La Paz Assisted Living III.

“Based on record review and interview, the assisted living home failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled.  Findings include: 1. A review of R1's and R2's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9). However, the following were not included in the documentation: - A copy of the resident's health insurance portability and accountability act 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. - A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. - 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.  2. In an interview, E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.”

“Based on observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk if no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility.  Findings include:  1. During a facility tour, the Compliance Officer observed a posting in the dining room which stated, "Designation of Manager by the Governing Authority." The designation listed four employees, however E5 was not listed.  2. A review of the facility's personnel schedule for June 2025 revealed E5 had not been documented to have worked at the facility at any time. However, the work schedule revealed a single caregiver was present at the facility on each shift. 3. A review of R2's medical record revealed a medical administration record (MAR) dated June 2025. The MAR indicated E5 had administered medications to R2 on June 1, 2025, June 8, 2025, June 15, 2025, June 22, 2025 and June 29, 2025. 4. In an interview, E1 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. E1 reported E5 was an "as needed" worker who had been covering some shifts during the previous month. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 23, 2023 and the on-site compliance inspection conducted on June 11, 2024.”

“Based on observation, document review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services or behavioral health services for one of three personnel members sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.   Findings include:   A review of E5's personnel record revealed documentation of verification of E5's skills and knowledge was not available for review. In an interview, E1 reported E1 did not have E5's personnel record on site, but had scanned and printed E5's personnel file for the Compliance Officers to review. E1 acknowledged documentation of verification of E5's skills and knowledge had not been provided for review.”

“Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include:  1. A review of R2's medical record revealed a medical administration record (MAR) dated June 2025. The MAR indicated E5 had administered medications to R2 on June 1, 2025, June 8, 2025, June 15, 2025, June 22, 2025 and June 29, 2025. 2. A review of the facility's personnel schedule for June 2025 revealed E5 had not been documented to have worked at the facility at any time. 3. In an interview, E1 acknowledged the facility failed to maintain documentation of the caregivers and assistant caregivers working each day, including the hours worked by each.”

“Based on record review and interview, the manager failed to ensure a caregiver received orientation before providing assisted living services to a resident. Findings include: A review of E5's personnel record revealed documentation of orientation was not available for review. In an interview, E1 acknowledged documentation of E5's orientation had not been provided for review.”

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, for one of two sampled residents. A review of R2's medical record revealed, based on R2's date of occupancy, completed TB documentation was required. A review of R2's medical record revealed documentation of a single Mantoux skin test (TST). However, the TST induration had been read 26 hours after the injection of the tuberculin serum. Online research at cdc.gov revealed the time frame for reading a TST result is between 48 to 72 hours after injection of the serum. In an interview, E1 acknowledged R2's documentation of freedom from infectious TB included a TST with an invalid read date.”

“Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f) at least once every 6 months for a resident receiving personal care services and at least once every three months for a resident receiving directed care services, for two of two residents reviewed. The deficient practice posed a risk if there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services, updated on June 21, 2025, more than three months after the previous service plan dated March 15, 2025. 2. A review of R2's medical record revealed a current service plan for personal care services, updated on May 3, 2025, more than six months after the previous service plan dated September 23, 2024. 3. In an interview, E1 acknowledged the service plans for R1 and R2 had not been updated within the required timeframe. 3. A review of R2's only service plan revealed it had been completed on June 15, 2023, and that R2 was receiving supervisory care services. On the first page of the service plan at the top in the center, it stated, "Next due Date: 6/15/2024." However, the only service plan on record was from June 15, 2023. 4. There were no service plans on record for R3. E1 and E2 stated R3 received personal care services, which would mean that R3 should have had at least four service plans on record based on R3's admission date. 5. In an interview, E1 acknowledged the service plans for R1 and R2 were past due and that there should have been service plans on record for R3.”

“Based on record review and interview, the manager failed to ensure a service plan, for one of one sampled resident receiving directed care services, included the requirements in R9-10-814(F)(1) or documentation of the resident's weight. Findings include: 1. A review of R1's medical record revealed a service plan, dated June 21, 2025, for directed care services. However, the service plan did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, and did not include documentation of R1's current weight at the time the service plan had been updated. The service plan form included both sections, however, they had been left blank. 2. In an interview, E1 acknowledged R1's service plan did not include all required components.”

“Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a refrigerator, located in the kitchen, was accessible to residents. Inside the refrigerator, the Compliance Officers observed a metal box with a combination lock, labeled, "narc's." However, the box had been left open and unlocked at the time of the inspection. Inside the box, the Compliance Officers observed containers of Morphine, Lorazepam, and Aplisol. 2. In an interview, E1 acknowledged medications stored by the facility had not been stored in a locked area.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials.   Findings include:   1. During an environmental inspection of the facility, the Compliance Officers observed a cabinet below the sink in a common bathroom accessible to all residents. The cabinet had a magnetic lock, however, the lock appeared to be stuck open.  Inside the cabinet, the Compliance Officer observed containers of, "All purpose Cleaner with Bleach.”   2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.   This is a repeat deficiency from the on-site compliance inspection conducted on May 24, 2022, the on-site compliance and complaint inspection conducted on May 23, 2023, and the on-site compliance inspection conducted on June 11, 2024”

“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 one of one sampled residents for whom an emergency responder had been contacted. Findings include: 1. A review of facility documentation revealed an incident report for R1 dated March 5, 2024. The incident report stated R1, "Was sent out to the ER." 2. The Compliance Officer requested to review the facility's copy of the documentation which had been provided to the emergency responder after R1's incident. However, the documentation was not provided for review. 3. In an interview, 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 observation and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk if no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. During a facility tour, the Compliance Officer observed a posting in the dining room which stated, "Designation of Manager by the Governing Authority." The designation listed seven employees, however E4 was not listed. 2. A review of the facility work schedule for May 2024 revealed the following: - E4 worked alone on the 7 pm to 7 am shift on May 7,8,14,15,21,22,28, and May 28, 2024. 3. In an interview, E1 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 23, 2023.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen counter. The cabinet had a magnetic lock, however, cabinet had not been fully closed and the lock had not engaged. Inside the cabinet, the Compliance Officer observed containers of, "Pine-sol," "Lysol," and, "Jazzle bleach." 2. During an environmental inspection of the facility, the Compliance Officer observed spray bottle of, "Great Value Cleaner with Bleach," on top of the a refrigerator in the kitchen area. 3. In an interview, E1 and E2 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on May 24, 2022 and the on-site compliance and complaint inspection conducted on May 23, 2023.”