A Golden Retreat Care Home, LLC.

“Based on observation, record review, and interview, for two of two caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to a resident if a caregiver did not have the documented skills and knowledge to provide wound care services for a resident.   Findings include: 1. In observation, the Compliance Officer observed R1 in bed, and had an open wound on the sacrum. 2. In record review, R1's medical record included a progress note from O1, dated April 8, 2025, which documented R1 had a "pressure Ulcer Stage 4... 4.6 x 4.5 x 1.5 cm...," and received treatment from O1, since March 18, 2025. The note documented, "... Cleanse with Sterile Wound Cleanser. Pat Dry. Fill loosely with filler Collagen Dry Form. Dress with Ca. Alginate Rope, cover with Gauze and super absorbent dressing, and secure with Retention Tape. Change dressing every 2 days and PRN for loss of Integrity/Soiling." 3. In record review, R1's record (received directed care and medication administration services) included a document titled, "Assisted Living Facility Daily Activity Record." The Record had a section titled "Apply Skin Barrier... Skin Condition/Wound Care," which had a check mark documented every day from April 1 - 20, 2025, and signed by E2. 4. During an interview, E1 reported the caregivers, including E1, observed O1 provide wound care for R1, and then provided R1 with wound care services, as needed, when R1's bandage became wet or soiled. E1 acknowledged the verification of the caregivers' skills and knowledge for providing wound care services was not documented, as required.”

“Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident's service plan was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk to a resident if the resident's service plan was not updated when the resident developed a stage 4 pressure ulcer, and the service plan did not include the services provided. Findings include: 1. In observation, the Compliance Officer observed R1 in bed and had a wound on the sacrum. 2. In record review, R1's medical record included a progress note from O1, dated April 8, 2025, which documented R1 had a "pressure Ulcer Stage 4... 4.6 x 4.5 x 1.5 cm...," and received treatment from O1, since March 18, 2025. 3. In record review, R1's record (received directed care and medication administration services) indicated R1's pressure ulcer was documented by E1 on March 12, 2025. 4. In record review, R1's service plan, dated March 1, 2025, was not updated to reflect R1's wound, and skin maintenance services provided for R1. 5. During an interview, E1 reported R1's pressure ulcer was observed on or around March 12, 2025, and acknowledged R1's service plan was not reviewed and updated, as required.”

“Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk if services were not provided per the physician's order, and/or the services provided could not be verified. Findings include: 1. In observation, the Compliance Officer observed R1 in bed and had an open wound on the sacrum. 2. In record review, R1's medical record included a progress note from O1, dated April 8, 2025, which documented R1 had a "pressure Ulcer Stage 4... 4.6 x 4.5 x 1.5 cm...," and received treatment from O1, since March 18, 2025. The note documented, "... Cleanse with Sterile Wound Cleanser. Pat Dry. Fill loosely with filler Collagen Dry Form. Dress with Ca. Alginate Rope, cover with Gauze and super absorbent dressing, and secure with Retention Tape. Change dressing every 2 days and PRN for loss of Integrity/Soiling." 3. In record review, R1's record (received directed care and medication administration services), included a document titled, "Assisted Living Facility Daily Activity Record." The Record had a section titled "Apply Skin Barrier... Skin Condition/Wound Care," which had a check mark documented every day from April 1 - 20, 2025. R1's record did not include documentation that indicated O1's treatment plan orders were followed. 4. During an interview, E1 reported the caregivers observed O1 provide wound care for R1, and followed O1's treatment plan. However, E1 acknowledged the wound care services provided for R1 were not documented in R1's record.”

“Based on record review and interview, for one of two residents reviewed, who received medication administration, the manager failed to ensure a resident's medical record included the dosage of medication administered to the resident. The deficient practice posed a risk if documentation of a medication administered to a resident did not include the dosage administered to the resident, ensuring the resident was administered the correct dosage per the resident's medication order.   Findings include: 1. A review of R2's medical record (received directed care and medication administration services) included a medication order dated January 2, 2025, for: Insulin Lispro Injection Solution 100 u/ml. inject as per sliding scale SQ (Subcutaneous), AC (before meals), and HS (at bedtime). 130 - 150 - 8U 151 - 180 - 12U 181 - 210 - 16U 211 - 250 - 20U 2. In record review, R2's medication administration record (MAR), dated March and April 2025, included documentation of the medication order (noted above); however, the MAR indicated R2 received "Insulin Lispro Injection Solution...at 11:15 am and 4:15 pm daily, and not before meals and at bedtime, as ordered." The MARs also did not include the dosage of Insulin administered to R2. 3. During an interview, E1 reported R2 was administered Insulin at 11:15 am and 4:15 pm, daily, and not before meals and at bedtime, due to an issue with R2's insurance coverage, and not being able to procure the medication. E1 acknowledged the caregivers did not document the dosage of insulin administered to R2 daily.”

“Based on observation, record review, and interview, the manager failed to ensure the facility did not retain a resident who had a stage 4 pressure sore, without obtaining a signed and dated determination from a registered nurse (RN) or medical practitioner (MP), according to R9-10-814(B)(2). The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: R9-10-814(B)(2) states: B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident's representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility; and c. The resident's service plan includes the resident's increased need for personal care services. 1. In observation, the Compliance Officer observed R1 in bed, and had an open wound on the sacrum. 2. In record review, R1's medical record included a progress note from O1, dated April 8, 2025, which documented R1 had a "pressure Ulcer Stage 4... 4.6 x 4.5 x 1.5 cm...," and received treatment from O1, since March 18, 2025. 3. In record review, R1's record included documentation of a determination, dated November 11, 2024, and signed by a "Physician." The determination had a check mark and date of "3/12/2025," by "has stage 3/4 pressure sore as determined by a registered nurse medical practitioner..." 4. During an interview, E1 reported [E1] added the date of "3/12/2025," and documentation of the pressure sore, to the determination dated "11/14/2024." E1 acknowledged the facility retained R1, who developed a stage 4 pressure sore, without obtaining a signed and dated determination from an RN or MP, stating the resident's needs could be met by the facility within the facility's scope of services.”

“Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to a resident if the facility did not administer medication in compliance with a medication order, and a resident did not receive medication as ordered.   Findings include: 1. A review of R2's medical record (received directed care and medication administration services) included a medication order dated January 2, 2025, for: Insulin Lispro Injection Solution 100 u/ml. inject as per sliding scale SQ (Subcutaneous), AC (before meals), and HS (at bedtime). 130 - 150 - 8U 151 - 180 - 12U 181 - 210 - 16U 211 - 250 - 20U 2. In record review, R2's MAR, dated March and April 2025, included documentation of the medication order (noted above); however, the MAR indicated R2 received "Insulin Lispro Injection Solution... at 11:15 am and 4:15 pm daily, and not before meals and at bedtime, as ordered." 3. During an interview, E1 reported R2 was administered Insulin at 11:15 am and 4:15 pm, daily, and not before meals and at bedtime, due to an issue with R2's insurance coverage, and not being able to procure the medication. E1 acknowledged R2 was not provided medication administration in compliance with the medication order. 4. In record review, R2's medical record included a medication order, dated January 2, 2025, for Hydralazine 25 mg - 1 tab po Q 12 hours PRN for SBP > 155; DBP > 95 mm Hg. 5. A review of R2's MAR dated March and April, 2025, revealed the following discrepancy in the administration of the Hydralazine medication to R2: March 2025, MAR: March 9, R2's record included one BP measurement and not every 12 hours as ordered March 17, R2's BP was 152/86 and 146/82, and R2 was administered the medication at 7 am. March 22, R2's BP was 140/80, and R2 was administered the medication at 7 pm. March 24, R2's BP was 169/84, and there was no documentation R2 was administered the medication. March 31, R2's BP was 155/80, and there was no documentation R2 was administered the medication. April 2025, MAR: April 5, R2's BP was 115/80, and R2 was administered the medication. 6. During an interview, E1 acknowledged R2's Hydralazine medication administration documentation was not consistent with the medication order. This is a repeat deficiency from the inspections conducted on August 1, 2022 and on August 4, 2023.”

“Based on observation and interview, the manager failed to ensure a resident bathroom contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a health risk, if staff and residents did not have access to paper towels or a mechanical air hand dryer. Findings include: 1. During an environmental inspection, the Compliance Officer observed a resident bathroom had a paper towel dispenser; however, it was empty. A hand towel was observed hanging by the sink. 2. During an interview, E1 reported the bathroom was shared by three residents, and acknowledged the bathroom did not contain paper towels or a mechanical air hand dryer.”

“Based on documentation, record review, and interview, for two of two residents reviewed, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04. The deficient practice 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. In record review, the medical records for R1, and R2 did not include a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04, noted above. 3. In record review, R2's medical record indicated R2 had a medical emergency on April 20, 2025, and was transported to the hospital by EMS. The record did not include documentation that a standardized form was provided to EMS.   4. During an interview, E1 acknowledged the medical records for R1 and R2 did not include a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.”