Bridgewater la Cholla Operations, LLC.

“Based on documentation review, record review, and interview, the manager failed to maintain a personnel record which included all items required by this rule for three of five sampled employees. The deficient practice posed a risk as the required information could not be verified.     Findings include:     1. A review of facility documentation revealed a series of personnel schedules which indicated E3, E4, and E5 worked numerous shifts in November and December of 2025.     2. A review of E3’s, E4’s, and E5’s personnel records revealed evidence of documentation of each employee’s orientation, verification of skills and knowledge, and documentation demonstrating compliance with A.R.S. 36-411(C), was unavailable for review. Furthermore, evidence of documentation indicating E4 was compliant with A.R.S. 36-411(A) was unavailable for review. Lastly, evidence of documentation indicating E5 was a certified caregiver was unavailable for review.     3. Research conducted through the Arizona Department of Public Safety, https://psp.azdps.gov/services/cardStatusRequest, revealed E4 did have a valid fingerprint clearance card.     4. Research conducted through https://azcg.tmutest.com/ revealed E5 was a certified caregiver.     5. In an exit interview, the findings were reviewed with E1, who indicated E3, E4, and E5 were hired through a staffing agency. E1 provided no additional information.”

“Based on record review and interview, for three of eight residents sampled, the manager failed to ensure a resident had a written service plan, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager and a nurse or medical practitioner. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.       Findings include:     1. A review of R1’s medical record revealed a service plan dated December 8, 2024, indicating R1 received personal care services. The service plan included a signature page with a line for the “Resident or Resident Representative” to sign. However, the signature line was blank. Furthermore, as R1 was identified as receiving personal care services, R1 was required to have an updated service plan no less than six months from December 8, 2024. However, evidence of a current service plan dated within six months of December 8, 2024, was unavailable for review.     2. A review of R4’s medical record revealed a service plan dated October 20, 2025, indicating R4 received personal care services. The service plan was signed by the manager and nurse, and R5’s representative's name was listed on the plan. However, the signature line for the “Resident or Resident Representative” was blank.     3. A review of R5’s medical record revealed a service plan dated September 15, 2025, indicating R5 received directed care services. The service plan was signed by the manager and nurse, and R5’s representative's name was identified on the service plan; however, the signature line for R5’s representative was blank.     4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.     This is a repeat citation from a compliance and complaint survey conducted on October 21, 2025, a complaint investigation conducted on October 3, 2025, and a complaint investigation conducted on July 29, 2025.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential risk to infection control.   Findings include:    1. During a tour of the facility, the Compliance Officer observed a dark stain in the carpeting of a hallway of a residential unit. The stain appeared to be dry, continued down the hallway for several feet, and at its widest point measured approximately eight inches in diameter.      2. In an interview, E1 denied any knowledge as to what liquid may have caused the stain.     3. During the environmental tour, the Compliance Officer observed kitchen areas in Villa 2 and Villa 3, used for staging areas to serve food and store snacks for residents. Inside several cabinets in each kitchen area, the Compliance Officer observed what appeared to be rodent droppings.     4. In an interview, E8 advised the kitchen cabinets in Villa 2 were cleaned nightly. When the Compliance Officer showed E8 the rodent droppings in the cabinets, E8 advised the cabinets were cleaned “almost every night,” or as needed.     5. In an interview, E1 advised the facility did not have a current contract with a pest control company. E1 affirmed meals were not prepared in the kitchen areas of each Villa, but were rather prepared in the facility’s main kitchen. E1 said the Villa kitchen areas were only used to serve meals from and to store snacks for residents.     6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, document review and interview, the manager failed to ensure a pest control program, compliant with A.A.C. R3-8201(C)(4) was implemented and documented.       1. During a tour of the facility, the Compliance Officer observed kitchen areas in Villa 2 and Villa 3, used for staging areas to serve food and store snacks for residents. Inside several cabinets in each kitchen area, the Compliance Officer observed what appeared to be rodent droppings.     2. A review of facility documentation revealed an invoice from a pest control company for services rendered on April 21, 2025. Evidence of documentation of pest control services provided since April 21, 2025, was unavailable for review.     3. In an interview, E1 advised they were not aware of any pest control services at the facility since April 21, 2025. E1 stated the facility did not have a current contract with a pest control company.      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 poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents.       Findings include:       1. During a tour of the facility, the Compliance Officer observed a caregiver work area which was open and unoccupied. The Compliance Officer observed multiple cabinets in the work area, each affixed with locking mechanisms which required a magnetic key to secure and open. Several of the cabinets were left unsecured, and the Compliance Officer was able to open them with little effort. Inside one of the cabinets, the Compliance Officer observed a plastic spray bottle of “Ecolab Grease Express” degreaser, a can of “Comet” scouring powder, and a spray bottle of “Waxie-Green Glass & Surface Cleaner.” Each of the containers was marked “CAUTION KEEP OUT OF REACH OF CHILDREN.” An unlabeled, clear plastic bottle containing a yellow liquid, similar in color to the Waxie glass and surface cleaner, was also observed.        2. In an interview, E1 acknowledged the cleaners were not kept in a secure area, inaccessible to residents.      3. In an exit interview, the findings were reviewed with E1, 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 two of seven employees sampled. The deficient practice posed a potential TB exposure risk to residents.       Findings include:       1. A review of E1’s (date of hire August 25, 2025) personnel record revealed evidence of documentation of two negative skin tests for TB, administered seven days apart, in January 2024.  However, evidence of documentation of any additional negative skin tests for TB conducted within twelve months of E1’s date of hire was unavailable for review. Furthermore, evidence of documentation of a baseline assessment of signs and symptoms, or risk of exposure to active TB, signed by a registered nurse, medical provider, or local health authority, within twelve months of E1’s date of hire, was unavailable for review.      2. A review of E9’s personnel record revealed evidence of documentation of a negative T-Spot test for TB. However, documentation of a baseline assessment of signs and symptoms, or risk of exposure to active TB, signed by a registered nurse, medical provider, or local health authority, within twelve months of E9’s date of hire, was unavailable for review.       3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, for one of six caregivers sampled, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR), and first aid training.       Findings include:       1. A review of E5’s personnel record revealed evidence of documentation of current (CPR) or first aid training was not available for review.       2. A request was made to review E5's current CPR and first aid training card(s), and E1 was able to produce an image of E5's current CPR and first aid training card.       3. In an interview, E1 acknowledged E5's personnel record did not include documentation of E5's current CPR and first aid training.”

“Based on record review and interview, for three of seven residents sampled, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents.       Findings include:       1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline 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 [TB], ii. Determining if the individual has signs or symptoms of [TB].”       2. A review of R2’s and R7’s medical records revealed evidence of documentation of a negative skin test for TB. However, evidence of baseline screening for signs and symptoms of, and risk assessment for exposure to TB, was unavailable for review.       3 A review of R4’s medical record revealed evidence of documentation of a negative test for TB, and a baseline screening for signs and symptoms of, and risk assessment for exposure to TB, was unavailable for review.       4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a written notice of termination of residency included the date of the notice, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-term Care Ombudsman.       Findings include:       1. A review of R4’s medical record revealed a letter regarding R4’s “30-day notice to vacate due to non-compliance.” The letter included the reason for the termination of R4’s residency. However, the letter did not include the date of the notice, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-term Care Ombudsman as required.       2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, for two of seven residents sampled, the manager failed to ensure, when initially developed and when updated, a resident's service plan was signed and dated by the resident or the resident’s representative, and the manager. The deficient practice posed a risk if a resident was unable to exercise the right to participate or have the resident's representative participate in the development of, or decisions concerning, the resident's service plan.       Findings include:       1. A review of R3’s medical record revealed a service plan for Directed care services, dated August 26, 2025. The service plan included a section for signatures of parties involved in the development of the plan; however, the service plan was not signed by R3’s representative, a nurse or medical practitioner, or the manager.       2. A review of R7’s medical record revealed a service plan for Directed care services, dated September 15, 2025. The service plan included a section for signatures of parties involved in the development of the plan; however, the service plan was not signed by R7’s representative or the manager.       3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.        This is a repeat citation from a complaint investigation conducted on July 29, 2025, and a monitoring inspection conducted on October 3, 2025.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for pneumonia, according to A.R.S. § 36-406(1)(d), for four of seven residents sampled. The deficient practice posed a potential illness risk to residents.       Findings include:       1. A.R.S. § 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 license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."       2. A review of R1’s, R4’s, R5’s, and R6’s medical records revealed evidence of documentation indicating the flu and pneumonia vaccines were made available to each resident in February 2024. However, evidence of documentation indicating the flu and pneumonia vaccines were made available to each resident since February 2024 was unavailable for review.       3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.       This is a repeat deficiency from a complaint inspection conducted on November 15, 2025.”

“Based on document review and interview, the manager failed to ensure the disaster plan required in R9-10-819(A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.     Findings include:     1. A review of facility documentation revealed a disaster plan compliant with R9-10-819(A)(1). However, evidence of documentation the disaster plan had been reviewed within the previous twelve months was unavailable for review.     2. In an interview, E4 advised they did not know when the disaster plan had last been reviewed.     3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on document review and interview, the manager failed to ensure an evacuation drill was conducted at least every six months.       Findings include:       1. A review of facility documentation revealed evidence of documentation of an evacuation drill conducted on April 18, 2025. However, evidence of documentation of an evacuation drill conducted in the 6 months following April 18, 2025, was unavailable for review.       2. In an interview, E4 advised they were unable to locate documentation of any evacuation drill conducted after April 18, 2025.         3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, for three of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative. 2. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 3. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative. 4. In an interview, E1 and E2 acknowledged the service plans for R3, R5, and R7 were not signed as required by the resident or resident's representative. E2 took the unsigned service plans and met with each of the three resident’s and obtained resident signatures during the inspection.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record for seven of seven resident records 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 R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for September 2025. The document recorded the service provided and initials of the person who provided the service.   2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025;  - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025. 3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on September 29, 2025, and October 1, 2025; - “Bathing: Full Assistance”, on September 29, 2025; - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; - “Dressing: Full Assistance”, on September 29, 2025, and October 1, 2025; - “Full Mobility Assistance (Every 3-6 Hours)”, on September 29, 2025, and October 1, 2025; - “Grooming Moderate Assistance”, on September 29, 2025, and October 1, 2025;  - “Resident Laundry+Put Away”, on September 29, 2025;  - “Skin Evaluation”, on September 29, 2025; and  - “Toileting Assistance”, on September 29, 2025, and October 1, 2025. 4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and - “Resident Laundry”, on September 29, 2025. 5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025;  - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025;  - “Resident Laundry+Put Away”, on October 1, 2025; and  - “Status Checks: 2 Hours”, on September 29, 2025, and October 1, 2025. 6. A review of R5's medical record revealed R5 received personal care level services. A review of R5's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on September 29, 2025, and October 1, 2025; - “Daily Housekeeping”, on September 29, 2025, and October 1, 2025; - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025;  - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; - “Dressing: Limited Assistance”, on September 29, 2025, and October 1, 2025; and - “Grooming Limited Assistance”, on September 29, 2025, and October 1, 2025. 7. A review of R6's medical record revealed R6 received personal care level services. A review of R6's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; - “Dressing: Limited Assistance”, on September 29, 2025, and October 1, 2025; and - “Grooming Limited Assist”, on September 29, 2025, and October 1, 2025. 8. A review of R7's medical record revealed R7 received personal care level services. A review of R7's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; and - “Toileting Assistance”, on September 29, 2025, and October 1, 2025. 9. In an interview, E1 and E2 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, and R7 did not contain accurate documentation of the services provided on September 29, 2025, and October 1, 2025, for seven of seven resident records reviewed.”

“Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of seven resident records reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R6's medical record revealed a service plan update, signed and dated November 1, 2024, for personal care services. A reviewed and updated service plan was required on or before May 31, 2025. However, no updated service plan was available for review. 2. In an interview, E1 acknowledged R6's service plan was not reviewed and updated at least once every six months. E2 further reported the system, that let them know when a service plan was due, in process, or completed, was not functioning properly and the facility was unaware it was unsigned.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, and the manager, for five of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed an updated service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative.   2. A review of R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative. 3. A review of R4's medical record revealed an initial service plan, for personal care level of services, dated July 6, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 4. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 5. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative. 6. In an interview, E1 and E2 acknowledged the service plans for R1, R3, R4, R5, and R7 were not signed as required by the resident or resident's representative and the manager.”

“Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for seven of seven resident records 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 R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for July 2025. The document recorded the service provided and initials of the person who provided the service.   2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Bathing Limited Assistance”, on July 2 and 9, 2025; - “Daily Trash Removal and Bed Making”, on July 1, 2, 8, 9, 10, 11, 19, 22, and 24, 2025;  - “Daily Wellness Checks”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025; - “Dining Moderate Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 24, and 25, 2025; - “Dressing: Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025; - “Grooming Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025; - “Resident Laundry+Put Away”, on July 2 and 9, 2025; - “Skin: Evaluation Assistance”, on July 9 and 19, 2025; and  - “Status Checks: 2 Hours”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025. 3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on July 19, 20, 26, and 27, 2025; - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; - “Dining Limited Assistance”, on July 19, 20, 26, and 27, 2025; - “Dressing: Full Assistance”, on July 19, 20, 26, and 27, 2025; - “Full Mobility Assistance (Every 3-6 Hours)”, on July 19, 20, 26, and 27, 2025; - “Grooming Moderate Assistance”, on July 19, 20, 26, and 27, 2025; and  - “Toileting Assistance”, on July 18, 19, 20, 23, 24, 25, 26, 27, and 28, 2025. 4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; and - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025. 5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25, 26, and 27, 2025;  - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; and  - “Status Checks: 2 Hours”, on July 18, 19, 20, 23, 25, 26, and 27, 2025. 6. A review of R5's medical record revealed R5 received personal care level services. A review of R5's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; - “Bathing Full Assistance”, on July 2 and 9, 2025; - “Daily Housekeeping”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; - “Daily Trash Removal and Bed Making”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025;  - “Daily Wellness Checks”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; - “Dining Limited Assistance”, on July 12, 19, 20, 26, and 27, 2025; - “Dressing: Moderate Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; - “Grooming Limited Assistance”, on July 11, 12, 18, 19, 20, 23, 25, 26, and 27, 2025; and - “Resident Laundry+Put Away”, on July 20 and 27, 2025. 7. A review of R6's medical record revealed R6 received personal care level services. A review of R6's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Bathing Limited Assistance”, on July 19 and 26, 2025; - “Daily Trash Removal and Bed Making”, on July 19, 20, 26, and 27, 2025; - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; - “Dining Limited Assistance”, on July 2, 19, 20, 26, and 27, 2025; - “Dressing: Limited Assistance”, on July 2, 19, 20, 26, and 27, 2025; and - “Grooming Limited Assist”, on July 2, 19, 20, 26, and 27, 2025. 8. A review of R7's medical record revealed R7 received personal care level services. A review of R7's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Bathing Limited Assistance”, on July 20 and 27, 2025; - “Daily Trash Removal and Bed Making”, on July 19, 20, 26, and 27, 2025; - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; - “Resident Laundry+Put Away”, on July 20 and 27, 2025; and - “Toileting Assistance”, on July 18, 19, 20, 23, 24, 25, 26, 27, and 28, 2025. 9. In an interview, E1 and E2 acknowledged that the medical records for R1, R2, R3, R4, R5, R6, and R7 did not contain accurate documentation of the services provided for seven of seven resident records reviewed.”

“Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. 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 R2’s medial record revealed a service plan which indicated R1 received directed care services, including medication administration. R2’s medical record contained a medication order for the following medications to be administered as indicated:     -“Brivact 50 MG TABLET, Take 2 tablets by mouth twice daily;” and -“Trihexyphenidyl 5 MG TABLET, Take one tablet by mouth every night at bedtime.”     2. Further review of R2’s medical record revealed a Medication Administration Record (MAR) which included sections for documenting the administration of Brivact and Trihexyphenidyl. The record reflected Brivact was administered as ordered during the month of January 2025; however, documentation revealed Brivact and Trihexyphenidyl were not administered during the following days and times:     Brivact: -January 12, 2025, at 5:00 p.m.; -January 13, 14 and 15, 2025, at 8:00 a.m., and 5:00 p.m.; -January 16, 2025, at 8:00 a.m.; and -January 17, 2025, at 8:00 a.m.     Trihexyphenidyl: January 2, 3, 4, 5, and 6, 2025, at 8:00 p.m.     3. R2’s medical record contained a document titled “Medication Exception Report,” for the month of January, 2025. The report documented “Medication not available” for the dates noted when Brivact, and Trihexyphenidyl were not administered.     4. In an interview, E1 advised R2 had run out of Brivact and Trihexyphenidyl in January 2025, and the facility had been contacting the pharmacy attempting to obtain a refill of the medication. E1 reported documentation of efforts to contact R2’s pharmacy was unavailable for review. E1 advised documentation of efforts to contact R2’s physician to request a refill order or a discontinue order for R2’s Brivact and Trihexyphenidyl were unavailable for review. E1 agreed R1 had not been administered Brivact and Trihexyphenidyl in compliance with a medical order.  This is a repeat deficiency from the compliance/complaint inspection conducted October 4, 2024.”

“C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;”

“J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (J)(1); and c. The report in subsection (J)(2); 4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.”

“Based on documentation review and interview, the manager failed to implement a policy and procedure to protect the health and safety of a resident that covered how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility policy and procedures, last reviewed November 4, 2024, revealed a policy titled "CL39 - Sudden, Intense, or Out of Control Behaviors." The policy outlined how care staff were to respond to a residents behaviors and stated all staff were to "...document the incident and notify all required parties and agencies." 2. A review of facility incident reports filed between October 1, 2024 and January 15, 2025 revealed six reports documenting the sudden, intense or out of control behavior of R1, R2, R3 or R4. 3. According to the report, dated October 18, 2024, one "case staff" observed R1 "hitting" "and scratching" another care staff member in the face. The report was authored by E3, but did not identify the second care staff member present during the incident. 4. A review of staff schedules revealed E3 and E4 were working together between 1:45 p.m. and 10:00 p.m., on October 18, 2024. A request was made to review the incident report documented by E4, however evidence of the report was unavailable for review. 5. A review of the incident report dated October 21, 2024, revealed R2 had been "having a heavy behaviors day...," and "...was being very verbally aggressive, combative, and argumentative with...staff." The report was submitted by E5, but did not identify any other care staff present. 6. A review of staff schedules revealed E5 and E6 were working together between 1:45 PM and 10:00 PM, on October 21, 2024. A request was made to review the incident report documented by E6, however evidence of the report was unavailable for review. 7. In an interview, E1 agreed staff did not document all incident reports as required, and the facility's policy had not been completely implemented.”

“Based on interview and document review, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the report made to a peace officer or to the adult protective services central intake unit. Furthermore, the manager failed to initiate and document an investigation of the suspected abuse, neglect, or exploitation within five working days. The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported as required. Findings include: 1. In an interview, E1 reported Adult Protective Services (APS) had been to the facility at least twice between October 1, 2024 and January 17, 2025, to investigate allegations of abuse, neglect or exploitation. E1 indicated they had called APS in approximately November 2024 and reported suspected exploitation of R5. E1 added APS had responded to the facility in recent weeks to investigate an allegation of R5's missing property. E1 reported APS had been to the facility on an unknown day in January 2025 to investigate an incident of alleged abuse between R6 and R7. 2. A request was made to review documentation of the report to APS made by E1 as well as the documented investigation initiated by E1. However, evidence of such documentation was unavailable for review. 3. A review of facility incident reports filed between October 1, 2024 and January 15, 2025 did not reveal any incident reports involving suspected abuse, neglect, or exploitation of a resident. 4. According to O2, O1 had responded to the facility on December 17, 2024 to conduct an investigation involving R5. 5. A review of facility visitor sign in rosters revealed two representatives from Adult Protective Services (APS) responded to the facility on January 12, 2025. 6. A request was made to review the documented investigation initiated by E1 pertaining to the January 12, 2025 response by APS. E1 advised they had not initiated or documented any such investigation. 7. In an interview, E1 reported they had not documented their APS report in November as required by R9-10-803.J.3. E1 advised they had not initiated or documented any investigation of suspected abuse, neglect or exploitation as required by R9-10-803.J.5.”

“Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for six of six residents sampled for whom an emergency responder had been contacted. Findings include: 1. A review of facility documentation revealed six separate incident reports, filed between March and September 2024, in which emergency responders had been contacted, responded to the facility and then transported six separate residents to a hospital. 2. A request was made to view the documentation provided to the emergency responders as required by ARS 36-420.04. However, the documentation was unavailable for review. 3. In an interview, E1 advised required documentation was provided to emergency responders, but copies of documentation provided were maintained separately for each individual incident. E1 acknowledged a copy of the documentation given to the emergency responder for each resident was not available for review as required by ARS 36-420.04.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination influenza (flu) and pneumonia were offered every 12 months, for five of eight residents sampled. The deficient practice posed a health and safety risk of residents not having the knowledge of the availability of the vaccinations. Findings include: 1. A review of R2's R5's, R6's and R7's (admitted 2022) medical records revealed evidence of documentation of the availability of the flu or pneumonia vaccine in 2023 was unavailable for review. 2. A review of R4's (admitted 2023) medical record revealed evidence of documentation of the availability of the flu or pneumonia vaccine in 2023 or 2024 was unavailable for review. 3. In an interview E1 acknowledged R2's, R4's, R5's, R6's and R7's medical record did not contain evidence of documentation of the availability of the flu or pneumonia vaccine being offered annually.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order for two of eight 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 R5's medical record revealed a current service plan which indicated R5 received personal care services and medication administration. Further review revealed a medication order, dated August 20, 2024, for "Diclofenac Sodium External Gel 1%, Apply 4g topically 4 times every day" In addition, R5's medical record contained a medication administration record (MAR) for September 2024. The document reflected Diclofenac was applied four times a day, at 7:00 AM, 11:30 AM, 4:30 PM and 8:30 PM, on September 1, 5 and 7. However, the medication was documented as not having been administered at 7:00 AM on September 3, 6, 8-10, and 29. In addition, the medication was documented as not having been administered at 11:30 AM on September 2, 3, 8, 9, 22, and 29. Furthermore, the medication was documented as not having been administered at 4:30 PM on September 2-4, 8, 9, 11-29, and 30. Lastly, the medication was documented as not having been administered at 8:30 PM on September 3, 4, 8, 9, and 11-30. R5's medical record also contained a medication order for "Allopurinol Oral Tablet 100 MG, take 1 tablet by mouth every day." R5's MAR reflected this medication was not administered as ordered on September 2-4, 6-10, 13-17, 20-30. 2. A review of progress notes for R5 revealed documentation on September 3, 17 and 22, 2024, indicating R5 was refusing application of Diclofenac. In addition, documentation on September 22, 2024 reflected "[R5] is still out of allopurinol waiting for the medication..." Documentation on September 25, 2024 indicated refills of R5's medications were requested from [Pharmacy 1], "specifically alopurinol (sic)." A second entry on September 25, 2024 read, "resident does not use [Pharmacy 1] despite what [R5's] profile says. MedTech says resident was using [Pharmacy 2]." 3. A review of R6's medical record revealed a current service plan which indicated R6 received personal care services and medication administration. Further review revealed a medication order, dated April 9, 2024, for "Bupropion HCL SR 40 MG Tablet, take 1 tablet by mouth once daily." In addition, R6's medical record contained a MAR for September 2024. The document indicated Bupropion HCL SR 100 MG tablet was not administered as ordered on September 4, 5, 8-12, 15-19, 23 or 24, 2024. 4. A review of R6's progress notes for the month of September revealed evidence of documentation describing why Bupropion HCL SR 100 MG tablet was not administered as ordered was unavailable for review. 5. In an interview E1 acknowledged R5 and R6 were not being administered medication as ordered.”

“Based on observation, record review, and interview, for one resident storing medications in their room, the manager failed to ensure the medication was stored according to the resident's service plan. The deficient practice posed a risk to the health and safety of the residents if the medications were accessible to other residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed the following medications being stored inside an unsecured medicine cabinet, in R14's residential unit: "-over the counter Acetaminophen caplets 500 mg;" "-Fluticasone 50MCG Nasal SP (120) RX;" "-90 mcg Albuterol" rescue inhaler; and "-Prednisolone Acetate ophthalmic suspension, USP 1%." 2. A review of R14's medical record revealed a current service plan which indicated R14 received personal care services, including medication administration. The service plan indicated "[R14] requires the assistance of one nurse or certified caregiver with the administration of medication..." However, the service plan did not include documentation to indicate medication was to be stored in R14's residential unit. 3. In an interview, E1 agreed R14's medications were stored in an unlocked manner and not stored according to R14's service plan.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency or injury and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation from July 2024 through August 2024 revealed three incident reports documenting accidents, emergencies or injuries where 911 was contacted. A review of the incident report dated August 14, 2024 revealed the report involved a resident experiencing chest pain, and contained most documentation required required per R9-10-818.D.2. The report included a section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future, however the section was not completed. A review of the incident report dated August 25, 2024 revealed the report involved a resident having difficulty transferring themselves and complaining of "numb" legs. The report contained most documentation required required per R9-10-818.D.2, however, the section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future was not completed. A review of the incident report dated September 14, 2024 revealed the report involved R8 and described a head injury sustained after an unwitnessed fall. The section for documenting "Follow-up" actions taken to prevent the incident from occurring in the future did not contain any evidence of documentation of action taken to prevent the incident from occurring in the future. 2. In an interview, E1 agreed the incident reports did not contain all documented required per R9-10-818.D.2.”

“Based on observation, document review and interview, the manager failed to ensure the premises was cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. During a tour of the facility the Compliance Officer observed a kitchen area which contained a refrigerator used for storing food and snacks for residents. The bottom of the refrigerator was stained with spilled liquids which were dark in color. The Compliance Officer also observed a cabinet which contained a metal cooking sheet. The bottom of the cooking sheet was covered with food particles including rice and what appeared to be dried carrots, as well as an oily looking substance which had pooled in the corner of the pan. In a cabinet, under a kitchen sink, the Compliance Officer observed what appeared to be a dried piece of meat, possibly poultry. 2. A review of facility policy and procedures, last reviewed December 2023, revealed a policy titled, "Environmental Standards." The policy read, in part, "1. Staff will clean and if necessary, disinfect, equipment according to established policies or manufactures' recommendations in order to prevent, minimize, and control illness or infection..." 3. In an interview, E1 reported acknowledged the kitchen area, including the refrigerator and cabinets, was not being kept clean.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than ten ambulatory residents, and the following: A cabinet located under the kitchen sink accessible to visitors and residents, which was not equipped with any type of device to prevent unauthorized access. The Compliance Officer was able to open the cabinet with little effort and observed one spray bottle of "Zep Spirit II detergent Disinfectant," one can of "Comet," scouring powder, and an aerosol can of "ECOLAB Stainless Steel Cleaner & Polish." Each container was marked, "KEEP OUT OF REACH OF CHILDREN;" and In a cabinet located under a second kitchen sink accessible to visitors and residents, which was equipped with a child safety locking mechanism. However, the locking mechanism was broken and the Compliance Officer was able to open the cabinet with little effort. Inside, the Compliance Officer observed a spray bottle of "Lysol Bleach Multi-Purpose Cleaner," a spray bottle of "Clorox Tilex Mold & Mildew" cleaner and a spray bottle of "Hillyard Non-Acid Restroom Disinfectant/Cleaner." All bottles were marked, "KEEP OUT OF REACH OF CHILDREN." In addition, another spray bottle was observed with no label indicating the contents of the bottle. The bottle contained an unidentified, purple/pink in color liquid. An office door was observed to be closed and affixed with a handle which locked with a key. However, the lock was not engaged and the Compliance Officer was able to open the door with little effort. Inside the office, the Compliance Officer observed a bookshelf which held a can of "Raid Ant & Roach" insecticide. Also observed was a spray can of "Hydro Balance Zip Clean Evaporator Coil Cleaner." The cleaner label read, "DANGER: CAUSES SEVERE SKIN BURNS AND EYE DAMAGE." A laundry room door was observed to be affixed with a locking handle which required a numerical code to open. However, the lock was not engaged and the Compliance Officer was able to open the door with little effort. The locking mechanism on the inside of the door was equipped with a thumb turn lock which had been disengaged, allowing the door to be opened without entering the code. The Compliance Officer observed a cabinet under the sink which was not equipped with a locking mechanism and the Compliance Officer was able to open the cabinet with little effort. Inside was a bottle of "Jazzle Liquid Laundry Bleach." 2. In an interview, E1 advised the office belonged to the facility's plant manager and should have been locked; E1 locked the office door upon leaving the room. E1 said the laundry room should have been locked as well. E1 agreed the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.”

“Based on documentation review and interview, the manager failed to ensure a dog or cat allowed in the facility was vaccinated against rabies. Findings include: 1. A review of facility's pet records revealed no documentation of current vaccination against rabies was available to review for the following: - cats, C1 and C2, who were living at the facility with R9; - cats C3 and C4 who were living at the facility with R10; - cat C5 who was living at the facility with R11; - cat C6 who was living at the facility with R12; and 2. A review of facility's pet records revealed documentation of rabies vaccination for dog, D1 had expired on June 7, 2023. No evidence of current vaccination against rabies was available for review. D1 was living at the facility with R13. 3. In an interview, E2 acknowledged there was no current documentation available to ensure C1, C2, C3, C4, C5, C6 and D1 were vaccinated against rabies.”

“Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On October 31, 2023, the Compliance Officer requested the following documents during the on-site inspection: - Documentation of E6's valid Cardiopulmonary resuscitation training and first aid certification; - Documentation of E2 and E4's skills and knowledge; - Documentation of E6's valid fingerprint clearance card or good cause exception; - Documentation of R2, R4, R5, R6, R7, R8, R9, and R10's signed service plans; - Documentation of disaster plan review; and - Documentation of evacuation drills with employees and residents. 2. In an interview, E1, and E8 acknowledged this information was not provided to the Compliance Officer within two hours after a Department request . This is a repeat citation from the complaint inspections conducted on January 26, 2023, and May 30, 2023.”

“Based on record review, documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for two of four caregivers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. The Compliance Officer requested the skills and knowledge checklist list for the following caregivers E2, E3, E4, and E5. 2. A review of E2 and E4's personal records revealed no documentation of skills and knowledge was available for review. E1 reported being unable to locate these documents. 3. In an interview, E1 acknowledged these documents were unavailable for review. This is a repeat citation from the complaint survey conducted on on January 26, 2023.”

“Based on record review, documentation review, and interview, the manager failed to ensure before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four caregivers sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A review of E5's personnel record revealed that E5 was hired as a caregiver in March 2023. 2. A review of documentation revealed E5 had a first aid training and cardiopulmonary resuscitation training certification issued by Save A Life from Tucson Fire Department, however, the certification expired May 10, 2023. No other documentation was provided during the compliance inspection to show E5 had valid first aid training and cardiopulmonary resuscitation training certification. 3. A review of staffing schedules revealed that E5 was scheduled to work on the following days: October 2, 3, 4, 5, 8, 9, 10, 11, 14, 22, 23, 23, 25, 29, and 31, 2023. 4. In an interview, E1 reported calling E5, however, E5 never returned E1's call while the Compliance Officer was on-site. This is a repeat citation from the complaint surveys conducted on January 26, 2023, and May 30, 2023.”

“Based on record review, documentation review, observation, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C), for three of three personnel sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A.R.S. \'a7 36-411 states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work.". And A.R.S. \'a7 36-411(C) states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of documentation titled " Arizona Team Member Fingerprinting Policy & Procedures" revealed "All team members must employed in the state of Arizona will maintain a valid Fingerprint Clearance Card as conducted by the Arizona Department of Public Safety. .... Copies of all documents pertaining to background checks will be kept in the employee's personnel file in the Business Office. .... 4. If any employee's fingerprint clearance card is denied or suspended, they will notify the community immediately. 5. If the employee is to eligible to file a good cause exception, the employee will be terminated effective immediately. 6. If the employee is eligible to file for a good cause exception, the community will maintain documentation of the good cause exception paperwork and process. The employee will be permitted to continue to work under the direct supervision of an employee with a valid fingerprint clearance card, while the good cause exception paperwork is reviewed. Every 30 days the employee's performance and job capabilities will be reviewed by a member of the management team. An employee will be permitted to work for a maximum of 90 days while applying for a good cause exception". 3. A review of E6's personnel record revealed an application from the Arizona Department of Public Safety for a fingerprint clearance card. The application was dated June 20, 2023, which was within the twenty days of E6's employment, however, the Compliance Officer observed a handwritten note attached to the application "July 13 - notice of not valid [E6] did not receive - as of 10/9 [E6] is contacting to follow up". The Compliance Officer did not find a copy of a request for good cause exception in E6's personnel record. E1 reported E6 is still employed by the facility and is not working under the direct supervision of another employee with a valid fingerprint clearance card. 4. In an interview, E1 reported E6 was working on the good cause exception, however, E1 did not provide any documentation to show E6 had requested a good cause exception. 5. During an interview E1 reported E6 is a housekeeper. The Compliance Officer requested E6's schedule, E1 reported the facility has two housekeepers and they do not have a printed-out schedule they work Monday through Friday from 7:30 am until 5:00 pm. No other documentation was provided to the Compliance Officer while on-site to show that E6 had a valid fingerprint clearance card. 6. A review of E6's personnel record revealed a document titled "Employment Application" with a signed date of May 2023. The Compliance Officer observed a document titled "Reference Check Form, however, the document was blank no evidence of documentation of contact with E6's previous employers to obtain information or recommendations that may be relevant to E6's fitness to work in a residential care institution. 7. A review of E4's personnel record revealed a document titled "Employment Application" with a signed date of May 2023. The Compliance Officer observed a document titled "Reference Check Form, however, the document was blank no evidence of documentation of contact with E4's previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution. 8. A review of E5's personnel record revealed no documentation of an application of employment or documentation of contact with E5's previous employers to obtain information or recommendations that may be relevant to E5's fitness to work in a residential care institution. 9. In an interview E1, acknowledged E6 did not have a valid fingerprint clearance card, and reported being unaware the reference documentation was not in the personnel records for E4 and E5.”

“Based on record review, documentation review, and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated was signed and dated by the resident's representative, the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for seven of nine directed care residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A review of R2's medical record revealed a service plan dated June 16, 2023, which indicated R2 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing: - The resident's representative had not dated or signed this document. 2. A review of R4's medical record revealed a service plan dated August 1, 2023, which indicated R4 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing: - The resident's representative; and - The manager. 3. A review of R5's medical record revealed a service plan dated September 28, 2023, which indicated R5 was receiving directed care services and medication administration. The service plan revealed the following signatures were missing: - The resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 4. A review of R6's medical record revealed a service plan dated August 9, 2023, which indicated R6 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing: - The resident or resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 5. A review of R7's medical record revealed a service plan dated July 19, 2023, which indicated R7 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing: - The resident or resident's representative. 6. A review of R8's medical record revealed a service plan dated August 1, 2023, which indicated R8 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing: - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan 7. A review of R9's medical record revealed a service plan dated June 12, 2023, which indicated R9 was receiving personal care services and medication administration. The service plan revealed the following signatures were missing: - The resident or resident's representative. 8. In an interview, E1 acknowledged the service plans provided did not have the required signatures and date. This is a repeat citation from the complaint inspection conducted on May 30, 2023.”

“Based on documentation review, and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: A.A.C. R9-10-818.A.3. states, "A manager shall ensure that documentation of the disaster plan review required in subsection (A)(2) includes: a. The date and time of the disaster plan review; b. The name of each employee or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement" 1. A review of facility documentation revealed no evidence of an annual disaster plan review. 2. In an interview, E1 acknowledged an annual disaster plan review was not available for review. This is a repeat citation from the compliance survey conducted on October 3, 2022.”

“Based on documentation review, and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. A review of facility documentation revealed no documention was available to review to show an evacuation drill for employees and residents was conducted at least once every six months. 2. In an interview, E1 acknowledged documentation of evacuation drills had not been provided to the Compliance Officer upon request. Technical assistance was given on the last compliance inspection completed October 3, 2022.”

“Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled, "Fall Prevention." This policy contained information on fall prevention and fall recovery. 2. A review of E2, E3, E4's personnel records revealed no documentation indicating the employees had reviewed or received the fall prevention and fall recovery training. 3. In an interview, E1,acknowledged E2, E3, and E4 did not have documentation that they reviewed or received the fall prevention and fall recovery training.”

“Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On August 28, 2023, the Compliance Officer requested the following documents during the on-site inspection: - Skills and knowledge checklist for E2; - Personnel record for E2; and - Documentation of fall prevention and fall recovery training for E2, E3, and E4. 2. In an interview, E1, acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request. Technical assistance was provided during the on-site compliance inspection conducted on May 30, 2023.”

“Based on observation, record review, and interview, the manager failed to ensure the facility caregivers demonstrated they had the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. For one of three caregivers sampled. Findings include: 1. The Compliance Officer requested a copy of the staffing roster. The Compliance Officer observed that E2 had a hire date of May 20, 2023, and a title of "Care Specialist". E1 reported a Care Specialist is a caregiver. 2. The Compliance Officer requested the personnel records for E2, E3, and E4. The Compliance Officer received E3, and E4's, however, E1 was unable to locate a personnel record for E2. 3. The following documentation was unavailable for review: - Qualifications, experience, skills, and knowledge checklist; - A caregiver certification, from a school approved by the NCIA Board; - CPR or First Aid certification which included a demonstration; - Fingerprint clearance card; and - TB documentation. 4. A review of staffing schedules revealed that E2 was scheduled to work on July 8, 15, 29, 2023, and August 5, 19, and 26 2023. 5. In an interview, E1 acknowledged that E2 did not have documentation of qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included the individual's name, date of birth, and contact telephone number, the individual's starting date of employment or volunteer service, documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, the individual's education and experience applicable to the individual's job duties, the individual's completed orientation and in-service education required by policies and procedures, the individual is a behavioral health technician, clinical oversight required in R9-10-115, cardiopulmonary resuscitation training, First aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) for one of three personnel members sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs. A.A.C. R9-10-101(165) states a "Personnel member" means, "except as defined in specific Articles of this Chapter and excluding medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services." Findings include: 1. The Compliance Officer requested a copy of the staffing roster. The Compliance Officer observed that E2 had a hire date of May 20, 2023, and a title of "Care Specialist". E1 reported a Care Specialist is a caregiver. 2. The Compliance Officer requested the personnel records for E2, E3, and E4. The Compliance Officer received E3, and E4's, however, E1 was unable to locate a personnel record for E2. 3. A review of staffing schedules revealed that E2 was scheduled to work on July 8, 15, 29, 2023, and August 5, 19, and 26 2023. 4. In an interview E1 acknowledged being unable to locate a personnel record for E2.”

“Based on documentation review, record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of six residents sampled. Findings include: 1. A review of documentation provided by O1, a Registered Nurse (RN) for Mercy Care of Arizona revealed the following; "The member did not receive scheduled pain medication because it was not available at Bridgewater Assisted Living Facility. On the medication administration record from the facility, it shows that on July 19, 2023, and July 20, 2023, Morphine Sulfate 15 mg was not given to member due to refills not being processed per protocol". 2. A review of documentation revealed that R6 was receiving personal care services and medication management from the facility, and was a member receiving services from Mercy Care of Arizona. 3. A review of R6's medical record revealed a signed medication order dated June 1, 2023 - June 30, 2023. This medication order included: - Morphine Sulfate ER 15 mg, Take 1 tablet by mouth every 8 hours for chronic pain. 4. A review of R6's medication administration record (MAR) revealed R6 was not given Morphine Sulfate ER 15 mg for pain as ordered by R6's physicians on the following dates: - June 19, 2023, 4:00 PM, Exceptions: "waiting on doctor sent new order to the pharmacy"; - June 20, 2023, 12:00 AM, Exception: "not recorded" - June 20, 2023, 8:00 AM, Exceptions: "waiting on pharmacy"; - June 20, 2023, 4:00 PM, Exceptions: "medication has not arrived yet"; and - June 21, 2023, 12:00 AM, Exceptions; "resident got this med as soon as this came a little bit after 10 PM when it was delivered". 5. A review of documentation revealed a document titled "Medication Refills". It states "1. The Nurse/Med Tech on duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication unless medication is on a cycle refill with the pharmacy. .... 3. Nurses/Med Techs work to ensure medications are not allowed to run out, unless directed to do so by the physician. This is done by coordinating refills with the pharmacy and responsible party. .... 4. Each shift of Nurses/Med Techs is responsible to make any necessary reminder and follow up calls to assist with receipt of medications". 6. In an interview, E1 reported the medication was faxed to "Korman Pharmacy" to be filled on Friday before the medication ran out. The Compliance Officer observed that date to be June 16, 2023. 7. In an interview, E1 acknowledged the medications were not administered to R6 in compliance with a medication order. Technical assistance was provided during the on-site compliance inspection conducted on May 30, 2023.”