Villas at King Road, The, Villa a.

“Based on record review, documentation review, and interview, 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 suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. Findings include: 1. A review of documentation revealed the facility had reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises. The document included all the requirements in R9-10-803.J.1-6 except for "the actions taken by the manager to prevent the suspected abuse from occurring in the future". 2. In an interview, E2 and E3 acknowledged the document did not include "the actions taken by the manager to prevent the suspected abuse from occurring in the future".”

“Based on record review and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of two residents sampled. The deficient practice posed a direct health or safety risk to residents and if the facility was unable to meet the needs of R2. Findings include: 1. A review of R2's medical record revealed a document titled "Diagnoses and Doctor's Orders," dated July 28, 2022. The document included a section titled, "Diagnoses:," which identified "Schizoaffective d/o Unspecified." Evidence of any other type of medical diagnosis of R2 was not available for review. 2. A review of R2's service plan (dated October 23, 2023) for directed care services revealed a section titled, "Medical Diagnosis/Health Problems:," which indicated "Depression, Schizoaffective Disorder, Bipolar Disorder, Hypothyroidism." The service plan indicated [R2] was "unable to reliably use [R2's] call button if [R2] in need of assistance...due to cognitive deficits." However, the service plan did not indicate if the cognitive deficit was linked to R2's listed diagnoses or another medical condition. Additionally, R2's service plan revealed R2 was largely independent of all activities of daily living, and required only behavioral care, medication administration, and required mainly Monitoring, cues or "Set-up/Standby" assistance with instrumental activities of daily living. The service plan also indicated R2 "requires a caregiver with [R2] while outside due to wandering risk," however the plan does not link the behavior to a medical diagnosis rather than a behavioral diagnosis. 3. In an interview, E1 acknowledged R2's medical record did not contain evidence which indicated the primary condition R2 needed assisted living services was other than a behavioral health issue.”