East Valley Mansion Assisted Living.

“Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services dated September 11, 2023. However, a service plan after September 11, 2023 was not available for review. 2. In an interview, E1 and E2 acknowledged R2 received directed care services and the service plan was not updated at least once every three months.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R2's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R2's medical record did not include current documentation that showed the flu and pneumonia vaccinations were received or refused.”

“Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of one sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan for personal care services dated October 22, 2024. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. In an interview, E1 and E2 acknowledged R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.”

“Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included: strategies to ensure a resident's personal safety; documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service, for one of one sampled residents receiving directed care services. The deficient practice posed a health risk to the resident. Findings include: 1. Review of R2's medical record revealed a current written service plan dated September 11, 2023 that stated R2 required directed care services. This service plan revealed no documentation of strategies to ensure personal safety, and documentation of the resident's weight. R2's medical record contained no documentation from a medical practitioner stating that weighing the resident was contraindicated. There was no documentation regarding coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan. 4. During an interview, E1 and E2 acknowledged R2's service plan did not include documentation of all the requirements for a resident receiving directed care services.”

“Based on observation, documentation review, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closed, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed a file cabinet that contained five residents' medication boxes. The cabinet was equipped with a locking mechanism, however, the cabinet was not locked. 2. During the environmental inspection of the facility, the Compliance Officer observed the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E2 acknowledged medications were stored in an unlocked manner and accessible to residents.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility with E2, the Compliance Officer observed an unlocked cabinet in the kitchen near the sink that contained the following: -Hot Shot Flying Insect Killer; -Easy-Off oven cleaner; -Cascade dishwashing detergent; -Raid insect killer; -Clorox disinfecting wipes; and -two cans of Glade Odor Eliminating aerosol 2. During the environmental inspection of the facility with E2, the Compliance Officer observed an unlocked cabinet in a resident's bedroom that contained the following: -Lysol disinfecting wipes; -Lysol toilet bowl cleaner; and -Glade Odor Eliminating air spray 3. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.”