The Gardens of Sun City.

“Based on documentation review and interview, the chief administrative officer failed to 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 potential TB exposure risk to residents as required information could not be verified. Findings include: 1. A review of facility documentation revealed no documentation demonstrating facility personnel assessed the health care institution’s risk of exposure to infectious TB. 2. In an interview, E1 reported facility personnel had not assessed the health care institution’s risk of exposure to infectious TB and documented said assessment within the last year. 3. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7 who offered no further comment. This is a repeat citation from the complaint and compliance inspection conducted on February 25, 2025.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of five caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings:  1. A review of facility documentation revealed a personnel schedule which indicated E8 worked on September 14-16, 2025. 2. A review of E8's personnel record revealed E6 was hired as a caregiver on September 12, 2025. The review revealed a photocopy of a caregiver certificate dated as issued on October 3, 2025, after E8 started working. 3. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed documentation of completion of a caregiver training program approved by the NCIA Board dated as issued on October 3, 2025. 4. In an interview, E2 reported E2 found out within a few days of hire that the caregiver certificate E8 originally provided upon hire was not valid. E2 reported E2 removed E8 from the schedule until E8 obtained a valid caregiver certificate. 5. A review of the aforementioned personnel schedules confirmed E2’s report. 6. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7 who offered no further comment.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the individual provided physical health services, for four of five sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Staffing and Training Requirements” dated June 1, 2025. The P&P stated: “5. Training Requirements: a. All care staff, including medication staff, will be training in accordance with state regulations. b. All training, including orientation, initial training, and annual training, will be documented in the employee’s file…e. Initial Training: ii. Care staff knowledge and skills will be verified and documented before staff are allowed to provide services to residents. 1. The Resident Care Director is responsible for verifying and documenting care staff skills and knowledge.” 2. A review of facility documentation revealed personnel schedules which indicated the following: - E8 worked on a regular basis in September 2025 and between January 2026 and March 2026, - E9 worked on a regular basis between August 2025 and March 2026, - E10 worked on a regular basis between May 2025 and March 2026, and - E11 worked on a regular basis in March 2026. 3. A review of R1’s, R2’s, R3’s, R4’s, R5’s, and R6’s medical records revealed documentation of assisted living services (ADLs) provided to the six residents as well as medication administration records (MARs), dated February 2026 and March 2026. The ADLs and MARs revealed E8, E9, and E10 provided services to residents in February 2026 and March 2026, and E11 provided services to residents in March 2026. 4. A review of E8’s, E9’s, E10’s, and E11’s personnel records revealed the following: - E8 was hired as a caregiver on September 12, 2025; - E9 was hired as a caregiver on July 22, 2025; - E10 was hired as a caregiver on May 15, 2025; - E11 was hired as a caregiver on March 16, 2026; and - No documentation demonstrating the manager, the Resident Care Director, or other facility personnel verified and documented E8’s, E9’s, E10’s, or E11’s skills and knowledge before the four caregivers started providing services. 5. In an interview, E1 reported E11 recently started working at the facility and may not have had E11’s skills and knowledge verified and documented just yet. E2 reported E2 had found caregivers without skills and knowledge verification documentation and that E2 was in the process of redoing them for several caregivers. 6. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7 who offered no further comment.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for five of five sampled caregivers. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution…and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. 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 specified 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)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel.” 4. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on February 25, 2025. The POC indicated this deficiency was corrected on March 14, 2025. 5. A review of facility documentation revealed personnel schedules dated between March 2025 and March 2026, which indicated the following: - E8 worked as early as September 12, 2025; - E9 worked as early as July 27, 2025; - E10 worked as early as May 16, 2025; - E11 worked as early as March 18, 2026; and - E12 worked as early as March 3, 2025. 6. A review of R1’s, R2’s, R3’s, R4’s, R5’s, and R6’s medical records revealed documentation of assisted living services (ADLs) provided to the six residents as well as medication administration records (MARs), dated February 2026 and March 2026. The ADLs and MARs revealed that E8, E9, and E10 provided services to residents in February 2026 and March 2026, and E11 provided services to residents in March 2026. 7. A review of E8’s personnel record revealed E8 was hired as a caregiver on September 12, 2025. The review revealed documentation of assessing risks of prior exposure to infectious TB and determining if E8 had signs or symptoms of TB dated after E8 began providing services. The review further revealed two negative TSTs dated as read after E8 began providing services. 8. A review of E9’s personnel record revealed E9 was hired as a caregiver on July 22, 2025. The review revealed documentation of assessing risks of prior exposure to infectious TB and determining if E9 had signs or symptoms of TB dated more than one year before E9 was hired, as well as other such documentation dated after E9 began providing services. 9. A review of E10’s personnel record revealed E10 was hired as a caregiver on May 15, 2025. However, the review revealed no documentation of assessing risks of prior exposure to infectious TB and determining if E10 had signs or symptoms of TB. 10. A review of E11’s personnel record revealed E11 was hired as a caregiver on March 16, 2026. The review revealed documentation of two negative TSTs dated as read more than two years before E11 began providing services. 11. A review of E12’s personnel record revealed E12 was hired as a caregiver on September 11, 2023. The review revealed documentation of determining if E12 had signs or symptoms of TB dated after E12 began providing services. The review further revealed a negative TST dated as read within one year before E12 was hired and a second negative TST dated as read after E12 was hired. However, the two TSTs were dated as read more than 12 months apart, and the review revealed no further documentation of TSTs or other TB tests as recommended by the CDC. 12. In an interview, E2 acknowledged the aforementioned issues with TB documentation. E2 reported not having further TB documentation for E8, E9, E10, E11, and E12. 13. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7, who offered no further comment. This is a repeat citation from the complaint and compliance inspection conducted on February 25, 2025.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for four of six residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. A review of R2's medical record revealed R2 was admitted to the assisted living facility more than seven days prior to the dates of the inspection. The review revealed a document titled “PHYSICIAN REPORT AND ADMISSION ORDERS - ARIZONA.” The document stated R2 was “Excused” from a TB test. The review further revealed an untitled document which indicated a physician ordered a TB blood test for R2 the day after R2 was admitted to the facility. However, the review revealed no result for the test. The review further revealed no documentation of assessing risks of prior exposure to infectious TB, determining if R2 had signs or symptoms of TB, or documentation of R2’s freedom from infectious TB. 3. In an interview, E2 reported the facility did not have the required TB documentation for R2. 4. A review of R4’s, R5’s, and R6’s medical records revealed R4, R5, and R6 were admitted to the assisted living facility more than seven days prior to the dates of the inspection. The review revealed documentation determining if R4, R5, and R6 had signs or symptoms of TB. However, the documents were dated more than seven days after R4, R5, and R6 were admitted to the facility respectively. The review further revealed no documentation of assessing risks of prior exposure to infectious TB. 5. In an interview, when the Compliance Officer informed E2 of the late and missing TB documentation, E2 stated, “Okay.” 6. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7, who offered no further comment. Technical assistance was provided on this rule during the complaint inspection conducted on February 25, 2026; the complaint and compliance inspection conducted on February 25, 2025; and the complaint inspection conducted on January 12, 2024.”

“Based on record review, interview, and observation, the manager failed to ensure a medication was administered in compliance with a medication order for five of six sampled residents. 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 that indicated R1 received medication administration. The review revealed a medication order for the following medications: - “Atorvastatin 40 mg oral tablet…TAKE 1 TABLET BY MOUTH DAILY,” - “Carvedilol 12.5 mg oral tablet…TAKE 1 TABLET BY MOUTH 2 TIMES DAILY WITH BREAKFAST AND DINNER,” - “Donepezil 10 mg oral tablet…1 tab, Oral…1 daily;” - “Gabapentin 600 mg oral tablet…1 tab, Oral, TID;” - “Hydrochlorothiazide-olmesartan 12.5 mg-40 mg oral tablet…1 tab…daily;” and - “Pantoprazole 40 mg oral delayed release tablet…TAKE 1 TABLET BY MOUTH EVERY DAY 30 MINUTES BEFORE BREAKFAST.” 2. A review of R1’s medical record revealed a series of medication administration records (MARs) dated February 2026 and March 2026. The MARs revealed the following: - R1 did not receive R1’s atorvastatin on February 1-28, 2026, and March 1-2, 2026; - R1 did not receive R1’s morning dose of carvedilol on February 11 and 13-27, 2026; - R1 did not receive R1’s evening dose of carvedilol on February 10, 12-15, and 17-28, 2026, and March 1-2, 2026; - R1 did not receive R1’s donepezil on February 9-10, 14-23, 25, and 28, 2026, and March 1, 3, 6-7, 11-15, 17-19, and 23, 2026; - R1 did not receive R1’s gabapentin on February 1-28, 2026, and March 1-23, 2026; - R1 received gabapentin 300 mg between one and three times a day on March 3-24, 2026, without a medication order; - R1 did not receive R1’s hydrochlorothiazide-olmesartan on February 1-28, 2026, and March 1-2, 2026; - R1 did not receive R1’s pantoprazole on February 25, 2026. 3. In an interview, E2 confirmed the medications were not administered because the facility did not have them on hand. Regarding the order for the gabapentin 300 mg, E2 stated, “If it’s not in the book, then we don’t have it.” 4. A review of R2’s medical record revealed a current service plan that indicated R2 received medication administration. The review revealed a medication order for “QUEtiapine Fumarate 25 mg Tab…1 tab po tid” dated October 19, 2025. The review further revealed MARs dated February 2026 and March 2026. The MARs revealed R2 did not receive R2’s evening (third) dose of quetiapine on February 19, 2026, or March 20, 2026, as the facility was “WAITING ON DELIVERY.” The MARs further revealed R2 did not receive R2’s morning and afternoon (first and second) doses of quetiapine on March 21, 2026, for the same reason. 5. A review of R3’s medical record revealed a current service plan that indicated R3 received medication administration. The review revealed a medication order for the following medications: - “ASPIRIN EC 81MG TAB CHEW AND SWALLOW 1 TABLET BY MOUTH EVERY OTHER DAY;” - “CLOPIDOGREL 75MG TAB TAKE 1 TABLET BY MOUTH EVERY DAY;” - “Isosorbide Mononitrate ER Oral Tablet…60 MG…Take one tablet by mouth daily;” - “METOPROLOL TART 25MG TAB TAKE 0.5 TABLET (12.5MG) BY MOUTH 2 TIMES DAILY;” - “Omeprazole 1 Tablet Enteric Coated ORAL 1 times a day…20 MG;” - “Oxybutynin Chloride Oral Tablet 5 MG…Take 1 tab by mouth every morning;” - “PHENAZOPYRIDINE 100MG TAB TAKE 1 TABLET BY MOUTH EVERY OTHER DAY;” - “POLYETH GLYCOL 3350 POWDER MIX 17GM (1 CAPFUL) WITH 8 OUNCES OF FLUID AND TAKE BY MOUTH EVERY OTHER DAY;” - “RANOLAZINE ER 500MG TAB TAKE 1 TABLET BY MOUTH EVERY DAY;” and - “STIMULANT LAX [SENNOSIDES] 8.6MG-50MG TAB TAKE 2 TABLETS BY MOUTH 2 TIMES DAILY.” 6. A review of R3’s medical record revealed a series of MARs dated February 2026 and March 2026. The MARs revealed the following: - R3 did not receive R3’s aspirin on February 28, 2026; - R3 did not receive R3’s clopidogrel on February 16-25 and 27-28, 2026, and March 3-5, 8-17, and 19-24, 2026; - R3 did not receive R3’s isosorbide mononitrate on February 28, 2026, and March 1-3, 2026; - R3 did not receive R3’s morning (first) dose of metoprolol on February 28, 2026, and March 17 and 24, 2026; - R3 did not receive R3’s afternoon (second) dose of metoprolol on February 28, 2026; - R3 did not receive R3’s omeprazole on February 23-25 and 28, 2026, and March 1-3, 2026; - R3 did not receive R3’s oxybutynin on February 27-28, 2026, and March 1-3, 5, 9, and 24, 2026; - R3 did not receive R3’s phenazopyridine on February 13, 2026; - R3 did not receive R3’s polyethylene glycol on February 14, 22, and 28, 2026, and March 16, 2026; - R3 did not receive R3’s ranolazine on February 5, 8-10, 14-23, and 27, 2026, and March 1-5, 8-17, and 19-24, 2026; - R3 did not receive R3’s morning (first) dose of sennosides on February 22, 2026, and March 9-16, 2026; and - R3 did not receive R3’s afternoon (second) dose of sennosides on February 20, 22-23, and 25, 2026, and March 8-10, 12-16, and 18-19, 2026. 7. The Compliance Officer observed R3’s metoprolol and oxybutynin pharmacy bottles. The Compliance Officer observed one-half tablet of metoprolol remaining and no tablets of oxybutynin remaining. 8. In an interview, E2 reported the facility did not have R3’s clopidogrel and ranolazine on hand. 9. A review of R4’s medical record revealed a current service plan that indicated R4 received medication administration. The review revealed a medication order for “Atorvastatin Calcium Oral Tablet 20 MG…Give 1 tablet by mouth at bedtime” and “dilTIAZem HCI ER Oral Capsule…120 MG…Give 1 capsule by mouth one time a day” dated January 14, 2026. The review further revealed a MAR dated February 2026. The MAR revealed R4 did not receive R4’s atorvastatin on February 8, 2026, or R4’s evening (second) dose of diltiazem on February 21-22, 2026. 10. A review of R5’s medical record revealed a current service plan that indicated R5 received medication administration. The review revealed a medication order for “HYDROcodone 5 mg-acetaminophen 325 mg tablet…one tab TID, dated August 20, 2025. The review further revealed a MAR dated February 2026. The MAR revealed R5 did not receive R5’s morning (first) dose of hydrocodone/acetaminophen on February 19-21, 2026; R5’s afternoon (second) dose of hydrocodone/acetaminophen on February 18-21, 2026; and R5’s evening (third) dose of hydrocodone/acetaminophen on February 18-19 and 21, 2026. 11. In an interview, E2 reported R5 did not receive R5’s evening (third) dose of hydrocodone/acetaminophen on February 20, 2026, either. E2 reported that a caregiver mistakenly documented the administration and no longer works at the facility. 12. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7, who offered no further comment.”

“Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a series of personnel schedules dated between March 2025 and March 2026. The schedules revealed three shifts labeled as “AM,” “PM,” and “NOC.” 2. In an interview, E2 reported that the facility utilized three shifts. 3. A review of facility documentation revealed no documentation of disaster drills for employees dated within the last year. 4. In an interview, E1 reported that E1 did not have access to the system used to document disaster drills. E1 reported that the previous maintenance director was the individual with access, but no longer worked for the facility. 5. In the exit interview, the Compliance Officer reviewed the findings with E1, E2, E3, E4, E5, E6, and E7, who offered no further comment.”

“Based on documentation review, interview, and observation, the governing authority failed to designate, in writing, a manager who had a certificate as an assisted living facility manager. The deficient practice posed a risk as the assisted living facility did not have a certified manager for more than one month. Findings include: 1. A review of Department documentation revealed an email from E3 dated December 30, 2025, which stated, “Effective today, 12/30/2025 I am no longer the manager at The Gardens of Sun City.” The review further revealed notification of E1’s appointment as manager effective February 2, 2026. The review revealed no documentation of a manager between December 31, 2025, and February 1, 2026. 2. In an interview, when the Compliance Officer asked who the current manager was, E4 reported that E1 was the current manager. When the Compliance Officer asked about previous management, E4 reported that E3 was the manager before E1. E4 reported E2 was the interim manager between E3 and E1 and was at the facility before E3 ended E3’s appointment and after E1 began E1’s appointment. 3. A primary review of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board) website conducted during the inspection revealed E2’s manager certificate had expired on June 30, 2015, more than ten years before the date of the inspection. 4. In an interview, when the Compliance Officer informed E4 that E2’s manager's certificate was not valid, E4 reported that E4 would check with the business office manager and other management. 5. The Compliance Officer observed a text message from E2 shared with the Compliance Officer by E4. In the text message, E2 stated: “Remember my certification is CA not AZ. During the time I was at Sun City, I was in a pending status waiting for Recert Admin process. My name did not show under active, but it did show under pending.” 6. In the exit interview, the Compliance Officer reviewed the findings with E4 and E4 offered no further comment. 7. A series of secondary reviews of the NCIA Board website conducted between the date of the inspection and April 1, 2026, confirmed E2’s manager certificate had expired on June 30, 2015, and did not indicate E2’s manager certificate was in pending status. 8. In a series of messages, a representative of the NCIA Board confirmed E2 did not submit an application for renewal of E2’s manager certificate after it expired in 2015.”

“Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff.    Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)...c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis..." 2. Review of facility documentation revealed a policy titled "IC15 - Tuberculosis: Care Staff". The policy stated "7. Northstar Senior Living will provide annual education to staff and volunteers regarding the signs and symptom of TB."  3. Review of E2's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. In an interview, E1 acknowledged the facility had not established, documented, and implemented a TB infection control program as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of five employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of E4's personnel record revealed completion of two-step TST testing. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the E4 had signs or symptoms of TB was available for review. 3. In an interview, E1 acknowledged E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date E4 began providing services at or on behalf of the assisted living facility.”

“Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to indicate if an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services, and whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of seven residents sampled. Findings include: 1. A review of R5's medical record revealed documentation titled "Physician Report and Admission Orders - Arizona" used to indicate whether R5 required continuous medical services, continuous or intermittent nursing services, or restraints dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. However documentation was not completed and was marked "unknown" and did not include if R5 was expected to receive supervisory care services, personal care services, or directed care services. 2. In an interview, E1 acknowledged R5 did not submit documentation signed by a medical practitioner or a registered nurse which stated whether R5 was requesting or is expected to receive supervisory care services, personal care services, or directed care service. E1 acknowledged the documentation did not indicate if R5 required continuous medical services, continuous or intermittent nursing services, or restraints.”

“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 seven 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 R3's medical record revealed a directed care service plan from November 2025, that indicated R3 would receive the following services: - Skin integrity, impaired – Observe skin (entire body) with showers and incontinent care and report any changes, problems, or concerns; - Grooming - Needs help brushing hair due to shoulder pain; - Transfers – Total Assist; and - Toileting – Total Assist – Toileting assistance with transfers and changing briefs.   2. A review of R3’s medical record revealed a document titled “Care Notes: Upper Partial” which documented the following services provided to R3: - Bathing – Two person assist – Sunday and Wednesday in the PM; and - Toileting – Total Assist – Toileting assistance with transfers and changing briefs. However, no documentation of “Skin integrity, impaired” being provided to R3 per R3's service plan was available for review.   3. A review of R3’s medical record revealed a document titled “Care Notes: Upper Partial” for February 2025. The Care Notes revealed the following services and dates were not documented as completed: - Grooming – Needs help brushing hair due to shoulder pain:                - February 8, 2025 – First and Second Shifts;                - February 15, 2025 – First Shift;                - February 17, 2025 – Second Shift;                - February 22, 2025 – Second Shift;                - February 23, 2025 – Third Shift; and                - February 24, 2025 – First and Second Shifts. - Transfers – Total Assist:                - February 8, 2025 – First and Second Shifts;                - February 9, 2025 – Third Shift;                - February 10, 2025 – Third Shift;                - February 15, 2025 – First Shift;                - February 17, 2025 – Second Shift;                - February 20, 2025 – First Shift;                - February 21, 2025 – First Shift;                - February 22, 2025 – Second Shift;                - February 23, 2025 – First and Third Shifts; and                - February 24, 2025 – First and Second Shifts. - Toileting – Total Assist – Toileting assistance with transfers and changing briefs:                - February 9, 2025 – Third Shift;                - February 10, 2025 – Third Shift;                - February 15, 2025 – First Shift;                - February 17, 2025 – Second Shift;                - February 20, 2025 – First Shift;                - February 21, 2025 – First Shift;                - February 22, 2025 – First and Second Shifts;                - February 23, 2025 – First and Third Shifts; and                - February 24, 2025 – First and Second Shifts.     4. In an interview, E1 reported R3 received all assisted living services included in R3's service plan. E1 acknowledged a caregiver failed to document the services provided in R3's medical record.”

“Based on record review and interview, the manager failed to ensure a caregiver documented services provided to a resident in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to verify required services were provided to a resident. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services. The service plan indicated R1 required "[Daily] Bathing, assistance...Resident will be clean and odor free daily. Effective March 7, 2023." Further review of R1's medical record revealed activities of daily living (ADL) logs. A review of R1's May 2023 ADL log revealed blank gaps indicating R1 did not receive daily bathing assistance on May 18, 23-24, and 31, 2023. Additionally, the ADLs did not include documentation indicating R1 refused or did not require this service. 2. A review of R2's medical record revealed a current service plan for personal care services. The service plan indicated R2's required "Bathing Stand By Assist...Resident will receive physical assistance to bathe as well as to transfer in and out of shower as needed. Effective May 30, 2023." Further review of R2's medical record revealed ADL logs. A review of R2's November 2023 ADL log revealed blank gaps indicating R2 did not receive bathing assistance on November 28 and 31, 2023. Additionally, the ADLs did not include documentation indicating R2 refused or did not require this service. 3. In an interview, the Compliance Officer asked E3 if R1 and R2 were out of the facility on the aforementioned dates. E3 stated, "No, caregivers didn't document services." E3 acknowledged a caregiver did not provide assistance with activities of daily living according to R1's and R2's service plan.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's, R2's, R3's, R4's, R5's, R6's and R7's medical records revealed no documentation to indicate R1, R2, R3, R4, R5, R6 and R7 were oriented to exits from the assisted living facility. 2. In an interview, E1 acknowledged the manager failed to ensure R1's, R2's, R3's, R4's, R5's, R6's and R7's medical records contained documentation of R1's, R2's, R3's, R4's, R5's, R6's and R7's orientation to exits from the assisted living facility.”

“Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed documentation of a disaster plan review. However, the documentation did not include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. 2. In an interview, E1 acknowledged the manager failed to ensure the disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.”