Hacienda at the Canyon.

“Based on document review, interview, and observation, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of facility documentation revealed an incident report documenting the elopement of R1 on March 14, 2026.   2. A tour of the facility revealed a secured courtyard which included a gate with a lock.   3. A review of the facility’s incident report revealed a staff member observed R1 walking on the road outside the memory care unit.   4. The facility documentation revealed an investigation was conducted to determine how R1 was able to get outside the memory care unit. The document noted all exits were found to be secure and a review of electronic records did not reveal any egress, during the time R1 was unaccounted for. The investigation did determine that the pendant R1 was wearing, to alert caregivers if R1 was near an exit, was not functioning at the time R1 eloped. Further investigation revealed the system also failed to notify the caregivers that the battery was low, 5. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility's caregivers. Findings: 1. A review of department documentation revealed the facility made a self-report on May 22, 2024. The reported stated "On May 8, 2024 the community received 180 tablets 6 individual cards, or Hydrocodone 10-325mg tablets. During the morning narcotic count on May 17, 2024, 2 associates notice 1 full card of Hydrocodone 10-325mg tablets missing from the narcotic box.. was in a locked medication cart, total missing equals 30 tablets. Community is doing currently an investigation, regarding missing Narcotics". 2. E1 started an investigation. E1 and E2 reported E4 and E5 were put on administrative leave until the investigation was completed. E6 had been terminated due to not starting the investigation as soon as the incident was reported to E6. The incident was reported to Adult Protective Services (APS) and the Pima County Sheriff's Department. 3. E1 and E2 reported the facility was unable to determine who was responsible for the missing 30 Hydrocodone tablets belonging to R1. 4. In an interview, E1 and E2 acknowledged R1's medication was missing.”

“Based on documentation review, observation, and interview, the manager failed to establish, document, and implement policies and procedures for all required procedures in R9-10-816(F)(3). Findings include: 1. A review of policies and procedures revealed the following "Controlled Substances Count Policy". The policy states " A. Policy Statement: It is the policy of Watermark Retirement Communities, LLC (WRC) and its affiliates to account for all Scheduled II-IV Medications at the end of each shift and to promptly investigate discrepancies in controlled substance counts. B. Procedure: I. All Scheduled Medications II-IV (Controlled substances) must be under double lock. II. The assigned medication-distributing associate is ultimately responsible for the security of controlled substances assigned residents during his/her shift unless properly relieved by another associate authorized to administer controlled substances. If relieved for any reason during the shift, a controlled substance count will be performed and properly documented by the outgoing associate and the associate assuming responsibility for the controlled substances". 2. A review of department documentation revealed the following "05/08/2024 community received 180 tablets-6 individual cards, or Hydrocodone 10-325mg tablets. During the morning narcotic count on 5?17/2024, 2 associates noticed 1 full card of Hydrocodone 10-325mg tablets missing from the narcotic box. The box was in a locked medication cart, total missing equals 30 tablets. Community is doing an investigation, regarding missing Narcotics". The narcotics belonged to R1. 3. A review of documentation provided by E1 revealed the following "DRC and ED made aware of the missing narcotics from 5/17/2024, suspensions of the 2 caregivers and the nurse done on 5/20; Investigation started with interview of suspended employees as well as additional caregivers that worked in assisted living; internal investigation concluded that company policy was not being followed regarding proper counting of narcotics; as a results nurse was terminated and the 2 suspended caregivers were given final written warnings; training with the assistance from Pharmacy on counting narcotics was given to suspended caregivers before returning to work on the floor; training for all other caregivers working in AL; Missing narcotic was never located. 4. In an interview, E1 and E2 acknowledged their policies and procedures on narcotic counting were not implemented by caregivers.”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of six caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in March 2024. 2. A review of E4's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The document stated " Standard - First-Aid". The course was taken on October 23, 2023. 3. An online search of the National CPR Foundation revealed this is an online course. No hands-on CPR training is included. 4. A review of the facility's policies and procedures titled "Cardiopulmonary Resuscitation (CPR) Policy". This document stated "... B. 1. Nurses and other care staff are educated to initiate CPE, as recommended by the American Heart Association (AHA)" .... XII. Certification is only obtained by attending a course offered through a certifying agency such as the American Red Cross, the American Heart Association or an associate employed at the community that is a current certified instructor through one of these agencies", and "Associate & Volunteer Training and Personnel Files Arizona Only". ..3. Documentation of: Prior to delivery of care to the residents the Business Office Manager will verity current training in First Aid through accredited vendor and will verify current training in CPR specific to adults from one of the following organizations: American Red Cross, American Heart Association or National Safety Council (with hands on demonstration of techniques)". 5. In an interview, E1 and E8 reported being unaware the National CPR Foundation was an online CPR course that did not include hands on demonstration of techniques. E1 and E8 acknowledged E4 did not have current documentation on hands-on CPR training before providing assisted living services.”