Adobe Adult Care Home

Based on record review, document review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for one of two residents in which an emergency responder had been contacted. Findings include: 1. A review of R1's medical record revealed a document titled "Vital Signs & ADL Sheet," used for documenting activities of daily living. Entries on the document indicated R1 was hospitalized on January 23, 2025. 2. A review of an incident report dated January 23, 2025 revealed documentation indicating R1 had injured a toe and 911 was called after consulting with R1's medical provider. 3. A review of R1's medical record revealed a form titled, "Preliminary Application," for documenting information required in A.R.S. 36-420.04. However, the form did not include the following required information: - The reason or reasons the emergency responder was requested on behalf of the resident; - The name, address and telephone number of the resident's current pharmacy; - The name and contact information for the resident's primary care physician and power of attorney or authorized representative; - 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 copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge; and - A copy of the resident's advance directives, if any. 4. In an interview, E1 acknowledged the provided documentation of what was given to the emergency responder for R1 did not include all of the required information.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a copy of resident follow-up instructions provided to the resident by the home health agency or hospice service agency. Findings include: 1. A review of R3's medical record revealed a document titled "Preliminary Application," used for obtaining initial information, including health related information, regarding a resident. The document indicated R3 was receiving medical services from "Bayada Home Care," and "United Wound." R3's medical record also contained a document titled "Medication, Diagnosis & Treatment Orders," which was signed by a medical provider on October 27, 2024, and indicated R3 was diagnosed with a "sacral pressure ulcer," upon acceptance into the facility. 2. A review of R3's medical record revealed a service plan indicating R3 received personal care services. The service plan indicated R3 was receiving services from "Bayada Home Health." In addition, R3's medical record contained a document titled, "Hospice Certification and Plan of Care, signed by a registered nurse on December 22, 2024, and signed by a medical provider on December 23, 2024 , which indicated R3 was receiving treatment for a "STAGE 3 COCCYX" pressure ulcer. The document identified the provider as "Agape Hospice & Palliative Care." 3. A request was made to review progress notes and any additional instructions entered into R3's medical record by representatives of the home health or hospice agency. However, evidence of such documentation was unavailable for review. 4. In an interview, E1 advised there was a binder in R3's bedroom which contained all of R3's medical records entered by representatives of the home health and hospice agency. However, E1 reported to have no knowledge of the binders whereabouts. E1 agreed the manager failed to ensure R3's medical record contained a copy of follow-up instructions provided to the facility by the home health agency or hospice service agency.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the required information from a home health agency, for one of one resident's medical record reviewed who had been receiving home health services. Findings include: 1. A review of R3's medical record revealed a document titled, "Medication, Diagnoses & Treatment Orders," dated one day prior to R3's admission, which indicated R3 was receiving intermittent nursing services to treat a "ulcer to toe and sacral pressure ulcers, care provided by HH and specialty wound agency." 2. A review of R3's medical record revealed a service plan dated November 11, 2024 for personal care services. The service plan included a section titled, "Home Health Agency," which included the name, address and contact information of the agency treating R3's wounds. The section also stated the following: "1) Ask the nurse/therapist for a copy of the signed plan of care (called a 485) and all orders; 2) Maintain either a log of the nurse/therapist visits or a copy of their visit notes; 3) Nurse visits 2 times a week for wound care; 4) PT visits 2 times a week for strengthening and gait (walking) training; and 5) OT visits 2 times a week for increased independence with ADL's." 3. A request was made to review the home health visit log, copy of visit notes or any instructions provided by the home health agency. However, evidence of such documentation was unavailable for review. 4. In an interview, E1 reported there was "no" documentation. E2 advised the home health agency left a binder in R3's room, however the binder was no longer in the facility. E1 agreed R3's medical record did not contain the required information from the home health agency as required.

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 five of five employees reviewed. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. 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 E3's personnel record revealed a date of hire of June 7, 2024. The personnel record contained documentation of two Mantoux skin tests. The first test was administered on June 19, 2024 and read June 21, 2024, while the second test was administered on July 31, 2024 and read on August 2, 2024. Furthermore, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 3. A review of staffing schedules for June 2024 and July 2024 revealed E3 worked the day shift (7:30 a.m. - 7:30 p.m.) on June 20 - 22, 25 - 29, July 2 - 6, 9 - 13, 16 - 20, 23 - 27, 30 and 31, 2024. 4. In an interview, E2 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed a form titled, "Determination for Admission," which was designed to provide documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. However, the form was signed and dated twenty two days after R2's date of admission. 2. In an interview, E1 acknowledged R2's admission forms were completed after R2's date of admission.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed a document titled, "Medication, Diagnoses & Treatment Orders," dated one day prior to R3's admission, which indicated R3 was diagnosed with "lymphedema, sacral pressure ulcer, weakness, C-Spine stenosis, DJD [degenerative joint disease], Chronic pain, depression, anxiety, insomnia, gout, breast cancer, bedbound status." The document indicated R3 was receiving intermittent nursing services to treat an "ulcer to toe and sacral pressure ulcers, care provided by HH and specialty wound agency." 2. A review of R3's medical record revealed a service plan dated November 11, 2024 for personal care services. The service plan included a description of R3's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, as "chronic pain, depression, anxiety, insomnia." However, the service plan did not include a description of R3's diagnosed lymphedema, sacral pressure ulcer, weakness, C-spine stenosis, gout, DJD or breast cancer. 3. In an interview, E1 acknowledged R3's service plan did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on 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 three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated September 17, 2024, for personal care services. The service plan identified the service "Toileting," reflected R1 required "Complete" assistance, and stated, "care staff toilet every 2-3 hours during the day and check at night during rounds." 2. A review of R1's medical record revealed a form titled, "Vital Signs & ADL Sheet," used for tracking activities of daily living (ADLs) in the month of January 2025. The form included a section for documenting the service, "Toileting" which indicated R1 was "Independent" and reflected R1 was toileted every day from January 1 through January 22, 2024, at "7am" and "7pm." Further review revealed ADLs for December 2024 and November 2024 which indicated R1 was "Independent" in toileting. 3. In an interview, E1 advised R1 required total assistance in toileting when they were initially accepted into the facility. E1 reported R1 became ambulatory in the following months and was now able to toilet themselves. E1 acknowledged R1's service plan had not been updated within 14 calendar days after R1 had a significant change in condition concerning R1's ability to ambulate.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed, and services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan, dated September 17, 2024, for personal care services. The service plan identified the service "Toileting" reflected R1 required "Complete" assistance, and stated, "care staff toilet every 2-3 hours during the day and check at night during rounds." 2. A review of R1's medical record revealed a form titled, "Vital Signs & ADL Sheet," used for tracking activities of daily living (ADLs) in the month of January 2025. The form included a section for documenting the service, "Toileting," which indicated R1 was toileted every day from January 1, 2025 through January 22, 2025, at "7am," and "7pm." Evidence R1 was being toileted every two to three hours per R1's service plan was unavailable for review. 3. A review of R3's medical record revealed a document titled, "Medication, Diagnoses & Treatment Orders," dated one day prior to R3's admission, which indicated R3 was receiving intermittent nursing services to treat an "ulcer to toe and sacral pressure ulcers, care provided by HH and specialty wound agency." Further review of R3's medical record revealed a service plan, dated November 11, 2024, for personal care services. The service plan included a section titled, "Basic Skin Care," which read, "Encourage/assist [R3] to change position every 2 -3 hours to help with circulation and skin breakdown prevention." The service plan included the name, address and contact information for the home health agency treating R3. However, the service plan did not include a description of any care instructions provided to the facility by the home health agency. 4. A review of R1's ADL tracking sheet for the month of December 2024 revealed evidence of documentation of the service Basic Skin Care was unavailable for review. 5. In an interview, E1 acknowledged R1 and R3 were not being provided the services as described in R1's or R3's service plan.

Based on interview and record review, the manager failed to ensure the requirements in R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for two of two non-ambulatory residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. In an interview, E1 revealed R2 and R3 were non-ambulatory upon admission. 2. A review of R2's medical record revealed a document titled, "Medication, Diagnosis & Treatment Orders," signed on June 5, 2024. The document indicated R2 was "non-ambulatory." Further review of R2's medical record revealed documentation of R2's, or R2's representative's request to be accepted by the facility was unavailable for review. In addition, evidence of documentation indicating R2 had been examined by a medical practitioner within 30 days of R2's acceptance, and the medical practioner had reviewed the facility's scope of service and determined R2's needs could be met by the facility was unavailable for review. 3. A review of R3's medical record revealed a document titled, "Medication, Diagnosis & Treatment Orders," signed on October 27, 2024. The document indicated R3 was "bedbound status." Further review of R3's medical record revealed documentation of R3's, or R3's representative's request to be accepted or retained by the facility was unavailable for review. Lastly, evidence of documentation indicating R3 had been examined by a medical practitioner within 30 days of R3's acceptance, and the medical practioner had reviewed the facility's scope of service and determined R3's needs could be met by the facility was unavailable for review. 4. In an interview, E1 acknowledged R2's condition had improved and R2 was now ambulatory. E1 agreed R2's and R3's medical record did not contain the requirements in R9-10-814(B)(2) for admission of a resident who was confined to a bed or chair because of an inability to ambulate even with assistance were not being met.

Based on record review and interview, the manger accepted or retained a resident with a stage 3 pressure sore, as determined by a registered nurse or medical practioner, without meeting the requirements as noted in R9-10-814(B)(2). The deficient practice posed a risk to the health and safety of a resident if the facility was unable to meet a resident's needs. Findings include: 1. A review of R3's medical record revealed a service plan indicating R3 received personal care services. R3's medical record contained a document titled, "Medication, Diagnosis & Treatment Orders," signed by a medical provider on October 27, 2024 which indicated R3 was diagnosed with a "sacral pressure ulcer" upon acceptance into the facility. The document indicated R3 had been diagnosed with a stage 3 or stage 4 pressure sore. However, evidence of documentation of the staging of the ulcer upon acceptance was unavailable for review. R3's medical record also contained a document titled, "Hospice Certification and Plan of Care, signed by a registered nurse on December 22, 2024, and signed by a medical provider on December 23, 2024, which indicated R3 was receiving treatment for a "STAGE 3 COCCYX" pressure ulcer. Further review of R3's medical record revealed documentation of R3's, or R3's representative's request to be accepted or retained by the facility was unavailable for review. Lastly, evidence of documentation indicating R3 had been examined by a medical practitioner within 30 days of R3's acceptance or at the onset of the stage 3 pressure ulcer, and the medical practioner had reviewed the facility's scope of service and determined R3's needs could be met by the facility was unavailable for review. 2. A request was made to review progress notes and any additional instructions entered into R3's medical record by representatives of the providing hospice agency. However, evidence of such documentation was unavailable for review. 3. In an interview, E1 acknowledged R3 was accepted into the facility with a pressure ulcer to R3's sacral area. E1 reported not knowing the stage of R3's pressure ulcer upon admittance or when the pressure ulcer was diagnosed as stage 3. E1 advised there was a binder in R3's bedroom which contained all of R3's medical records entered by representatives of the hospice agency. However, E1 reported to have no knowledge of the hospice binders whereabouts. E1 agreed R3 was at least retained after having been diagnosed with a stage three pressure sore, without meeting the requirements as required in R9-10-814(B)(2).

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R3's medical record revealed a document titled "Preliminary Application," used for obtaining initial information, including health related information, regarding a resident. The document indicated R3 was receiving medical services from "United Wound" and included a section for documenting "Physical Aids" used by R3 which included an "LAL mattress." R3's medical record also contained a document titled "Medication, Diagnosis & Treatment Orders," which was signed by a medical provider on October 27, 2024, and indicated R3 was diagnosed with a "sacral pressure ulcer," upon acceptance into the facility. 2. A review of R3's medical record revealed a service plan indicating R3 received personal care services. The service plan included a section titled "Basic Skin Care to help prevent bruising, skin tears, injuries infections and decubitus ulcers." The section included actions such as using "lotion all over body," "do skin checks with each shower," and "encourage/assist [R3] to change position every 2-3 hours to help with circulation and skin breakdown prevention." However, the service plan did not mention any special care instructions to address treatment of R3's sacral pressure ulcer, nor did the service plan contain any instructions pertaining to the LAL mattress. 3. In an interview, E1 acknowledged R3's service plan did not contain sufficient information to treat R3's existing pressure ulcer, as required.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an emergency and needed medical services, as required per R9-10-818(D)(2). Findings include: 1. A review of facility Quality Management (QM) reports from October 1, 2024 through January 24, 2025 revealed four incidents involving emergencies where residents needed medical services. The Quality Management reports indicated one incident occurred in October, and involved a "Fall," requiring an "Emergency Room Visit" and "Hospitalization" for an injury described as "upper bone to leg/knee broken. Will not have surgery, leg will be immobilized in rehab center." The QM reports indicated there were two incidents in November 2023 involving the same resident who required emergency room visits and hospitalization. 2. A request was made to review the incident report for the October 2024 incident, and the two incidents in November 2024, however evidence of documentation of any incident reports in which residents had an accident, emergency or injury which required medical services was unavailable for review. 3. A review of R1's medical record revealed a document titled "Vital Signs & ADL Sheet," used for documenting activities of daily living. Entries on the document indicated R1 was hospitalized on January 23, 2025. 4. A review of an incident report dated January 23, 2025 revealed documentation indicating R1 had injured a toe and 911 was called after consulting with R1's medical provider. The report did not include a description of the injury to the toe, nor did it include documentation of notification of R1's emergency contact. 5. In an interview, E1 agreed all four incidents were not documented as required per R9-10-818(D)(2), for incidents involving residents who had an accident, injury or emergency requiring medical services.

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. A review of facility documentation revealed an annual assessment of the health care institution's risk of exposure to infectious tuberculosis was not available for review. 2. In an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures, reviewed November 10, 2023, revealed a policy titled, "Quality Management (QM)." The policy stated, "5. A report concerning the events identified, documented, and any actions taken will be submitted to the governing authority at least once every six months." 2. A review of the facility's documentation revealed evidence of a quality management report submitted to the governing authority between April 2023 and February 2024 was unavailable for review. 3. In an interview, E1 advised a quality management report was unavailable for review and had not been created or submitted to the governing authority at least once every six months per policy.

Based on record review and interview, the manager failed to ensure a written service plan, when updated, was signed and dated by the manager, for four of four residents sampled. Findings include: 1. A review of R1's, R2's R3's and R4's medical record revealed current services plans, based upon each resident's designated level of care. The service plans were signed by a registered nurse and each resident or their representative, however, the service plan was not signed and dated by the manager. 2. In an interview, E1 reported E4 had signed the service plans, and acknowledged E4 was not the facility manager and had not been delegated in writing to sign on behalf of the manager. E1 agreed R1's, R2's R3's and R4's service plans were not signed and dated by the manager.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a risk if medications were not properly disposed of and if the standards expected of employees were not followed. Findings include: 1. During a tour of the facility the Compliance Officer observed a refrigerator in the facility garage used. Inside the refrigerator, the Compliance Officer observed several prescriptions medications to include the following: "Trulicity, Inject 0.5ML (0.75MG) Under the Skin Every Week," prescribed to R5, with a "Use By" date of "7/16/2020;" "Morphine Sulfate Oral Solution, 100 mg per 5 ml (20mg/ml)," prescribed to R6, with a "Use By" date of "10/30/2021;" "Bisacodyl Supp 10MG," prescribed to R7, with an expiration date of "7/21/20;" and "Etanercept 50MG/ML Inj Sureclick," prescribed to R8, with a "Discard After" date of "7/15/2021." Also inside the refrigerator was a sealed box labeled "Comfort Pak 1 Pak, do not open unless directed by a nurse or a physician," prescribed to R9, with a "Discard After" date of "4/24/23." 2. A review of facility policy and procedures, reviewed November 10, 2023, revealed a policy titled, "Policies and Procedures on Medications and Treatments." The policy read, "4. All expired or discontinued medication, including those of deceased residents, are disposed of according. Returned to the resident, resident representative or resident family, returned to the pharmacy for proper disposal, returned to the Dispose-o-med program, mix medication with small amount of water and an undesirable substance, such as coffee grounds or kitty litter, and put them in impermeable, non-descript containers, such as empty cans or sealed bags." 3. In an interview, E1 advised the Comfort Pak prescribed to R9 likely contained morphine and Lorazapam, as R9 was on hospice care. E1 reported the medication had been prescribed to residents who had passed away and not lived at the facility for many months. E1 agreed the medication had not been discarded according to the facility's policy.

Based on observation, documentation review, and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. A review of the facility's posted menu revealed a menu for the week of March 18 through March 24, 2024. The Tuesday, March 19 lunch menu stated: "Chicken and vegies (sic) pasta salad, Cookies." 2. During a tour of the facility, the Compliance Officer observed E2 preparing lunch which appeared to be chicken salad sandwiches. The Compliance Officer also observed several residents eating similar sandwiches. 3. During an interview, E2 reported chicken salad for the residents, and not "chicken and vegies pasta" as posted on the menu. 4. A review of facility menus between January 15, 2024 and March 17, 2024, revealed substitutions written on the menus with regularity. The menu for the week of March 11, 2024 through March 17, 2024 identified the same dinner substitution of "Shepard's Pie," on both March 11 and 12. 5. During an interview, E1 advised they could not recall what was served for dinner on March 11 or March 12, but E1 was certain it was not Shepard's Pie on both dates. E1 acknowledged meals provided by the facility were not being served according to posted menus.

Based on observation and interview, the manager failed to ensure food was free from spoilage and was safe for human consumption. Findings include: 1. The Compliance Officer observed in the facility's kitchen refrigerator the following items which were spoiled: - two pumpkins which appeared withered and to have a gray fuzzy substance, - two apples which appeared withered and to have black spots 2. In an interview, E1 acknowledged the observed items were spoiled and should have been thrown items.

Based on documentation review, record review, and interview, the manager failed to establish and document policies and procedures for administering an opioid to protect the health and safety of a patient in compliance with R9-10-120.F. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. The Department was unable to determine substantial compliance as the documentation was not in the policies and procedures during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. In documentation review, a review of the facility's policy and procedures manual revealed no documentation of policies and procedures covering opioid administration. 2. During a tour of the facility the Compliance Officer observed a refrigerator in the facility garage used. Inside the refrigerator, the Compliance Officer observed several prescriptions medications to include the following: "Morphine Sulfate Oral Solution, 100 mg per 5 ml (20mg/ml)," prescribed to R6, with a "Use By" date of "10/30/2021;" Also inside the refrigerator was a sealed box labeled "Comfort Pak 1 Pak, do not open unless directed by a nurse or a physician," prescribed to R9, with a "Discard After" date of "4/24/23." 3. In an interview, E1 advised the Comfort Pak prescribed to R9 likely contained morphine and Lorazapam, as R9 had been on hospice care. E1 reported the medication had been prescribed to residents who had passed away and not lived at the facility for many months. E1 reported the facility did not have documented policies and procedures for administering opioid medication.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of two residents sampled who received personal care services. Findings include: 1. A review of R2's medical record revealed a service plan dated March 3, 2023, for personal care services. However, no current service plan dated on or before September 3, 2023, was available for review. 2. In an interview, E1 acknowledged R2's service plan had not been reviewed and updated at least once every six months while R2 received personal care services.

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 for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed R1 was admitted in 2023. Further review of R1's medical record revealed a service plan dated July 31, 2023. The service plan was signed by an RN and a manager, however the service plan was not signed by R1 or R1's representative. 2. In an interview, E1 acknowledged that R1's service plan was not signed by R1 or R1's representative as required by the rule.

Based on document review, observation, record review and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom or residential unit being used by a resident receiving directed care services. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During a facility tour, the Compliance Officer observed R4's bedroom was not equipped with a bell, intercom or other mechanical means to alert employees to R4's needs or an emergency. 3. A review of R4's (admitted in 2019) medical record revealed a current service plan for directed care services. 3. In an interview, E1 acknowledged the residential units were occupied, however did not include a bell, intercom or other mechanical means to alert employees to a resident's needs.