The Oasis at Fellowship Square Surprise.

“Based on documentation review and interview, the assisted living center failed to provide a written document which covered A.R.S § 36-420.04.A.1-9, when the assisted living center contacted an emergency responder on behalf of the resident, for one of one resident sampled. Findings include: 1 . A review of R1's medical record revealed an incident where R1 was sent to the hospital by the facility on January 13, 2026. However, documentation of a written document presented to emergency medical services (EMS) that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of the incident was not available for review at the time of inspection. 2. In an exit interview, the finding was discussed with E1 and E2, and no additional information was provided.”

“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 six employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (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 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)." 2. 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." 3. A review of E2's personnel record revealed documentation of a completed chest X-ray. However, E2's personnel record revealed no documentation stating E2 had a prior positive TB test. E2's personnel record did not include documentation of a completed skin test or blood test required per CDC recommendation. 4. In an interview. E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date E2 began providing services at or on behalf of the assisted living facility”

“Based on record review and interview, the manager failed to ensure that a caregiver documented services provided in one resident's medical record. Findings include: 1. A review of R4's medical record contained a service plan dated April 22, 2025, for directed care services. A review of the service plan revealed a section titled Safety Checks that stated "every two hour visual checks while resident is unattended in room." However, there was no documentation available for review to demonstrate that this service was provided. 2. During an interview with E1, E1 reported that the service was provided to R4 and acknowledged that there was no documentation to demonstrate that this service was provided.”

“Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was maintained for at least 12 months after the date of the drill and included an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated.  Findings include:  1. A review of facility evacuation drill documentation revealed a drill was conducted on November 26, 2024. However, the documentation did not include an identification of residents needing assistance for evacuation and an identification of the residents who were not evacuated.  2. In an interview, E13 reported the facility used a resident roster to document the aforementioned information. E1 acknowledged the roster did not include an identification of the residents needing assistance for evacuation and an identification of residents who were not evacuated.”

“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 six residents 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 R5's medical record revealed a service plan, dated in January of 2024 for directed care services. However, a service plan after January 2024 was not available for review. 2. In an interview, E1 and E4 reported the service plan was reviewed and updated. However, the service plan was not available for the department to review at the time of inspection. 3. In an interview, E1 acknowledged R5 received directed care services and the current service plan was not available for the department to review at the time of inspection.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from a nurse or medical practitioner, for three of seven residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R4's medical record revealed written service plans dated October 2023 and January of 2024. The service plans indicated R4 received medication administration; however, these service plans were not signed and dated by a nurse or medical practitioner. 2. Review of R6's medical record revealed written service plan dated March of 2024. The service plans indicated R6 received medication administration; however, the service plan was not signed and dated by a nurse or medical practitioner. 3. Review of R7's medical record revealed a written service plan dated March of 2024. The service plan indicated R7 received medication administration; however, this service plan was not signed and dated by a nurse or medical practitioner.` 4. In an interview, E1 acknowledged R4's, R6's, and R7's service plans did not include a signature and date from a nurse or medical practitioner.”

“Based on observation, documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During the environmental tour, the Compliance Officer observed the facility provided medication administration services. 2. A review of facility documentation revealed a policy titled, "Medication Policies and Procedures." However the medication services policy and procedure was not reviewed by a medical practitioner, registered nurse, or pharmacist, signed and dated. 3. In an interview, E2 acknowledged the medication services policy and procedure was not reviewed by a medical practitioner, registered nurse, or pharmacist, signed and dated.”