Adagio Alh LLC

Based on documentation, record review, and interview, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1's and R2's medical records revealed no documentation or standardized form which included all information required by statute. 3. In an interview, E1 reported E1 was not aware of the HIPAA form requirement. E1 acknowledged the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of ten residents sampled. 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. A review of R1's medical record revealed documentation of R1's freedom from infectious TB was not available for review. R1's medical record included a Mantoux skin test administered January 04, 2025, however, the skin test results were not read and documented. 3. In an interview, E1 acknowledged completed documentation of R1's freedom from infectious TB was not available for review.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed an initial service plan dated January 24, 2025. However, this was more than 14 calendar days after R1's date of acceptance. 2. In an interview, E1 acknowledged a written service plan was not completed no later than 14 calendar days after R1's date of acceptance.

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of one residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. The deficient practice posed a risk as false or misleading documentation was provided to the department. Findings include: 1. A review of R2's medical record revealed a personal care service plan, dated October 1, 2024, that indicated R2 would receive the following services: - Catheter - Caregiver empties two times daily and as needed. However, no documentation of catheter care being provided to R2 per R2's service plan was available for review. 2. In an interview, E1 reported R1 received all assisted living services included in R2's service plan. E1 acknowledged a caregiver failed to document the services provided in R2's medical record.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed the facility had two staff shifts. 2. A review of the facility's disaster drill documentation, revealed the disaster drill form stated "A disaster drill for employees is conducted on each shift at least once every three months." 3. A review of the facility's disaster drill documentation revealed a disaster drill conducted on the following dates and shifts: - October 1, 2023 indicating day shift conducted at 8:30AM; - October 1, 2023 indicating evening shift conducted at 7:30PM; - January 1, 2024 indicating day shift conducted at 9:00AM; - January 1, 2024 indicating evening shift conducted at 8:00PM; - April 1, 2024 indicating day shift conducted at 9:30AM; - April 1, 2024 indicating evening shift conducted at 8PM; - July 1, 2024 indicating day and evening shift conducted at 9:00; - October 7, 2024 indicating day and evening shift conducted at 10:00; and - December 06, 2024 indicating day and evening shift conducted at 10:30. However, no documentation of disaster drills for each shift or identification of shift the drill was completed on during July, October, and December 2024 was available for review. 4. In an interview, E1 acknowledged a disaster drill for employees was not conducted at least once every three months on each shift and documented.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. A review of department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection, the Compliance Officer observed ambulatory residents in the home. 3. During the environmental tour, the Compliance Officer observed the following safety concerns: - A water damaged baseboard and wall next to the walk-in shower of a bathroom used by multiple residents; - A towel and a bathroom floor mat laid across the floor of the bathroom creating a tripping hazard in the bathroom; - A light switch in a resident bathroom missing the protection plate allowing access to the wires powering the switch; and - An electrical receptacle in the hallway of the home missing the protection plate allowing access to the wires behind the receptacle. 4. In an interview, E1 acknowledged the premises at the assisted living facility was not free from a condition or situation which may cause a resident or other individual to suffer physical injury.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection, Compliance Officer observed ambulatory residents in the home. 3. During the environmental tour, the Compliance Officers observed the following poisonous or toxic material in the unlocked cabinet in the kitchen accessible to residents: - One bottle of "Lysol All Purpose Cleaner"; - One can of "Easy-Off Heavy Duty Oven Cleaner"; - One container of " Comet with Bleach"; - One can of "Eco Smart Flying Insect Killer"; - One container of "Lysol Power Clinging Gel Toilet Bowl Cleaner"; - One container of "Finish Powerball Quantum Automatic Dishwasher Detergent"; - One container of "Orange GLO Wood Furniture 2-in-1 Clean & Polish"; and - Two cans of "Raid Ant & Roach" spray. 4. During the environmental tour, the Compliance Officers observed the following poisonous or toxic material in the laundry area of the home accessible to residents: - One bag of "Roma Laundry Detergent"; and - One mop bucket containing with used floor cleaner. 5. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. In an interview, E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted annually.