The Villas at Wilmot, Villa a.

“Based on record review and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of two sampled personnel. Findings include: R9-10-113(A)(2)(b)(ii) states: "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: ii. Annually obtaining documentation of the individual’s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101. A review of E2's personnel record revealed E2 had been hired as a caregiver in January of 2023. A review of E2's personnel record revealed documentation indicating a likely latent tuberculosis infection with no active disease in September 2023. A review of E2's personnel records revealed an annual TB symptom screen dated October 2024. However, an annual TB symptom screen dated on or before October 2025 was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan for a resident who required behavioral care included the psychosocial interactions or behaviors for which the resident requires assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of one sampled resident who required behavioral care services. Findings include: A review of R2's medical record revealed a diagnosis of schizophrenia. A review of R2's medical record revealed a service plan, dated December 11, 2025, for personal care services including medication administration. A review of R2's medical record revealed a behavioral care plan dated March 28, 2026. The plan was reviewed and signed by a medication practitioner. However, the plan indicated the following: In the section "Psychosocial Interactions / Behaviors Requiring Assistance," the medical practitioner had written, "High Blood Pressure, Schizophrenia." In the section "Psychotropic Medications," the medical practitioner had written, "Invega Sustenna," and "Hydroxyzine Pam." In the section "Side effects to report to PCP," the medical practitioner had written, "Catatonia, increase in confusion." In the section "Frequency of Psychosocial interactions / Behaviors," the medical practitioner had written, "Daily Redirection." In the section "Goals for Changes in Psychosocial Interactions / Behaviors and Frequency," the section had been left blank. In the section "Interaction / Behavior," the medical practitioner had written, "Stop Invega, start Ability PO, Continue Hydroxyzine, Go to coffee social," and In the section "Planned Strategies/Actions," the section had been left blank. In an exit interview with E1, the finding was reviewed and no additional information was provided.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel records reviewed.  The deficient practice posed a risk if E5 was a danger to a vulnerable population.   A.R.S. § 36-411 states:   "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.   B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.   C. Each residential care institution, nursing care institution and home health agency 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.   3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee.   4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee.   5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459.   D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.   E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.   F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.   G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.   H. For the purposes of this section:   1. "Direct supportive services":   (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:   (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.   (ii) Assistance with self-administration of medication.   (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.   (iv) Transportation services, including van services.   (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.   2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.   3. "Home health services" has the same meaning prescribed in section 36-151."     Findings include:   1. A review of E5's personnel record revealed E5 had been hired as a caregiver in January of 2023.   2. A review of E5’s personnel record revealed documentation of a valid fingerprint clearance card was not available for review. E5's personnel record contained a fingerprint clearance card with a marked expiration date of January 17, 2025. 3. Online verification of E5's fingerprint clearance card at www.azdps.gov revealed E5's fingerprint clearance card was expired.   4. In an interview, E1 acknowledged the personnel record provided for E5 had not included documentation of a valid fingerprint clearance card. E1 reported E5 would be suspended until E5 produced evidence of a valid fingerprint clearance card..”

“Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's service plan for one of two residents sampled.   Findings include:   1. A review of facility staff schedules revealed the facility operated two shifts per day, 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m.   2. A review of R1’s medical record revealed a service plan, dated January 5, 2025, for directed care services. The service plan included the provision of showering twice per week to include, "Set-up, Lower body, hair, and back," and stated, "See shower schedule for current days. Document when showers are given."   3. A review of R1’s medical record revealed a document, titled, "Caregiver ADL Checklist" used for tracking activities of daily living (ADLs), Dated March, 2025. The document included sections for documenting the service “Bathing” The ADL documented the following showering services were provided during March, 2025: On March 1, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 4, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 7, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 14, 2025, on the "7a-7p" shift, "Bathing" was marked with an "R" to indicated R1 refused the shower; On March 19 , 2025, on the "7a-7p" shift, "Bathing" was marked with an "R" to indicated R1 refused the shower; and On March 27, 2025, on the "7a-7p" shift, "Bathing" was marked, "cue."   4. In an interview, E1 acknowledged the ADL documentation provided for R1 did not document R1 had been provided with two showers per week as required by R1's service plan.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. Findings include: A review of R1's medical record revealed R1 received directed care services and medication administration. A review of R1's medical record revealed a signed but undated medication order, for "Valproic Acid, 250 MG/5ML, Take 5ML by mouth twice daily at 8:00 AM, 5:00 PM." A review of R1's February 2025 medication administration record (MAR) revealed R1 had received 5 milliliters of Valproic Acid at 8:00 AM and 5:00 PM on each day except as follows: On February 13, 2025 at 5:00 PM, reason, "Refused;" On February 16, 2025 at 8:00 AM, reason, "Refused;" On February 20, 2025 at 8:00 AM, reason, "Refused;" On February 23, 2025 at 8:00 AM, reason, "Not in med cart;" and On February 24, 2025 at 8:00 AM, reason, "Not in med cart." A review of R1's medical record revealed documentation of progress notes as follows: On February 17, 2025 at 6:01 PM, "Resident remained in [their] room throughout the day, refused to get up from bed, also refused medication until RCC talked to [them] then [they] took meds. On February 22, 2025 at 9:16 AM, "Staff went to give resident ..... medication while resident was laying down on ...... resident turned over and just grabbed onto staff hair and started pulling it, staff asked resident multiple times for resident to let go of staff's hair, staff had to manually remove residents' hands off of her. Resident did not take ..... meds. A review of an incident report involving R1 revealed a statement signed by E4 on March 27 2025. The statement included the following: "...went to give [R1] ..... AM meds. The resident was already upset and sitting on the edge of the bed. [E4] went to hand ..... the liquid med, [R1] slapped it out of her hand it landed all over the resident.... The resident would not take any meds for that day, we tried for a week to give ......... meds but ..... would not take them, other staff members tried. A review of R1's February 2025 and March 2025 MAR's revealed the only liquid medication was Valproic Acid. However, E4 had not marked Valproic acid as refused at any time in the two months reviewed, and the medication had never been marked refused for more than a single dose. In an interview, E1 acknowledged medication administered to R1 had not been accurately documented in R1's medical record.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed, in the kitchen, a cabinet above the kitchen counter, without a lock, contained an unlabeled prescription bottle with a single tablet inside. 2. In an interview, E1 acknowledged a medication was not stored in a separate locked cabinet.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two residents sampled. 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 a service plan dated March 2, 2024, for directed care services. However, the service plan was not signed and dated by R3 or R3's representative, and documentation of attempts to contact R3's representative to obtain a signature was not available for review. 2. In an interview, E1 acknowledged the service plan provided for R3 had not been signed and dated by R3 or their representative when the plan was developed or updated. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 18, 2023.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. 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 medical record revealed a service plan, dated March 2, 2024, for directed care services, including medication administration. 2. A review of R2's medical record revealed a list of medication orders from R2's primary care physician, dated February 29, 2024, which included: - "Doxepin HCI 10 MG Oral Capsule, 1 capsule (10mg) orally daily at bedtime (start date: 12/19/2023)." 3. A review of R2's medical record revealed a list of medication orders from R2's psychiatric provider, dated January 16, 2024, which included: - "Continue Doxepin 10 mg PO QHS # PMHNP (insomnia)." 4. A review of R2's medical record revealed a medication administration record (MAR) dated May 2024. However, the MAR did not include documentation of administration of Doxepin 10 milligram capsules to R2. 5. The Compliance Officer observed multi-dose packages of medications for R2 did not include 10 milligram Doxepin capsules. 6. In an interview, E1 acknowledged R2 had not been provided 10 milligram Doxepin as ordered. E1 contacted R2's doctor during the on-site inspection and obtained an order to discontinue the medication. This is a repeat deficiency from the the on-site complaint inspection conducted on November 20, 2023 and the on-site compliance and complaint inspection conducted on May 18, 2023.”

“Based on record review, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk as administered medication could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan, updated August 10, 2023, for directed care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders, dated November 7, 2023, which included the following order: - "Glucose 4GM Chew Tab, Chew 4 tablets by mouth as needed for low blood sugar - chew tablets." 3. A review of R1's medical record revealed a signed list of medication orders, dated November 3, 2023, which included the following order: - "Check fingerstick blood sugar before meal and document result every day. If blood sugars are below 70 mg/dl: Call [medical provider]." 4. A review of R1's medical record revealed a form titled, "Resident Blood Sugar Tracking Form," dated November 2023. The form documented R1's blood sugar at "am," "noon," and, "pm," on each day between November 1, 2023 and November 16, 2023. The blood sugar chart documented the following: - On November 4, 2023 at, "am," R1's blood sugar had not been documented; - On November 5, 2023 at, "am," R1's blood sugar was documented to have been 55; - On November 5, 2023 at, "noon," R1's blood sugar had not been documented; - On November 5, 2023 at, "pm," R1's blood sugar had not been documented; - On November 6, 2023 at, "am," R1's blood sugar had not been documented; - On November 6, 2023 at, "noon," R1's blood sugar had not been documented; - On November 6, 2023 at, "pm," R1's blood sugar had not been documented; - On November 7, 2023 at, "noon," R1's blood sugar had not been documented; - On November 7, 2023 at, "pm," R1's blood sugar had not been documented; - On November 9, 2023 at, "noon," R1's blood sugar had not been documented; - On November 10, 2023 at, "noon," R1's blood sugar had not been documented; - On November 10, 2023 at, "pm," R1's blood sugar was documented to have been 65; - On November 12, 2023 at, "noon," R1's blood sugar was scribbled out and had been rendered illegible; - On November 12, 2023 at, "pm," R1's blood sugar was scribbled out and had been rendered illegible; and - On November 13, 2023 at, "noon," R1's blood sugar had not been documented. 5. A review of R1's medical record revealed an electronic medication administration record (eMAR) dated November 2023. The eMAR included, "Check Blood Sugars" at 7:00 AM, 11:00 AM, and 4:00 PM, starting November 15, 2023 at 4:00 PM through November 20, 2023 at 7:00 AM. The blood sugar chart documented the following: - On November 17, 2023 at 6:20 AM, R1's blood sugar was documented to have been 55; and - On November 17, 2023 at 4:01 PM, R1's blood sugar was documented to have been 67. 6. A review of R1's medical record revealed documentation of the administration of glucose tabs as needed for low blood sugar was not available for review. 7. A review of R1's medical record revealed documentation of notification of R1's medical practitioner of low blood sugar readings was not available for the low readings on November 10, 2023, or for November 17, 2023 at 6:20 AM. 8. In an interview, E1 and E2 acknowledged the provided documentation of medications administered to R1 was not in compliance with R1's orders. This is a repeat deficiency from the on-site complaint inspection conducted on May 18, 2023.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. The Compliance Officer requested incident reports as required by R9-10-818.D.1-2 for R1. The Compliance Officer was provided with one report dated November 17, 2023 at 4:30 pm. However, no other documentation was provided regarding R1 having an emergency, injury, or accident requiring medical services. 2. A review of R1's medical record revealed a discharge summary from a hospital dated August 29, 2023. The discharge summary stated the reason for admission was, "syncope, found slumped in chair by facility staff." However, a facility generated document regarding this emergency medical service was not available for review. 3. In an interview, E1 reported R1 was also hospitalized on September 29, 2023, when R1's medical provider was at the facility and called paramedics due to concerns of a bowel obstruction. E1 reported R1 went to the same hospital as on the August 29, 2023 incident. However, a facility generated document regarding this emergency medical service was not available for review. 4. A review of R1's medical record revealed a blood sugar log dated November 2023, which indicated R1's blood sugar had not been checked before any meal on November 14, 2023. The log included the comment, "hospital." However, a facility generated document regarding this medical service was not available for review. 5. In an interview, E1 and E2 acknowledged documented incident reports for R1 detailing each accident, emergency, or injury requiring medical services had not been provided for review.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an incident resulting in the resident needing medical services. Findings include: 1. The Compliance Officer requested incident reports as required by R9-10-818.D.1-2 for R1. The Compliance Officer was provided with one report dated November 17, 2023 at 4:30 pm. However, no other documentation was provided regarding R1 having had an emergency, injury, or accident requiring medical services. 2. A review of R1's medical record revealed a discharge summary from a hospital dated August 29, 2023. The discharge summary stated the reason for admission was, "syncope, found slumped in chair by facility staff." However, a facility generated document regarding this emergency medical service was not available for review. 3. In an interview, E1 reported R1 was also hospitalized on September 29, 2023, when R1's medical provider was at the facility and called paramedics due to concerns of a possible bowel obstruction. E1 reported R1 went to the same hospital as on the August 29, 2023 incident and was discharged a few days later. However, a facility generated document regarding this emergency medical service was not available for review. 4. A review of R1's medical record revealed a blood sugar log dated November 2023, which indicated R1's blood sugar had not been checked before any meal on November 14, 2023. The log included the comment, "hospital." However, a facility generated document regarding this medical service was not available for review. 5. In an interview, E1 and E2 acknowledged documented incident reports for R1 detailing each accident, emergency, or injury requiring medical services had not been provided for review.”