioned services were provided as required. This is a repeat/uncorrected deficiency from the complaint inspection conducted on April 18, 2024.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of two sampled residents. The deficient practice posed a risk as 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 March 19, 2024. However, R1's service plan did not include the level of care R1 was expected to recieve. 2. In an interview, E1 and E2 reviewed and acknowledged R1's service plan did not reflect R1's level of care.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with assistance with activities of daily living according to the resident's service plan, for one of two 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 R1's service plan dated March 19, 2024 reflected R1 required assistance with the following items: -"Activities encouragement" every day in "AM" and "PM"; -Bathing every Wednesday and Saturday in "AM"; -Oral care every day in "AM" and "PM"; -Meal reminders every day in "AM"; -Nighttime checks twice every night; -Grooming every day in "AM"; -Housekeeping weekly every Monday; and -Safety checks every day in "AM". 2. A review of R1's medical record revealed a document titled "Service Checklist" dated April 2024. The document reflected the following: -R1 was not assisted with grooming in the morning on April 8, 14, 15, and 18, 2024; -R1 was not assisted with housekeeping on April 1-18, 2024; -R1 was not assisted with bathing on April 3, 2024; -R1 was not provided meal reminders on April 8, 14, 15, and 18, 2024; and -R1 was not assisted with oral care on April 8, 14, and 15, 2024. 3. In an interview, E1 and E2 reviewed R1's service plan and documentation of services provided and acknowledged there was no documentation to reflect the aforementioned services were provided on the aforementioned dates.”

“Based on record review and interview, the manager failed to ensure when there was a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager documented actions taken to prevent the suspected abuse, neglect, or exploitation from occurring in the future. The deficient practice posed a risk if residents were not adequately protected from abuse, neglect, or exploitation. Findings include: 1. A review of R1's and R2's medical records revealed untitled documents dated March 7, 2024. The documents stated: "Interviewed [E3] who was the only witness to this incident. [E3] heard yelling coming from [R1]'s room. [E3] went to [R1]'s room to assist. [E3] couldn't open [R1]'s door all the way. When [E3] tried to open the door more [E3] saw [R1] hitting [R2] on [R2]'s back and shoulders. When [E3] tried to push the door open to help [R2] get out of the room [R1] slammed door almost shutting [E3]'s fingers in the door. [E3] opened the door again and squeezed through the door to assist the resident who wandered into [R1] room. [E3] removed [R2] and went back into [R1]'s room to assist [R1] to get dressed and ready for the day. To clean up resident room from urine all over the floor. [E3] tried to assist [R1] in changing wet clothes, [R1] started screaming at [E3] to get out of [R1]'s room, [R1] proceeded to grab [E3] by the neck and push [E3] as [E3] was trying to exit room [R1] kicked [E3] on the way out of the room. Refusing to let staff help clean room, bedding or help change [R1]." The document did not address actions taken by the manager to prevent abuse from occuring in the future. 2. A review of R3's medical record revealed an untitled document dated March 9, 2024. The document stated: "[E2] stated [E2] heard yelling coming from the York neighborhood. [E2] stated [E2] heard a voice say, "you're going to kill me leave me alone." [E2] ran to [R3]'s room and observed the door open and [R4] standing above [R3] hitting [R3] with open hands. [R3] had both arms up trying to protect [R3]. [E2] rushed between both residents to protect them. Another caregiver came to assist and was able to help [R4] back into [R4]'s wheelchair and out of [R3]'s room. At that time med tech [E3] was also called for assistance. [R4] was put in the common hallway. Caregivers were trying to assist [R4] as [R4] sat on [R4]'s wheelchair yelling at caregivers. Med Tech [E3] escorted [R4] to the activity room to try to calm [R4] down." The document did not address actions taken by the manager to prevent abuse from occuring in the future. 3. In an interview, E1 reviewed and acknowledged the documetation did not include actions or strategies taken to prevent abuse from re-occuring.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for two of six residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R5's and R6's medical records revealed current service plans, both dated March 27, 2024. The service plans included a line to indicate the level of service R5 or R6 were expected to receive. However, the line was left blank on both service plans. 2. In an interview, E1 and E5 reviewed R5's and R6's service plans and acknowledged the service plans did not include the level(s) of service the residents were expected to receive.”

“Based on observation, record review, and interview, the manager failed to ensure a written service plan included how medication would be stored and controlled, for two of two sampled residents who stored medications in the resident's bedroom or residential unit. The deficient practice posed a risk if medication was stored improperly. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R5's residential unit. R5's residential unit contained a locked cabinet inaccessible to anyone visiting R5's unit. 2. In an interview, E1 reported the locked cabinet in R5's residential unit contained R5's medications. 3. A review of R5's medical record revealed a doctor's order dated March 2, 2024. The doctor's order stated "Patient may self-administer meds." Further review of R5's medical record revealed a service plan dated March 27, 2024. The service plan did not include how R5's medication would be stored or controlled. 4. A review of R6's medical record revealed a doctor's order dated February 8, 2024. The doctor's order stated "After careful consideration and discussion with [R6's primary care provider]...It is in [R6]'s best interest [R6] manages medication independently." Further review of R6's medical record revealed a service plan dated March 27, 2024. The service plan did not include how R6's medication would be stored or controlled. 5. In an interview, E1 acknowledged R5's and R6's service plans did not include how R5's and R6's medications would be stored and controlled.”

“Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for three of six sampled residents. The deficient practice posed a risk if services were not provided as required to meet the needs of residents. Findings include: 1. A review of R1's medical record revealed a service plan dated March 27, 2024. The service plan reflected R1 required assistance with making R1's bed daily, daily assistance with grooming, housekeeping weekly, and oral care reminders daily. Further review of R1's medical record revealed a document titled "Service Checkoff List" dated March 2024. The document reflected R1 was not provided oral care reminders on March 3-7, 10, 12-16, 22, and 26, 2024, and was not provided bathing assistance on March 12-18, and 21-28, 2024. 2. A review of R5's medical record revealed a service plan dated March 27, 2024. The service plan reflected R5 required physical assistance with bathing and dressing every day. There was no documentation in R5's medical record for the month of March 2024 to reflect R5 was provided the required services as noted in R5's service plan 3. A review of R6's medical record revealed a service plan dated March 27, 2024. The service plan reflected R6 required assistance with bathing ("cueing/standby") every Sunday and Tuesday, dressing ("cueing/standby") every day, bed making every day, housekeeping weekly, transfer ("cueing/standby") every day, and toileting ("occasional assist") every day. There was no documentation in R6's medical record for the month of March 2024 to reflect R6 was provided the required services as noted in R6's service plan. 4. In an interview, E1 reviewed R1's, R5's, and R6's medical records and acknowledged there was no documentation to reflect the aforementioned services were completed as required.”

“Based on record review and interview, the manager failed to ensure a resident's service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for two of two sampled residents receiving personal care services. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of R5's medical record revealed a current written service plan dated March 27, 2024. The service plan included a line to indicate the level of service R5 was expected to receive. However, the line was left blank. R5's medical record also included a document titled "Ridgeline Evaluation" dated March 15, 2024, which reflected R5 required personal care services. R5's service plan revealed no documentation of skin maintenance to prevent bruises, injuries, pressure sores, and infections. 2. A review of R6's medical record revealed a current written service plan dated March 27, 2024. The service plan included a line to indicate the level of service R6 was expected to receive. However, the line was left blank. R6's medical record also included a document titled "Ridgeline Evaluation" dated December 20, 2023, which reflected R6 required personal care services. R6's service plan revealed no documentation of skin maintenance to prevent bruises, injuries, pressure sores, and infections. 3. In an interview, E1 reviewed R5's and R6's service plans and acknowledged the service plans did not include skin maintenance to prevent bruises, injuries, pressure sores, and infections.”

“Based on record review and interview, the manager failed to ensure a service plan included incontinence care to ensure a resident maintained the highest practicable level of independence when toileting, for one of two sampled residents receiving personal care services. Findings include: 1. A review of R5's medical record revealed a current written service plan dated March 27, 2024. The service plan included a line to indicate the level of service R5 was expected to receive. However, the line was left blank. R5's medical record also included a document titled "Ridgeline Evaluation" dated March 15, 2024, which reflected R5 required personal care services. R5's service plan did not address incontinence care. 2. In an interview, E1 acknowledged R5's service plan did not include documentation of incontinence care to ensure R5 maintained the highest practicable level of independence when toileting.”

“Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, and was accurately documented in the resident's medical record, for one of four sampled residents who recieved medication administration. 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 R4's medical record revealed medication orders dated February 26, 2024 for "Citalopram 10 mg (milligrams) tablet by mouth daily", "Lisinopril 2.5 mg daily", "Memantine 5 mg daily", "Quetiapine 25 mg tablet by mouth daily", and "Sulfamethoxazole one tablet by mouth daily". Further review of R4's medical record revealed a medication administration record (MAR) dated March 2024. The MAR reflected R4 did not receive R4's "Citalopram", "Lisinopril", "Memantine", "Quetiapine", or "Sulfamethoxazole" on March 4 and 9, 2024. 2. In an interview, E1 reviewed and acknowledged there was no documentation to reflect the aforementioned medications were administered as required on March 4 and 9, 2024.”

“Based on record review and interview, the manager failed to ensure the written service plan when initially developed and when updated, for two of two sampled residents receiving medication administration services, were signed and dated by a nurse or medical practitioner, which could pose a health risk to the resident. Findings include: 1. Review of R1's current service plan dated November 17, 2023 and R2's current service plan dated November 2, 2023 stated the residents required directed care and medication administration services. However, the service plans were not signed and dated by a nurse or medical practitioner. 2. In an interview, E1 and E4 acknowledged that R1 and R2 were receiving directed care services and their current service plans had not been signed and dated by a nurse or medical practitioner. E1 and E4 reported the facility has "no nurse". This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”

“Based on record review and interview, the manager failed to ensure the caregiver providing services documented the services provided in the resident's medical record, for two of two sampled resident, which posed a health and safety risk. Findings include: 1. Review of R1's and R2's medical records revealed the service plans stated the residents required directed care and medication administration services. R1 and R2 needed assistance with bathing and other activities of daily living. There was no documentation of the services provided for R1 and R2 in January 2024 to present. 2. During an interview, E1 and E4 reported there was no documentation of the services provided. The facility is in the process of changing to different tracking program. E1 and E4 acknowledged the sampled residents' medical records did not include documentation of the services provided to them in January to present. This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”

“Based on observation and interview, the manager failed to ensure the location at which the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was conspicuously posted. Findings include: 1. During a tour of the facility on February 12, 2024, and February 13, 2024, the Compliance Officer observed no posting indicating where the most recent inspection report could be located. 2. In an interview, E1 acknowledged documentation of the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was not posted.”

“Based on documentation review, record review, and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803(J), which posed a health and safety risk and if false or misleading documentation was provided to the Department. Findings include: A.R.S. \'a7 46-454. states, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures." Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay." 1. A review of facility documentation revealed an incident of alleged abuse involving E2 and R3 on November 21, 2023. However, the documentation did not include the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. 2. A review of documentation revealed an incident of alleged abuse involving E3 and R2 on October 16, 2023. However, the documentation did not include the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. 3. A review of the investigation report provided by E1 included two documents stapled together. The first document was a typed summary of investigation which did not include the name of the author. The second page of the investigation report included a document titled "Progress Notes for [R5]." The typed summary of the investigation indicated the alleged incident between alleged abuse that occurred between R5 and R6 dated October 29, 2024. It stated "On Sunday 10/29 I was informed when I was out of the community that [R5] was found on the floor with a cut on [R5's] cheek area ... [E11] stated that [E11] found [R5] on the floor with a cut ... It was believed that resident [R6] possibly pushed [R5], but that was not confirmed. Also, the lamp was broken near the area ... we did APS self-report." However, the attached progress note indicated a different date. The second page of the investigation report indicated the progress note was completed by E11 on October 29, 2023 at 3: 19 PM. E11's progress note revealed the incident took place on September 24, 2023 at 10:45 AM and identified the incident as an "unwitnessed injury fall." the progress note stated "when medtech walked into the room medtech observed resident sitting on the floor in [R5's] bedroom on [R5's] bottom next to [R5's] bed with [R5's] rubber soled slippers on ... There was broken glass all over the floor due to broke lamp. Resident had small cut above [R5's] right eye. Caregiver observed Resident [R6] leaving residents room before finding [R5] on the floor." A review of the provided report revealed documentation of the report according to A.R.S. \'a7 46-454 was not documented. Additionally, the documentation did not include the correct dates and times to determine if immediate action was taken and if the investigation of the event was completed within five working days. 4. In an interview, E5 reported E5 was on shift on the day of the aforementioned resident on resident altercation. E5 reported E5 witnessed R6 leave R5's room with R5's donut in R6's hands. R5 went into R5's room to investigate and found R5 on the floor bleeding. 5. A review of R5's medical record revealed R5 received directed care services. R5's medical record did not include documentation of the reported allegation, the facility's investigation, and the required reporting per A.R.S. \'a7 46-454. 7. A review of documentation provided by E1 revealed ten incident reports involving R7 dated between November 2, 2023 to February 3, 2024. The following dated incident reports involved aggressive behavior displayed by R7 towards R6: - December 12, 2024; "Type of incident: Aggressive behavior; ...[R7] had [R6] by [R6's] hair trying to to get [R6] to go to their room..."; - December 14, 2024; "Type of incident: Aggressive behavior; ...[R7] proceeded to make [R6] come back to the room, but [R6] did not want to come with. That got [R7] upset..."; - December 15, 2023; "Type of incident: Aggressive behavior; ...[R7] was attempting to take [R6] to their room... [R7] had [R7's] left hand on [R6's] right forearm and was attempting to pull [R6] out of the activity room..."; and - December 22, 2023; "Type of incident: Aggressive behavior; ... [R7's] left hand was holding [R6's] right hand pulling [R6] down the hall... [personnel member] explained to [R7] that [R6] was in a safe environment and did not need to go back to their room... [R7] released [R6's] hand and walked away stating 'This is bull[expletive]"; and - December 27, 2023; ""Type of incident: Aggressive behavior; ...[R7] attempted to get [R6] to go to their room. [R7] attempted to grab [R6] with [R7's] left hand on [R6's] right upper arm. [R6] jerked away and [personnel member] asked [R7] to let [R6] go and it's ok for [R6] to be with other residents..." Nine incident reports identified notifications made to an entity labeled "licensing." However, for the December 12, 2023 it was documented "licensing" had been notified two days before the event occurred. 8. In an interview, E12 reported the date of the notification to the entity labeled "licensing" on the December 12, 2024, incident report may have been an error as staff was getting used to the new system. E12 reported E12 recently completed an audit of the facility and identified personnel members were inaccurately documenting notifications (to family, physician, etc..) in the system that were not actually completed. E12 reported with the change of the electronic medical record system, there may be additional documentation of incidents for R7 found in R7's progress notes within R7's electronic medical record. The Compliance Officer requested to review R7's progress notes. 9. A review of documentation provided by E12 revealed a five-page document titled "Progress Notes, [R7]." The progress notes were dated between November 2, 2023 to February 3, 2024. The following dated progress notes involved aggressive behavior displayed by R7 towards R6: - November 7, 2023, 1:43 PM; "...[R7] kept telling [R6] to go to the room, but [R6] wanted to sit out with the other residents ... [R7] started yelling and screaming at [R6] telling [R6] [R7] was sick of [R6's] [expletive]. [R7] is being really aggressive with [R6] pulling [R6] by [R6's] arms and trying to push [R6] toward the room...; and - December 14, 2023, 4:40 PM; "... [R7] started yelling at [R6], and another resident. [R7] wants [R6] to be in room 24/7." 10. A review of R6's medical record revealed R6 received directed care services. R6's medical record did not include documentation of the suspected abuse that occurred between R6 and R7 on any of the above referenced dates. 11. In a joint in”

“Based on documentation review and interview, the manager failed to ensure a documented report submitted to the governing authority included any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. A review of facility documentation revealed documents titled "Quality Management Monthly Meeting." The documents revealed monthly meetings dated between January 19, 2023 to December 31, 2023. The documents included the following: -Monthly infections, falls, medication errors; -Monthly skin log review; -Service Planning (Up to Date?); -Controlled Substance Audit Findings; -Weekly Med Room Audit; and -Weekly MAR Audits. However, the documents did not include any changes made or actions taken as a result of the identification of concerns about the delivery of services related to resident care. 2. In an interview, E1 acknowledged the facility's quality management monthly meeting did not indicate a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care.”

“Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted signed documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for three of nine residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "Physician's Report (Arizona)." The documentation was dated within 90 calendar days before R1 was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. However, the documentation was incomplete. There were six dedicated spaces indicated for the resident's information, which included name, birthdate, age, signature, address, and date. However, the only space completed appeared to be a misspelling of R1's surname. 2. A review of R4's medical record revealed a document titled "Physician Referral to Assisted Living." The documentation appeared to indicate whether R4 required continuous medical services, continuous or intermittent nursing services, or restraints. However, the documentation was undated. 3. A review of R6's medical record revealed a document titled "Physician's Report (Arizona)," the documentation was dated within 90 calendar days before R6 was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. However, the documentation did not include any of R6's demographic information. 4. In an interview, E1 reported the errors found in the aforementioned documentation were an oversight by the facility and reported the documentation for R1, R4, and R6 were incorrectly completed by R1's, R4's, and R6's physicians.”

“Based on record review and interview, the manager accepted an individual requiring continuous medical services, for one of nine residents sampled. The deficient practice posed a risk as an assisted living facility cannot provide continuous medical services. Findings include: 1. A review of R7's medical record revealed a document titled "Physician's Report" The document stated "... 16. Arizona Regulatory Questions: 1. Please indicate if this individual requires: Continuous Medical Services..." A box next to "Continuous Medical Services" was marked to indicate R7 required continuous medical services. The document was signed by a medical practitioner. 2. In an interview, E1 reported R7 does not receive continuous medical services. E1 reported the box indicating R7 required continuous medical services should not have been marked.”

“Based on record review and interview, the manager accepted an individual requiring continuous nursing services, for one of nine residents sampled. The deficient practice posed a risk as an assisted living facility cannot provide continuous nursing services. Findings include: 1. A review of R7's medical record revealed a document titled "Physician's Report" The document stated "... 16. Arizona Regulatory Questions: 1. Please indicate if this individual requires: Continuous nursing services..." A box next to "continuous nursing services" was marked to indicate R7 required continuous nursing services. The document was signed by a medical practitioner. 2. In an interview, E1 reported R7 does not receive continuous nursing services. E1 reported the box indicating R7 required continuous nursing services should not have been marked.”

“Based on record review and interview, the manager failed to ensure that a documented residency agreement included the signature and date of the individual designated to make health care decisions, for one of nine residents reviewed. Findings include: 1. A review of R1's medical record revealed R1 had a guardian. A review of R1's medical record revealed a residency agreement. The residency agreement did not include the signature and date of the individual designated to make health care decisions. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 and E8 acknowledged R1's residency agreement did not include a signature and date of the resident, the individual designated to make health care decisions, as required.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident, including medication administration, for one of nine residents sampled. The deficient practice posed a risk if services were not provided at the required amount, type, and frequency. Findings include: 1. A review of R1's medical record revealed a service plan. The service plan indicated R1 was to receive directed level of care and medication administration services. The service plan stated: "... Need: Cognition: Resident is not oriented to place; Service: Resident will receive safety checks to ensure their safety." The service plan did not include the amount, type, and frequency of safety checks to be provided for R1. 2. In an interview, the findings were reviewed with E1, who acknowledged R1 received directed care services, and the service plan did not include the amount, type, and frequency of services provided. This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan, for nine 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 service plan dated November 2, 2023. However, the service plan was not signed and dated by a nurse or medical practitioner 2. A review of R2's medical record revealed a service plan dated December 14, 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 3. A review of R3's medical record revealed a service plan dated on November 18, 2023. However, the service plan was not signed and dated by the resident or resident's representative, and a nurse or medical practitioner. 4. A review of R4's medical record revealed a service plan dated December 30, 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 5. A review of R5's medical record revealed a service plan dated November 24, 2023. However, the service plan was not signed and dated by a nurse or medical practitioner. 6. A review of R6's medical record revealed a service plan dated November 2, 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 7. A review of R7's medical record revealed a service plan dated December 28, 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 8. A review of R8's medical record revealed a service plan dated December 28, 2023. However, the service plan was not signed and dated by the resident or resident's representative, and the manager. 9. A review of R9's medical record revealed a service plan dated December 6, 2023. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 10. In an interview, E1 acknowledged the residents' service plans were not signed and dated by the resident or resident's representative, the manager, or by the nurse or medical practitioner who reviewed the service plans. This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”

“Based on record review and interview, the manager failed to ensure the caregivers providing services documented the services provided in the resident's medical record, for nine of nine sampled residents. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's, R2's, R3's, R5's, R6's, R7's, and R9's medical records revealed service plans dated between November 2, 2023 to December 28, 2023. The service plans indicated the residents required directed care services and medication administration services. A review of R1's, R2's, R3's, R5's, R6's, R7's, and R9's service plans indicated the resident's needed to receive regular safety checks, assistance with bathing, assistance with toileting and assistance with other activities in daily living. 2. A review of R4's medical record record revealed a service plan dated December 30, 2023. The service plan indicated R4 required personal care services and medication administration services. R4's service plan indicated R4 required assistance in bathing and other activities with daily living. 3. A review of R8's medical record revealed a service plan dated December 20, 2023. The service plan indicated R8 required personal care services, including assistance in dressing other activities in daily living. 4. In an interview, E1 reported there was no documentation of the services provided. E1 reported the facility was switching to a new electronic medical record system to track services rendered. Currently, the facility's documentation has been progress notes within the record. However, documentation was not always consistent. E1 acknowledged the manager failed to ensure a caregiver documented the services provided according to the service plan. E1 acknowledged the sampled medical records did not include documentation of the services provided to them from September 2023 to present. This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”

“Based on documentation review and interview, the manager failed to ensure a resident was treated with consideration. Findings include: 1. A review of facility documentation revealed an investigation report that occurred after an altercation between E3 and R2. The documentation included statements from other personnel members and documentation of self-reports to Adult Protective Services and Arizona Department of Health Services. A statement authored by E4 stated " On 10/17/23 our nurse [O2] brought it to my attention that a caregiver reported seeing another staff member [E3] holding [R2's] fists looking as if [E3] was trying to restrain [R2] from being able to strike someone... When [E3] was interviewed, [E3] admitted to [O2] and I about grabbing [R2's] wrists out of frustration and stated that [E3] did it to prevent [R2] from potentially striking people/residents. [E3] has been suspended pending investigation and will be terminated per no abuse policy in our community." 2. In an interview, E1 reported E3 was suspended following notification of the altercation, then terminated three days after the event. E1 acknowledged E3 did not treat R2 with dignity, respect, and consideration.”

“Based on documentation review and interview, the manager failed to ensure a resident was not subjected to a restraint. Findings include: Arizona Administrative Code (A.A.C.) R9-10-101.199. defines "Restraint" as "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 1. A review of facility documentation revealed an investigation report that occurred in response to an altercation between E3 and R2. The documentation included statements from other personnel members and documentation of self-reports to Adult Protective Services and Arizona Department of Health Services. A statement authored by E4 stated " On 10/17/23 our nurse [O2] brought it to my attention that a caregiver reported seeing another staff member [E3] holding [R2's] fists looking as if [E3] was trying to restrain [R2] from being able to strike someone... When [E3] was interviewed, [E3] admitted to [O2] and I about grabbing [R2's] wrists out of frustration and stated that [E3] did it to prevent [R2] from potentially striking people/residents. [E3] has been suspended pending investigation and will be terminated per no abuse policy in our community." 2. In an interview, E1 reported E3 was suspended following notification of the altercation, then terminated three days after the event. E1 acknowledged the manager failed to ensure a resident was not subjected to restraint.”

“Based on record review, interview, and observation, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of one resident receiving personal care services sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. The Compliance Officer observed R4 was nonambulatory at the time of the inspection. 2. A review of R4's medical record revealed R4 received personal care services and an undated document titled "Physician Referral to Assisted Living." The document stated "... 2. Does your patient require assistance in any of the areas below? If yes, please describe: Ambulation, help with bathing, walking, (fall risk)..." However, R4's medical record did not include evidence of a determination signed and dated by the resident's primary care provider at least once every six months throughout the duration of R4's condition. 3. In an interview, E1 acknowledged the examination required from the resident's primary care provider or other medical practitioner every six months during R4's residency was not available for review.”

“Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for two of two residents receiving directed care services sampled who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed R1 received directed care services and a document titled "Physician's Report," (dated 2021). The document stated "14. AMBULATORY STATUS: ... 2. For the purposes of fire clearance this patient is considered: Nonambulatory... b. If this patient is nonambulatory, this status is based upon: Both Physical and Mental Condition..." However, R1's medical record did not include evidence of a determination signed and dated by the resident's primary care provider at least once every six months throughout the duration of R1's condition. 2. In an interview, E1 acknowledged a determination was not signed and dated by the resident's primary care provider at least once every six months throughout the duration of the resident's condition. 3. A review of R9's medical record revealed R9 received directed care services and a document titled "Physician's Orders" dated September 19, 2022. The document stated "... Ambulatory Status: ... Unable to exit the community in an emergency without the assistance of another person..." However, R9's medical record did not include evidence of a determination at least once every six months throughout the duration of R9's condition 4. In an interview, E1 acknowledged the examination required from the resident's primary care provider or other medical practitioner every six months during R1's and R9's residency was not available for review.”

“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, for six of nine residents sampled. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. A review of R1's, R3's, R5's, R6's, R7's, and R8's medical records revealed documentation the resident's received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was not available for review. Based on R1's, R3's, R5's, R6's, R7's, and R8's date of acceptance, this documentation was required. 2. In an interview, E1 reported orientation to the exits was not typically conducted with residents living in the memory care unit. E1 acknowledged R1's, R3's, R5's, R6's, R7's, and R8's orientation to the exits and the route to be used when evacuating the assisted living facility was not in R1's, R3's, R5's, R6's, R7's, and R8's medical records.”

“Based on interview and record review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or assistant caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. Findings include: 1. A review of R2's medical record revealed a progress note dated December 31, 2023 at 10:34 AM. The note stated "TYPE OF INCIDENT: Sent to ER- FALL, INCIDENT DATE: 12/31/2023, INCIDENT TIME: 9:15 AM... DID THE RESIDENT RECEIVE MEDICAL CARE?: Yes; EMERGENCY SERVICES NOTIFIED: No; FAMILY NOTIFIED: Yes... ; DATE: 12/31/2023, TIME: 7:31 AM; PHYSICIAN NOTIFIED: Yes, ...; DATE: 12/31/2023; TIME: 10:00 AM;... LICENSING NOTIFIED: Yes, ...; DATE: 12/31/2023 TIME 9:55 AM." However, the notification made to the family was documented as being completed one hour and 44 minutes prior to the time of the incident and the title of the incident indicated the resident was "sent to ER" without any further details described. The note did not accurately document a description of the accident, emergency, or injury, the names of individuals who observed the emergency; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; or any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. A review of Department documentation revealed a report, the report documented a reported allegation of suspected abuse which occurred on or around November 1, 2023. The report stated, "... suspected resident to resident altercation ... found one resident [R5] on the ground and had a cut bleeding above [R5's] eye. There was also a broken lamp on the ground and [R6] was next to the lamp pieces. When both residents were asked what happened the injured resident [R5] stated that [R5] was hit in the face. [R6] was irate and unable to construct a coherent sentence... Safety Precautions were taken after this incident occurred. POA, PCP, ED, and Nurse Notified." 3. A review of the documentation provided on February 13, 2024 revealed the facility's investigation report of the aforementioned incident between R5 and R6. The investigation report included two documents stapled together. The first document was a typed summary of the investigation which did not include the name of the author. The second page of the investigation report included a document titled "Progress Notes for [R5]." The typed summary of the investigation indicated the alleged incident between R5 and R6 occurred on October 29, 2024 which stated "On Sunday 10/29 I was informed when I was out of the community that [R5] was found on the floor with a cut on [R5's] cheek area ... [E11] stated that [E11] found [R5] on the floor with a cut ... It was believed that resident [R6] possibly pushed [R5], but that was not confirmed. Also, the lamp was broken near the area ... we did APS self-report... [Hospice Nurse] evaluated [R5] to ensure that [R5] was okay and the other resident was admitted to [Behavioral Health Inpatient Facility]" However, the attached progress note indicated the incident occurred on a different date. The second page of the investigation report indicated the progress note was completed by E11 on October 29, 2023 at 3: 19 PM. E11's progress note indicated the incident took place on September 24, 2023 at 10:45 AM and identified the incident as an "unwitnessed injury fall." the progress note stated "... [R5] had cut above [R5's] right eye... Caregiver observed [R6] leaving [R5's] room... INJURIES: Cut, ABOVE RIGHT EYE RIGHT... WHAT DID YOU DO?: assist off floor and called hospice; DID THE RESIDENT RECEIVE MEDICAL CARE?: No; LICENSING NOTIFIED: Yes." The progress note indicated medical care was not provided to [R5]. However, the investigation summary, indicated the hospice nurse evaluated [R5]. The documentation provided did not accurately document, the date and time of the accident, emergency, or injury, a description of the accident, emergency, or injury, the names of individuals who observed the emergency; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; or any action taken to prevent the accident, emergency, or injury from occurring in the future. 4. In an interview, E12 reported E12 recently completed an audit of the facility and identified personnel members were inaccurately documenting notifications (to family, physician, etc..) in the system that were not actually completed. E12 reported the facility has implemented better procedures moving forward to ensure personnel accurately document incidents and notifications made by personnel members to the required individuals. This is a repeat deficiency from the complaint investigation conducted on September 19, 2023.”