Acacia Cove Assisted Living

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “FALL PREVENTION AND RECOVERY TRAINING.” The P&P stated: “The facility, as a licensed healthcare institution, has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery.” The P&P continued, “All employees of the facility will attend refresher training on an annual basis on Fall Prevention and Fall Recovery that meets the same guidelines as initial training.” 2. A review of E2’s personnel record revealed E2 was hired as the manager more than one year before the date of the inspection. The review revealed documentation of training on fall prevention and fall recovery dated September 2, 2024, more than one year before the date of the inspection. However, the review revealed no documentation of training on fall prevention and fall recovery annually after September 2, 2024. 3. In an interview, E4 stated, “[E2] doesn’t have it for this year.” E4 reported E2 must not have told the training school used by the facility that E2 needed the annual training on fall prevention and fall recovery.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The webpage stated: "The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting." 2. A review of E2’s personnel record revealed E2 was hired as the manager more than one year before the date of the inspection. The review revealed documentation of training and education related to recognizing the signs and symptoms of TB dated September 2, 2024, more than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB annually after September 2, 2024. 3. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver less than one year before the date of the inspection. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB upon hire. 4. In an interview, E4 stated, “[E2] doesn’t have it for this year.” E4 reported E2 must not have told the training school used by the facility that E2 needed the annual training on recognizing the signs and symptoms of TB. E1 reported E5 received the training but it was not documented. Technical assistance was provided on this rule during the compliance inspection conducted on August 1, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the individual provided physical health services, for one of one sampled assistant caregiver. The deficient practice posed a risk if a caregiver or an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMPLOYEE JOB DESCRIPTIONS, DUTIES AND QUALIFICATIONS (INCL. REQUIRED SKILLS AND KNOWLEDGE, EDUCATION AND EXPERIENCE).” The P&P stated: “The hiring person or manager will ensure, check and document that each caregiver or assistant caregiver providing physical health services or behavioral care services [has] the required skills and knowledge before providing any service…The skills and knowledge are verified by [the] manager at the time of the orientation, before providing assisted living services to a [resident] and documented.” The review further revealed a personnel schedule which indicated E5 worked several shifts before November 18, 2025. 2. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. However, the review revealed E5’s skills and knowledge specific to “Memory Care & Behavioral Management” were not verified until November 18, 2025. The review revealed no documentation demonstrating the manager verified E5’s skills and knowledge apart from memory care and behavioral management. 3. In an interview, when the Compliance Officers asked if E1 had documentation demonstrating the manager verified E5’s skills and knowledge before E5 provided services, E1 stated, “I don’t” and “[E5] has to have it even if [E5’s] a caregiver assistant.”

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. The deficient practice posed a risk as a service plan guides a resident’s care. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan revealed R1 required assistance with medication administration, transferring, and showering twice per week. However, the service plan did not include the frequency of these services. The review further revealed documentation of assisted living services (ADLs) provided to R1 dated November 2025. The ADLs revealed R1 received assistance with partial baths on days R1 did not receive a shower. However, the service plan did not include partial baths. 2. A review of R2's medical record revealed a current service plan. The service plan revealed R2 required assistance with medication administration. However, the service plan did not include the frequency of medication administration. The review further revealed ADLs provided to R2 dated November 2025. The ADLs revealed R2 received assistance with partial baths on days R2 did not receive a shower. However, the service plan did not include partial baths. 3. In an interview, E1stated R1 received a shower “in the shower” at least three times a week and not two times per week as reported in R1’s service plan. Regarding the frequency of medication administration and partial baths, E4 stated, “I don’t think we have a frequency” and “I will add that” respectively. E1 acknowledged the service plans did not include the complete and correct amount, type, and frequency of assisted living services being provided to R1 and R2. Technical assistance was provided on this rule during the compliance inspection conducted on August 1, 2023.

Based on documentation review, interview, and record review, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for eight of eight total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “DOCUMENTATION IN RESIDENT RECORDS (INCLUDING ELECTRONIC RECORDS).” The P&P stated: “Documentation will be completed by the caregiver or personnel completing the task, providing the service or assisting the resident. No person is to document care or services provided by another individual.” The review further revealed a personnel schedule dated November 2025 which indicated E3 worked from 8:00 AM to 7:00 PM on November 3-7, 10-14, 17-21, and 24-28, 2025. The schedule revealed E3 did not work on Saturdays and Sundays. 2. In an interview, when one of the Compliance Officers asked if E3 worked any of the Saturdays or Sundays in November, E3 stated, “No.” 3. A review of R1's, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed documentation of assisted living services (ADLs) provided to the eight residents dated November 2025. The ADLs revealed documentation demonstrating E3 provided assisted living services on November 1-6, and 11-25, 2025, including Saturdays and Sundays on November 1-2, 15-16, and 22-23, 2025, in contradiction with the personnel schedule and E3’s statement. 4. In an interview regarding E3’s initials on November 1-2, 15-16, and 22-23, 2025, E1 stated the initials were “supposed to be mine [E1’s].” E1 reported E1 worked those dates, E3 did not work those dates, and E1 was supposed to have initialed for the services on the ADLs, not E3.

Based on documentation review, record review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the correct time of administration or assistance, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION SERVICES.” The P&P stated: “13. A Nurse, the Manager, a Trained Caregiver, the Resident's Representative or a Family Member will administer medications from the medication organizer to the resident by placing the medication in the resident's hand, transferring the medications to a medicine cup and handing the cup to the resident or by placing the medications directly in the resident's mouth…14. The caregiver will initial in the MAR for the date and time the medication was given to the resident and the medications taken…22. The trained caregiver will sign off the medication for the date and time the medicine was given to the resident and the medications taken by initialing the Medication Administration Record or completing the PRN Flow sheet…28. Time and date will be recorded as well as the initials of the person that administered the medication or assisted in the self-administration of medication.” 2. A review of R1’s medical record revealed a medication administration record (MAR) dated November 2025. The MARs revealed documentation demonstrating the following: - R1 received nifedipine 30 mg at 8:00 AM on November 1-24, 2025; - R1 received olanzapine 5 mg at 8:00 AM and 7:00 PM on November 1-24, 2025; - R1 received senna 8.6 mg at 8:00 AM on November 1-24, 2025; - R1 did not receive quetiapine 100 mg on November 1-24, 2025; and - R1 did not receive quetiapine 200 mg on November 1-24, 2025. 3. The Compliance Officers observed R1’s medications and medication organizer. In the morning compartment of the medication organizer, the Compliance Officers observed one tablet each of quetiapine 100 mg and quetiapine 200 mg, among other medications. In the evening compartment, the Compliance Officers observed one tablet each of olanzapine 5 mg, quetiapine 200 mg, and senna 8.6 mg, among other medications. 4. A comparison between the MAR and the medication organizer revealed the following: - R1 did not receive R1’s nifedipine 30 mg at the time documented on the MAR, - R1 did not receive R1’s olanzapine 5 mg at 8:00 AM as documented on the MAR, - R1 received R1’s senna 8.6 mg at 7:00 PM and not at 8:00 AM as documented on the MAR, - R1 received R1’s quetiapine 100 mg without the time being documented on the MAR, and - R1 received R1’s quetiapine 200 mg without the time being documented on the MAR. 5. In an interview, E1 reported the MAR was incorrect and did not include the correct times of administration. E1 reported the senna was administered at 7:00 PM and

Based on documentation review, interview, and record review, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering the medication, for eight of eight total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “DOCUMENTATION IN RESIDENT RECORDS (INCLUDING ELECTRONIC RECORDS).” The P&P stated: “Documentation will be completed by the caregiver or personnel completing the task, providing the service or assisting the resident. No person is to document care or services provided by another individual.” The review revealed a P&P titled "MEDICATION SERVICES.” The P&P stated: “14. The caregiver will initial in the MAR for the date and time the medication was given to the resident and the medications taken…22. The trained caregiver will sign off the medication for the date and time the medicine was given to the resident and the medications taken by initialing the Medication Administration Record or completing the PRN Flow sheet…27. Medication administration records will be filled by the authorized personnel that are doing medication administration and or assisting in self-administration.” The review further revealed a personnel schedule dated November 2025 which indicated E3 worked from 8:00 AM to 7:00 PM on November 3-7, 10-14, 17-21, and 24-28, 2025. The schedule revealed E3 did not work on Saturdays and Sundays. 2. In an interview, when one of the Compliance Officers asked if E3 worked any of the Saturdays or Sundays in November, E3 stated, “No.” 3. A review of R1's, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) dated November 2025. The MARs revealed documentation demonstrating E3 administered medication on November 1-25, 2025, including Saturdays and Sundays on November 1-2, 15-16, and 22-23, 2025, in contradiction with the personnel schedule and E3’s statement. 4. In an interview regarding E3’s initials on November 1-2, 15-16, and 22-23, 2025, E1 stated the initials were “supposed to be mine [E1’s].” E1 reported E1 worked those dates, E3 did not work those dates, and E1 was supposed to have initialed for the services on the MARs, not E3.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three caregivers. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required. 4. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records 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. 1. In record review, the Compliance Officer requested to review the medical record for R2, however, no medical record was provided. 2. During an interview, E1 acknowledged the facility was unable to locate R2's medical record. It was reported R2's residency was terminated less than six years ago.

Based on record review and interview, the manager failed to ensure a resident's representative was designated for a resident who was unable to direct self-care, for one of one resident who received directed care services. The deficient practice posed a risk as no individual was designated to participate in decisions concerning the assisted living services the resident was to receive. Findings: A.R.S. 36-401(A)(16) "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R1's medical record revealed service plans (dated December 2023 and March 2024) for directed care services. R1's service plans stated " Mental status: confused..forgetful...agitated...depressed"." R1's service plan revealed R1 signed both service plans no signature from a representative or POA had signed. Documentation was not available for review to demonstrate R1 had a designated representative or POA. 2. In an interview, E1 stated R1 was at directed care. E1 stated "I have asked R1's family for POA paperwork and never received so I didn't know if it was true or not."

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted 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 two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record did not contain documentation of an incident on April 9, 2024 that resulted in a 911 call and R1 transported to the hospital. E1 reported that R1's blood pressure was high on April 8, 2024 and speech slurred. E1 reported Hospice and 911 were called. Paramedics arrived, however, R1 refused to go to the hospital. E1 reported the hospice nurse came back over to the facility on April 9, 2024 and recommended the R1 go to the hospital to get checked out. E1 reported 911 was called and R1 was transported to the hospital. There was no documentation available for review that included 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. 2. In an interview, E1 stated not having time yet to complete the "incident report". E1 acknowledged R1's medical record did not include documentation of 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.