North Star Adult Care Home.

“Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order for each medication that was administered to a resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1’s medical record revealed a medication order for Omeprazole 20 mg “take one tab orally twice a day” with a start date of February 2026. However, the order did not have a signature from a medical practitioner.  2. A review of R1’s medical record revealed an April 2026 MAR. The MAR revealed no documentation of Omeprazole 20 mg being administered.  3. The Compliance Officer observed an Omeprazole 20 mg blister pack with two pills missing. The Compliance Officer observed R1’s medication organizer with Omeprazole 20 mg inside the organizer.  4. In an interview, E1 reported E1 followed what was written on the MAR when administering medications. E1 reported E1 was aware the order for Omeprazole 20 mg was not signed.  5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered 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. A review of R1’s medical record revealed a current service plan dated November 2025. The service plan indicated R1 received medication administration.  2. A review of R1’s medical record revealed R1’s medication orders. R1 had a medication order for pantoprazole 40 mg, "administer one tablet daily,” with a start date of December 2025.  3. A review of R1’s medical record revealed an April 2026 medication administration record (MAR). The MAR stated, “pantoprazole 20 mg take one tab BID”. Pantoprazole was administered twice a day at 8 am and 5 pm. No medication order for “pantoprazole 20 mg take one tab BID” was provided at the time of the inspection. 4. A review of R1’s medical record revealed a medication order for Omeprazole 20 mg “take one tab orally twice a day” with a start date of February 2026. However, the order did not have a signature from a medical practitioner.  5. A review of R1’s medical record revealed an April 2026 MAR. The MAR revealed no documentation of Omeprazole 20 mg being administered.  6. The Compliance Officer observed an Omeprazole 20 mg blister pack with two pills missing. The Compliance Officer observed R1’s medication organizer with Omeprazole 20 mg inside the organizer.  7. In an interview, E1 reported E1 followed what was written on the MAR when administering medications. E1 reported E1 was aware the order for Omeprazole 20 mg was not signed.  8. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation, interview, and documentation review, the manager failed to ensure medication was stored according to the instructions on the medication container. The deficient practice posed a risk to the health and safety of the resident if the medication was not stored properly. Findings include: 1. The Compliance Officer observed Lorazepam 2mg was stored in the medication cabinet. The medication instruction label stated, "Refrigerate. Do not freeze.” 2. In an interview, E1 reported E1 did not notice the instruction label said to refrigerate the Lorazepam 2mg.  3. A review of facility documentation revealed policies and procedures. The policy titled, “Storage of Medications" stated, “6. Insulin and other medication that requires refrigeration should be stored in the refrigerator in a lock box.” 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. The Compliance Officer observed the following medications in an unlocked caregiver room: Ferrous Sulfate 325 mg Acetaminophen 500 mg Acetylsalicylic Acid 81 mg 2. The Compliance Officer observed ambulatory residents in the facility.  3. In an interview, E1 reported the medication did not belong to the residents but to a caregiver. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on documentation review, observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were stored 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. Review of Department documentation revealed the facility was licensed to the directed level of care.  2.The Compliance Officer observed an unlocked door that led to the garage. In the garage was a cabinet with a key in the keyhole. The following chemicals were found within the cabinet:  A spray bottle of Windex, Three bottles of Simple Green all purpose cleaner, A spray bottle of Clorox bleach all purpose cleaner, A bottle of the Pink Stuff cream cleaner,  A bottle of Soft Scrub cleanser A bottle of Finish Jet-Dry rinse aid, and; Two spray canisters of Pledge cleaner. 3. The Compliance Officer observed ambulatory residents. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on documentation, record review, and interview, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency.   Findings include:   1. A.R.S. 36-420.04.A 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 (HIPAA) 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."   2. A review of R1's medical record revealed no documentation or standardized form which included all information required by statute. 3. A review of R2's medical record revealed a standardized form which included all information required by statute. However, the form was not prefilled and did not include the medication list, Health Insurance Portability and Accountability Act release, or Directive as required by statute.   4. In an interview, E1 reported they were not aware of the requirement as R1 was receiving hospice services. E1 acknowledged the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A”

“Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff.   Findings include:   1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available.   2. In an interview, E1 reported E1 had not completed the annual risk assessment. E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted annually.”

“Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services and according to policies and procedures for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.   Findings include:   1. A review of E2's and E3's personnel records revealed no documentation verifying a caregiver's or assistant caregiver's skills and knowledge.   2. A review of the facility's employee schedule for February 2025 revealed E2 providing services the following dates from and times: - February 1, 2025 from 10:00PM to 6:30AM; - February 4 – February 8, 2025 from 10:00PM to 6:30AM; and - February 11 – February 14, 2025 from 10:00PM to 6:30AM.   3. A review of the facility's employee schedule for February 2025 revealed E3 providing services the following dates and times: - February 2, 2025 at 6:00AM – February 4, 2025 at 6:30AM; and - February 9, 2025 at 6:00AM – February 11, 2025 at 6:30AM;   4. In an interview, E1 acknowledged E2's and E3's skills and knowledge were not verified and documented before E2 and E3 provided physical health services.”

“Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two 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. A review of R1's medical record revealed a service plan from February 2025 that indicated R1 would receive the following services: - Incontinence care daily during days and nights every two hours; - Transfer two times daily using Hoyer lift; and - Grooming – Total care – AM and PM daily. However, no documentation verifying R1 received the aforementioned services was available for review.   2. A review of R2's medical record revealed a service plan from January 2025 that indicated R2 would receive the following services: - Toileting – Partial assist – Day, Night, and as needed; - Comb Hair - Twice daily; - Transfers - With Assist Of One Caregiver; and - Ambulates - With Assist Of One Caregiver. However, no documentation verifying Re received the aforementioned services was available for review.   3. In an interview, E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical records.”