A Country Retreat

Based on observation, interview, and documentation review, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the modification, as the facility did not submit an updated floor plan. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a modification to the facility. Two new resident bedrooms were observed near the back right of the facility. These rooms did not appear in the facility floor plan on file with the Department. R2 was observed to be residing in one of the new rooms. 2. In an interview, E1 reported that R4 resided in one of the new rooms before R4 left the facility (passed away). 3. In an interview, E3 reported the modification was finished in February 2025. 4. Review of Department records revealed no documentation of a request for approval for the modification. 5. In an interview, E4 reported a request for approval for the modification was not submitted to the Department. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained any information provided by the hospice service agency or a copy of follow-up instructions provided to the resident. Findings include: 1. A review of R4’s medical record revealed documentation indicating R4 was receiving services from a hospice service agency. 2. A review of R4’s medical record revealed no documentation of any information provided by the hospice service agency or a copy of follow-up instructions provided to the resident. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on interview and record review, the manager failed to ensure a personnel record was established and maintained for each employee or volunteer as required, for one of the four personnel reviewed. The deficient practice posed a risk as the required information for a personnel member could not be verified. Findings include: 1. In an interview, E1 reported that E4 came to the facility to provide services for R4 on July 8, 2025. In addition, E1 stated that E4 changed the resident's brief, bed, and gave a bed bath. Administered oxygen and medication. E1 did not state which medications E4 administered. 2. A personnel record was not available for E4 at the time of the inspection. 3. In an interview, E1 reported there was no personnel record for E4. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed ambulatory residents in the facility. 3. The Compliance Officer observed a door exiting the facility to the front yard. However, this door was not monitored or alerted. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one of five residents reviewed. 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 signed medication order dated June 16, 2025, for Risperidone 1 MG tab, take one tablet by mouth twice a day. 2. A review of R2's July 2025 medication administration record (MAR) stated “Risperidone 1 MG tab, take one tablet by mouth morning and night”. However, the MAR showed Risperidone 1 MG was only administered at 8PM on July 1-14, 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises were cleaned. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the following: -a pungent odor of feces, dried feces on the floor, in the bedside commode, and feces and a used brief inside the bedside commode in R2's room; -multiple large piles of dog and cat feces in the backyard; -multiple piles of cat feces on the front porch and front yard; -a buildup of dirt and debris along the toilet and baseboards in the common area bathroom; and -a black substance on the back and around the toilet in the common area bathroom. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 3. This is a repeat deficiency from the inspection conducted on March 22, 2023.

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the following: -dry, rotted wood that was splintered on the back porch; -the ramp from the back door leading to the backyard was wobbly and unstable with sharp rusted metal on the rail; -multiple piles of furniture/belongings throughout the yard of the property; -nine brown tents with items such as children's bicycles, tarps, pallets, and broken furniture, at the entry of the tents; -multiple plastic bags with empty aluminum cans and empty plastic gallon jugs along the fence line; -broken plastic tubs along the back fence of the backyard; -loose wires were coming from the top and bottom of the facility in the backyard; -multiple old appliances: stove, three vacuums, refrigerator, and air unit on the back porch; -three wood planks with protruding rusty nails in the backyard; -multiple large piles of dog and cat feces in the backyard; and -an open anti-diarrhea pill package with a half pill in the backyard rocks; 2. In an exit interview, the findings were reviewed with an E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the facility inspection with E1, the Compliance Officer observed the following toxin materials accessible to residents: -Members Mark disinfecting wipes on the bathroom counter; -sanitizing wipes were on the dining room table; and -nail polish remover on the bathroom counter. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that combustible or flammable liquids and hazardous materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a facility inspection, the Compliance Officer observed the following combustible or flammable liquids and hazardous materials: - a can of Dust-Oleum protective enamel sitting on a wooden rail on the front porch; and -a cigarette lighter sitting on the activity table. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training, as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program that indicated the training will include initial training and continued competency training as required in A.R.S. \'a7 36-420.01. 2. During an interview, E1 acknowledged the facility training program failed to indicate the training would include initial training and continued competency training.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.