A Special Place Care Home

Based on record review, observation, and interview, the manager failed to ensure that medication was administered in compliance with a medication order and documented in the resident’s medical record, for one of three residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed a signed medication order dated February 28, 2025 for the following medications: Tamsulosin HCL (FLOMAX) 0.4 milligram (MG) - Take 1 cap by mouth daily hold if BP <100/60; Atorvastatin Calcium 10MG - Take 1 tab by mouth daily; Probiotic 250MG - Take 1 cap by mouth 1 time a day; Sennosides 8.6MG - Give 2 tab by mouth 2 times a day; Levothyroxine 25 microgram - (0.025MG) - Take 1/2 tab by mouth daily; Lactulose - take 15 milliliter (ML) by mouth at bedtime for constipation; Lisinopril 2.5MG - take 1 tab by mouth daily hold if BP <100/60; Monitor daily blood pressure; Spirinolactone 25MG - Take 1 tab by mouth daily hold if BP <100/60; Acetaminophen 500MG - Take 1 tab by mouth 2 times a day; Polyethylene Gly (Miralax) 17 grams - mix in a 8 ounce fluid - Take by mouth daily; and Klor-Con 10 MEQ Tablet, Take 1 tab by mouth daily. However, all later medication orders did not contain a dated signature. 2. A review of R2's medical record revealed a document titled "Medication Administration Record" (MAR) for the month of January 2026. The MAR revealed the following medications were not documented as administered to R2 on January 13, 2026: Spirinolactone 25MG - Take 1 tab by mouth daily hold if BP <100/60; Polyethylene Gly (Miralax) 17 grams - mix in a 8 ounce fluid - Take by mouth daily; Tamsulosin HCL (FLOMAX) 0.4 milligram (MG) - Take 1 cap by mouth daily hold if BP <100/60; Atorvastatin Calcium 10MG - Take 1 tab by mouth daily; Probiotic 250MG - Take 1 cap by mouth 1 time a day; Sennosides 8.6MG - Give 2 tab by mouth 2 times a day; and Levothyroxine 25 microgram - (0.025MG) - Take 1/2 tab by mouth daily. 3 . A review of R2's MAR revealed R2 was documented as receiving the following medication from January 1, 2026 to January 12, 2026: Furosemide 20MG tablet - Take 1 tab by mouth daily at 8:00AM; and Magnesium Oxide 400MG - Take 1 tab by mouth every day at 8:00AM. However, no signed and dated medication order was available for review. 4. In an exit interview, the findings were reviewed with E1 and E2. No further information was provided.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the policy and procedure for an assisted living facility to terminate residency, and the manager’s signature and date signed, for three of three resident records reviewed. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the document did not include the manager's signature and date signed. 2. A review of R1’s, R2’s and R3's medical record revealed residency agreements which included a termination policy that was not consistent with R9-10-807.G. The agreements stated, “…7. The Manager reserves the right to terminate this contract with 14 calendar days written notice, should the resident or the resident’s representative … and/or should the resident refuse to comply with this residency agreement or facility rules.”, and “9. The Manager reserves the right to terminate this residency agreement without notice … or should the resident’s urgent medical needs require immediate transfer to another health care institution; or should the resident’s care and service needs exceed the services the facility is licensed t provide.” 3. In an interview, E1 acknowledged R1's residency agreement did not contain the signature of the manager and the date signed. E1 also acknowledged R1’s, R2’s, and R3's residency agreements included a termination policy that was not complaint with R9-10-807.G.

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, the manager, and the nurse or medical practitioner who reviewed the service plan, when initially developed and when updated, for two of three resident records reviewed. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. A review of R2's medical record revealed an initial service plan, dated June 30, 2025. Further review of R2’s service plan revealed R2 received personal care level services and medication administration, however R2’s service plan was signed but not dated by the manager and the nurse or medical practitioner who reviewed the service plan. 2. A review of R3's medical record revealed a multiple service plan updates, which included directed care level services and medication administration. The service plan update dated April 1, 2025, was not signed and dated by the resident or resident’s representative, and the nurse or medical practitioner who reviewed the service plan. The medical record also revealed a service plan update dated July 1, 2025, which did not include a date for the signature of the nurse or medical practitioner who reviewed the service plan. The medical record included a service plan update dated October 1, 2025, which was not signed and dated by the resident or resident’s representative, and the nurse or medical practitioner who reviewed the service plan. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. This is a repeat deficiency from the compliance/complaint inspection conducted May 13, 2025.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for one of three resident records reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical records revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 acknowledged the medical record for R1 did not include the required documentation dated within 90 calendar days before R1 was accepted by the assisted living facility. This is a repeat citation from the on-site compliance inspection and complaint inspection conducted on January 8, 2024.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that is completed no later than 14 calendar days after the resident's date of acceptance; includes the level of service the resident is expected to receive; for a resident who requires medication administration, review by a nurse or medical practitioner; and for a personal care level service plan, is updated every six months, for two of three resident records reviewed. Findings include: 1. A review of R1’s medical record revealed a service plan for supervisory care services. 2. A review of R1’s service plan revealed R1 was receiving medication administration, one person assists with grooming, dressing, and personal hygiene, and staff are to assist as needed with bowel and bladder hygiene. 3. Further review of R1’s service plan revealed the service plan was developed within 14 days of admission and signed timely by the resident and the manager. However, the service plan was signed by the nurse 53 days after admission. 4. A review of R2’s medical record revealed a service plan dated October 13, 2024, for personal care services. A service plan update was required by April 13, 2025; however, no updated service plan was provided for review. 5. In an interview, E1 acknowledged R1's service plan was supervisory in error and should have been personal care. E1 further acknowledged the manager failed to ensure R1 had an initial service plan that was completed within 14 days of admission, which included the level of service the resident was expected to receive, and was signed by a nurse, and for R2 a service plan update which was completed within six months.

Based on documentation review and interview, the manager failed to ensure that a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents sampled. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical record as follows... If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The Compliance Officer requested to review R4's medical record. However, R4's medical record was unavailable for Compliance Officer review. 3. In an interview, E1 reported R4 was in the facility for a few days to a week and was unable to locate the file. E1 acknowledged R4's medical record was not maintained according to A.R.S. Title 12, Chapter 13, Article 7.1.

Based on record review and interview, the manager failed to ensure a personal care service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of three resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan, dated October 13, 2024, for personal care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. In an interview, E1 acknowledged R2's services plan did not include a description of the skin maintenance the resident required to prevent and treat bruises, injuries, pressure sores, and infections.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies and licensed consistent with local ordinances. Findings include: 1. The Compliance Officer observed three small dogs in the facility. 2. A review of facility documentation revealed a rabies vaccination for O2, which expired on October 6, 2024. The documentation further revealed the license for O2 expired on October 26, 2024 3. A review of the documentation revealed no license for O3. In an interview, E1 reported O3 was never licensed due to age, though it was now old enough and would need a license. 4. In an interview, E1 acknowledged O2 was currently not vaccinated against rabies, and O2 and O3 did not have current licenses.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. Review of E3's personnel record, who was hired November 27, 2022, revealed that E3 had not completed the fall prevention and fall recovery training, as required. 2. During an interview, E1 and E2 acknowledged that E3 had not completed the required fall prevention and fall recovery training.

Based on observation, documentation review, record review, and interview, the governing authority failed to designate a manager who had either a temporary or permanent manager's certificate from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers, which posed a health and safety risk. Findings include: 1. On November 21, 2023 the Department received in writing from O1 that O1 was no longer this facility's manager. 2. At the time of the compliance and complaint inspection, the compliance officer observed E1 had a temporary manager's certificate posted on the resident's living room wall. 3. Review of E1's personnel record revealed that E1 started as the manager on December 11, 2023. 4. E2 acknowledged the facility had no manager from November 21 to December 11 of 2023.

Based on observation, documentation review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager which posed a health and safety risk. Findings include: 1. At the time of the compliance and complaint inspection, the compliance officer observed E1's manager's certificate with a temporary certificate number conspicuously posted on the residents' living room wall. E1 arrived after the compliance inspection had begun. Review of E1's personnel record revealed that E1 started as the manager on December 11, 2023.. 2. There was no documented evidence that the Department had been notified in writing that E1 was the manager of this facility. 3. In an interview, E1 and E2 acknowledged the Department had not been notified of the change in the manager.

Based on observation, record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for one of four caregiver personal records reviewed who were required to complete first aid and CPR training. Findings include: 1. Review of E2's personnel record reveal that E2 was hired December 1, 2014 as a caregiver. E2's record contained a copy of a first aid and CPR card that had expired on December 20, 2023. The compliance officer observed E2 was working as a trained caregiver. 2. In an interview, E1 and E2 acknowledged E2's first aid and CPR had expired and E2 was working as a caregiver. No other information was available for review.

Based on record review and interview, the manager failed to ensure that within 90 calendar days before or on the day the individual was accepted by an assisted living facility there was completed the required documented determination. The documentation should have included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; this was based on the date of acceptance, for four of five sampled residents' records reviewed which posed a health and safety risk. Findings include: 1. Review of R1's medical record, based on the date of acceptance, there was documentation of a pre-admission determination two days after the date of acceptance. 2. Review of R2's, R3's, and R5's medical records, based on the date of acceptance, found no documentation of a pre-admission determination prior to nor on the date of acceptance. Based on the residents' dates of acceptance, this documentation was required. 3. During an interview, E1 and E2 acknowledged there was no available evidence the pre-admission determination was completed as required for these sampled residents..

Based on record review and interview, the manager failed to ensure one of five resident records sampled contained a written service plan that included review by a nurse or medical practitioner for a resident that received directed care and medication administration services. Findings include: 1. A review of R3's medical record revealed a current service plan dated December 15, 2023. The service plan stated R3 required directed care and medication administration services. However, the service plan did not contain documentation of a review by a nurse or medical practitioner. 2. In an interview, E1 and E2 acknowledged R3 was receiving directed care and medication administration services and this service plan did not have a signature and date by a nurse or medical practitioner this individual had reviewed and approved this service plan.

Based on record review and interview, the manager failed to ensure that one of two sampled resident who were receiving directed care services had a written service plan reviewed and updated at least once every three months, which posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed that R4's written service plan was updated during the past twelve months on May 15, 2023 and October 3, 2023. Both service plans stated the resident required directed care services. In an interview E2 stated the resident required directed care services. 2. In an interview, E1 and E2 acknowledged the sampled resident's service plan did not appear to have been updated every three months as required for a resident receiving directed care services.

Based on record review and interview, the manager failed to ensure that for one of two sampled residents who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at onset and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. In an interview, E2 reported R6 was unable to ambulate even with assistance for the past year. 2. Review of R6's medical record found a documented determination completed on September 1, 2023 by R6's medical practitioner. There was no documented determination completed by R6's medical practitioner at least every six months throughout the duration of the resident's condition. The determination should have been based on a current examination of the resident, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility. 3. In an interview, E2 acknowledged E6's determination was not completed as required. E2 reported, "I don't have it".

Based on 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 that provides access to an outside area that controls or alerts employees of the egress of a resident from the facility, which posed a safety risk to residents. The facility is licensed to provided directed care services. Findings include: 1. During a facility tour of the outdoor area where residents may walk, E1 and the compliance officer observed one of two exit gates from this outdoor area could easily be opened that led to the front of the facility and the City street. There were no activated alarms to alert the employees of the egress of a resident from the facility. 2. In an interview, E1 and E2 acknowledged the unsecured outdoor area.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of the facility's documentation revealed evacuation drills were not conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during the past 12 months. 2. In an interview, E2 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.

Based on observation, document review, and interview, the manager failed to ensure a resident's sleeping area was not used as a passageway to another sleeping area or common bathroom. The facility was licensed after October 1, 2013. Findings include: 1. During the facility tour, the compliance officer observed E2 using R7's bedroom as passageway from the residents' common dining area to the facility's attached garage. 2. According to the Department's record, this facility was licensed in 2014 which was after the 2013 exception to the Rule. 3. In an interview, E2 acknowledged that this resident bedroom was used as a passageway to another facility area.