Ventana Winds LLC.

“Based on observation, record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated in March of 2023 for personal care services. A change in condition was documented in May of 2023 due to fall incidents in which R2 was changed to directed care services. In May of 2023, there was no service plan in the file to reflect a service plan update was conducted within 14 calendar days. 2. In an interview, E1 reported due to falls, R2's level of care was increased to assist with fall prevention. 3. In an interview, E1 acacknowledged the service plan for R2 was not updated within 14 days after a significant change in condition.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan when initially developed and when updated, for one of two residents sampled. Findings include: 2. A review of R2's medical record revealed a service plan was written in November of 2023 for directed care services. The service plan was not signed and dated by R2, R2's representative, the manager, or the nurse or medical practitioner as required. 3. In an interview, E1 acknowledged the service plan for R2 was not signed and dated by R2, R2's representative, the manager, or the nurse as required when the service plan was developed or updated.”

“Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for a resident receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R2's medical record revealed service plans dated August and November of 2023 for directed care services. These service plans revealed no documentation of R2's weight. In addition, R2's record revealed no documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. During an interview, E1 acknowledged R2's service plans did not include documentation of R2's weight and documentation was not available in R2's record from a medical practitioner stating weighing R2 was contraindicated.”

“Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility within 24 hours after the resident's acceptance for five of ten sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R3's, R5's, R8's, R9's, and R10's medical records revealed documentation of the resident's orientation to exits from the assisted living facility were not conducted within 24 hours of the residents' date of acceptance to the assisted living facility. 2. In an interview, E1 acknowledged R3's, R5's, R8's, R9's, and R10's medical records did not contain documentation of orientation to exits from the assisted living facility within 24 hours of R3's, R5's, R8's, R9's, and R10's date of acceptance to the assisted living facility.”

“Based on observation and interview, for one of ten residents sampled, the manager failed to ensure a resident was free from a condition that may cause a resident to suffer physical injury. The deficient practice posed a potential risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection, the Compliance officer observed prescription medications to include metoprolol, Nystatin, and Lisinopril as well as cleaning supplies such as bleach and multipurpose cleaners in unlocked areas throughout the room of R1. 2. During an interview in the presence of E1, R1 reported that she usually does not lock the front door of her room when she leaves. 3. During an interview, E1 acknowledged that prescription medications and other poisonous or toxic materials were not locked and inaccessible to residents to ensure that residents were free from a condition that may cause physical injury.”

“Based on interview and record review, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of four sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. In an interview, E1 reported R4's residency was terminated in mid June 2024. 2. A review of R4's medical record revealed documentation of assisted living services (ADLs) provided to R4 in June 2024. The ADLs revealed R4 received assisted living services for six days after R4 was no longer at the facility. 3. In an interview, E4 reported the aforementioned services had not been provided and the documentation was an error. E4 reported the caregivers must have misread the name on the ADLs when the caregivers signed off on the services.”

“Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for one of four sampled residents. The deficient practice posed a risk as resident records were not accurate. Findings include: 1. A review of R4's medical record revealed a document used when a resident was transported to and from medical appointments. The document included R4's name and date of birth. However, the "Appointment Date" was changed with white corrective fluid to make the initial entry illegible. 2. In an interview, E1 reported facility personnel were not supposed to change a resident's medical record to make the initial entry illegible. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on May 8, 2023.”

“Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of four sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "MEDICATION ADMINISTRATION." The policy and procedure stated, "It is the policy of this facility that all residents receive medications as prescribed by their physician." 2. A review of R2's medical record revealed a current service plan which indicated R2 was to receive medication administration. The review revealed the following medication orders: - "ATORVASTATIN 20 MG TABLET TAKE 1 TABLET BY MOUTH EVERY EVENING" dated March 7, 2024; - "OLANZAPINE 10 MG TABLET TAKE 1 TABLET BY MOUTH ONCE DAILY" dated March 7, 2024; - "OXYBUTYNIN 5 MG TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY" dated March 7, 2024; - "SUCRALFATE 1 GM TABLET TAKE 1 TABLET BY MOUTH THREE TIMES A DAY BEFORE MEALS," dated March 7, 2024; - "TRAZODONE 50 MG TABLET TAKE 1 TABLET BY MOUTH AT BEDTIME" dated March 7, 2024; and - "Omeprazole Tablet Delayed Release 20 MG Give 2 tablet by mouth at bedtime" dated June 5, 2024. The review further revealed medication administration records (MARs) dated April 2024 and June 2024. The April 2024 MAR revealed R2 did not receive R2's atorvastatin, olanzapine, oxybutynin, sucralfate, and trazodone on April 23, 2024, because the facility was "WAITING ON PHARMACY TO DELIVER" the medications. The June 2024 MAR revealed the following: - On June 10, 2024, R2 did not receive R2's oxybutynin because the facility was "WAITING ON PHARMACY TO DELIVER" the medication; - On June 19-21, 2024, R2 did not receive R2's omeprazole and sucralfate because the facility was "WAITING ON PHARMACY TO DELIVER" the medications; and - On June 24, 2024, R2 did not receive R2's sucralfate because the facility was "WAITING ON PHARMACY TO DELIVER" the medication. 3. A review of R4's medical record revealed a current service plan which indicated R4 was to receive medication administration. The review revealed a medication order for "BYDUREON BCISE 2 MG AUTOINJECT INJECT 2MG (0.85ML) SUBCUTANEOUSLY ONCE WEEKLY (WEDNESDAY)" dated December 21, 2023. The review further revealed a MAR dated May 2024 which indicated R4 did not receive R4's Bydureon BCise on May 8, 2024, because the medication was "not on [the medication] cart." 4. In an interview, E1 confirmed R2's and R4's aforementioned medications were not administered in compliance with the applicable medication orders. This is a repeat deficiency from the complaint investigation conducted on April 27, 2022, the complaint and compliance inspection conducted on May 8, 2023, and the complaint investigation conducted on August 15, 2023.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an open bathroom near the office accessible from the common courtyard. Next to the sink on the counter, the Compliance Officer observed a spray can of "Clorox Disinfecting Spray." 2. In an interview, E1 reported the spray should not have been in the bathroom but should have been stored in a locked area. This is a repeat citation from the complaint and compliance inspection conducted on May 8, 2023.”

“Based on documentation review, and interview, for three of ten residents reviewed, the manager failed to provide food per the residents preferences. The deficient practice posed a nutritional health risk to residents if they were unable or refused to go to the dining room for meals, and meals were not provided. Findings include: 1. During an interview, R1 reported the facility stopped allowing residents to have room trays delivered from the dining room, and many residents including R1 were upset by this. 2. In an interview, R5 reported that the caregivers refuse to bring food to resident bedrooms when residents are not able, or do not feel well enough to go to the dining room. R5 reported have a leg injury "a few months ago" that made getting to the dining room difficult. R5 reported that the facility did not provide food to R5's room. 3. In an interview, R7 reported that the caregivers have refused to provide food to R7 when R7 did not want to go to the dining room. 4. During an interview, O6 reported residents were no longer allowed to received room trays unless they were evaluated by the nurse, had vitals taken, and were sick. 5. During an interview, the Compliance Officer requested to review the facility's policy for providing food to residents in the dining room, or in their residential units. No policy was provided for review. E1, E2, and O3 reported the facility no longer allowed residents to have food from the dining room delivered to their units, and acknowledged some residents expressed preferences to have meal service provided to the residential units.”

“Based on record review, documentation review, and interview, for one resident reviewed, the administrator failed to document an allegation of neglect according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. In documentation review, the Department received a report from O7, from APS (Adult Protective Services), which documented the following report, "... Adult has had 3 open wounds and not ambulatory... facility never notified POA the adult had open wounds. Facility never notified the doctor that [Wound care agency] wasn't coming out... so the wounds kept getting worse... adult sent to [ER] ... had very low blood sugar and UTI with green discharge.. malnourished... started on an IV and .. care for the wounds... adult discharged back to the facility with wound care... facility said the adult cannot come back to the facility stating the adult needed a higher level of care..." 2. In email correspondence, O7 reported the allegations were investigated by an APS investigator, and the case was closed on January 11, 2024. 3. During an interview, the Compliance Officer requested to review the facility's investigation following the APS contact. E2 reported not being at the facility; however, remembered the complaint, and would check on the facility's follow up investigation. No further documentation was provided for review. 4. During an interview, the findings were reviewed with E1, E2, and O3, who acknowledged the facility must comply with R9-10-803.J., based on an allegation of abuse, neglect or exploitation of a resident.”

“Based on record review, documentation review, and interview, or two residents reviewed, the manager failed to terminate residency of a resident with a 14-calendar-day written notice of termination of residency, for any of the conditions in subsection (C). Findings include: 1. In record review, the medical records for R2 and R6 included a termination of residency letter, which documented, "Per Doctor's orders for higher level of care, you are being issued an immediate notice of termination of residency..." 2. Rule review of R9-10-807(G) on or after October 1, 2019, and the facility's policy and procedure titled "Termination of Residency" documented, A manager may terminate residency of a resident as follows: "G. 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency: a. For nonpayment of fees, charges or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason. Subsection (C). A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails." 3. During an interview, the findings were reviewed with E1, E2, and O3, who reported R2 and R6 required a higher level of care, and an immediate notice of termination of residency was given to the residents, instead of a 14 day written notice of termination of residency per the facility's policies and procedures. E2 reported R6 was doing better after medication changes, and R6's residency was no longer being terminated.”

“Based on record review, documentation review and interview, for two residents reviewed, the manager failed to ensure if written notice of termination of residency in subsection (G) was because the resident needed services the assisted living facility was either not licensed to provide or was licensed to provide but not able to provide, the written notice of termination of residency included a description of the specific services that the resident needed that the assisted living facility was either not licensed to provide or was licensed to provide but not able to provide. The deficient practice posed a risk, if a resident was not provided a description of the services needed, and the Department was unable to verify the reason for a resident's termination of residency. Findings include: 1. In record review, the medical records for R2 and R6 included a termination of residency letter, which documented, "Per Doctor's orders for higher level of care, you are being issued an immediate notice of termination of residency..." 2. During an interview, R2 reported being told [R2] had to move, after an incident where help was requested with incontinence care. R6 reported [R6] wanted to remain at the facility. R6 reported [R6] was doing better after a medication adjustment, and wanted to remain at the facility. 3. In documentation review, Rule R9-10-807(J) on or after October 1, 2019, documented: "If an assisted living facility issues a written notice of termination of residency as provided in subsection (G) to a resident or the resident ' s representative because the resident needs services the assisted living facility is either not licensed to provide or is licensed to provide but not able to provide, a manager shall ensure that the written notice of termination of residency includes a description of the specific services that the resident needs that the assisted living facility is either not licensed to provide or is licensed to provide but not able to provide." 4. In documentation review, a facility policy, titled, "Termination of Residency," did not include documentation which covered R9-10-807(J). 5. During an interview, the findings were reviewed with E1, E2, and O3, who reported R2 and R6 required a higher level of care, and an immediate notice of termination was given to the residents, and did not include a description of the specific services that the resident needed that the assisted living facility was not licensed to provide or was licensed to provide, but not able to provide.”

“Based on record review, documentation review, and interview, for one resident receiving transportation, the manager failed to ensure an evaluation of the resident was conducted before and after the transport, information from the resident's medical record was provided to a receiving health care institution, and if applicable, any communication with an individual at a receiving health care institution, the date and time of the transport. The deficient practice posed a health and safety risk to a resident if and evaluation of the resident was not initiated, and the required documentation was not in the resident's record and available for review. Findings include: 1. During an interview, E1 and E3 reported R7 was transported to a Dialysis clinic three times a week; Monday, Wednesday and Friday, and the transportation was coordinated by the facility. R7 reported the facility arranged for R7's transportation to the Dialysis clinic. 2. In documentation review, a facility policy titled, "Resident Transportation..." documented "It is the policy of the community to provide an evaluation of residents being transported to a medical facility prior to transport... will provide an evaluation of the resident before and after the transport/transfer. The community will also include orders that are in effect at the time of Transport/transfer. A caregiver or nurse will explain the risks and benefits of being transported to the resident or representative. A caregiver or nurse will coordinate the transport/transfer and the services being provided to the residents.... Documentation will include: Date and time of transfer/transport, mode of transportation, if applicable the name of the caregiver accompanying with the resident. Vitals, informed risk and benefit of transport/transfer. 3. In record review, R3's medical record did not include the required documentation of transport to the dialysis clinic. 4. During an interview, E1, E2, O2, and O3 acknowledged the facility did not implement the facility's transportation policy and procedures for R7's transportation to the dialysis clinic.”

“Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. During a tour of the facility, the Compliance Officers observed that the facility is a three story building with resident rooms on all three floors. The Compliance Officer observed that a dining room is only available on the first floor. 2. During an interview, R1 reported the facility stopped allowing residents to have room trays delivered from the dining room. 3. In an interview, R5 reported that the caregivers refuse to bring food to resident bedrooms when residents are not able, or do not feel well enough to go to the dining room. R5 reported have a leg injury "a few months ago" that made getting to the dining room difficult. R5 reported that the facility did not provide food to R5's room. 4. In an interview, R7 reported that the caregivers have refused to provide food to R7 when R7 did not want to go to the dining room. 5. During an interview, O6 reported residents were no longer allowed to received room trays unless they were evaluated by the nurse and had vitals taken, which showed they were sick. The residents reported their rights were being taken away. 6. In an interview, E2 reported the policy at the facility is that food is only provided in the dining room, and that room trays are only provided when a resident is sick and must be approved by E2 first. E2 reported that the purpose of this policy is to make residents leave their rooms.”

“Based on observation, record review, and interview, for three residents who received medication administration, the manager failed to ensure medication was stored by the assisted living facility. Findings include: 1. During an environmental inspection, the Compliance Officer observed medications were stored in the residential units for R2, R4, and R8. R2's unit had a container of Sudogest PE on a windowsill in the bedroom, and a bottle of Ibuprofen tablets on a cabinet in the common area. R4's unit had a bottle of Tylenol and Stool Softener in the common area, and the bathroom cabinet had several medications, including, but not limited to: Tamsulosin, Coricidin HBP, Dramamine, Pepto-Bismol Chewables, Memantine, Finasteride, Benadryl, Tylenol, Anti-Diarrheal, and Aspirin. R8's unit had a bottle of Tylenol on a table in the common area, and the bathroom cabinet contained Pain Reliever, Acetaminophen, two bottles of Pain Relief PM, Laxative, and Gas Relief. 2. During an interview, R2, R4, and R8 reported the facility kept and stored their medications and the medications were administered by the caregivers at the facility. 3. In record review, R4's service plan, dated December 2, 2023, documented R4 received medication administration and "staff administers medications..." R8's service plan, dated December 27, 2023, documented R8 received medication administration and "staff administers medications..." 4. During an interview, the findings were reviewed with E1, E2, and O3, who reported R2, R4, and R8 received medication administration services, and had medications stored in their residential units, instead of being stored by the facility, as required.”

“Based on interview, the manager failed to ensure a resident was provided a diet that meets the resident's nutritional needs as specified in the resident's service plan. Findings include: 1. In an interview R5 reported that the caregivers refuse to bring food to resident bedrooms when residents are not able, or do not feel well enough to go to the dining room. R5 reported have a leg injury "a few months ago" that made getting to the dining room difficult. R5 reported that the facility did not provide food to R5's room. 2. In an interview, R7 reported that the caregivers have refused to provide food to R7 when R7 did not want to go to the dining room. 3. In an interview, E2 reported residents were not provided a diet that meets the resident's nutritional needs as specified in the resident's service plan on days when the residents did not go to the dining room.”

“Based on observation, documentation review, and interview, the manager failed to ensure the facility's premises were cleaned to prevent, minimize, and control illness or infection. Findings include: 1. During an environmental inspection, the Compliance Officers observed R2's residential unit with multiple soiled linens in the bathroom and on the floor. The bathroom had an unpleasant odor. Dishes filled the kitchen sink. The inside of the refrigerator was dirty and soiled, including shelves and pull out drawers. 2. During an interview, R2 reported the housekeeping staff had not had not come to clean the unit for three weeks, and R2 wanted the unit to be cleaned. R2 reported having incontinence issues, the use of only one hand, and needed staff assistance. 3. Upon exiting R2's unit, the findings were reported to E1 and O3, and the environmental inspection continued. Shortly thereafter, E1 reported the housekeeper E8 attempted to enter R2's unit to clean, and R2 refused to allow the cleaning of R2's unit. The Compliance Officer requested to return to R2's unit, where the refusal of cleaning services was discussed with R2, who reported no one came to [R2's] unit to offer cleaning, and [R2] did not refuse cleaning services. R2 stated, "anyone can come in at anytime to clean..." An interview was conducted with E8, who reported R2 did not refuse cleaning services; however, stated R2's room would be cleaned, and then would be dirty again two hours later. The compliance officers observed E8 enter R2's unit to provide cleaning services. 4. In documentation review, a facility policy, titled, "Environmental Services," documented, "... Ventana Winds will ensure that the highest standards of practice are always in effect when it comes to environmental services... Facility and its grounds are: ... 2. Clean 3. Free of odors.." 5. During an interview, E1 and E6 acknowledged R2's unit was not maintained in a clean manner. E1 reported the residents received housekeeping services at least once weekly.”

“Based on observation and interview, the manager failed to ensure that garbage and refuse were stored in covered containers. The deficient practice posed a health risk to residents. Findings include: 1. During an environmental inspection with E1 and O3, the compliance officers observed uncovered garbage containers in several areas of the facility, to include but not limited to; R2's unit, R8's unit, the 2nd floor laundry room, two 3rd floor laundry rooms, and in some hallways. 2. In documentation review, a facility policy titled, "Environmental Services," documented, "... Garbage and Refuse will always be: 1. Stored in covered containers lined with plastic bags. 2. Removed from the premises at least once per week." 3. During an interview, E1 and O3 acknowledged the facility, and residential units had garbage cans without covers.”