Andara Senior Living

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was signed and dated by the resident or the resident's representative, and the nurse or medical practitioner, for one of eight residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R8’s medical record revealed a current written service plan dated November 25, 2025. The service plan indicated that R8 received medication administration. The service plan was not signed by the resident or the resident's representative, and the nurse or medical practitioner. There was a note in the record that the service plan would be signed on November 28, 2025 by R8's representation; however, the task had not been completed at the time of inspection. 2. In an exit interview, the findings were reviewed with E1 and E5, and no additional information was provided. 3. This is a repeat deficiency from the inspection conducted on September 12, 2024.

Based on documentation review and interview, the manager failed to ensure that a disaster plan included a plan for obtaining food for individuals present in the assisted living facility. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility’s documentation/policies and procedures revealed a disaster plan for the facility, however, the plan did not include a plan for obtaining food for individuals present in the assisted living facility. The plan revealed a letter of agreement for emergency relocation from another assisted living facility that would provide the following but not specifically food: Water Kitchen facilities to cook food Restrooms Telephone Areas to set up temporary cots / beds as needed for residents Transportation Wheelchair accessibility 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, and interview, for two of eight residents reviewed, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder which included the items listed in Arizona Revised Statutes A.R.S. \'a7 36-420.04(A)(1) through (9). The deficient practice posed a risk if the Department was unable to verify the facility provided the required documentation about the resident to the emergency responder. Findings include: 1. In record review, R1's medical record (received personal care and medication administration services) included documentation R1 required emergency medical services (EMS) on February 21 and April 15, 2024: - February 21, 2024 ... "resident was in bed and stated that ... was having a hard time breathing... Call 911, Hospitalization..." - April 15, 2024 - "... notified by resident services coordinator... to check vitals for resident... Systolic BP was below 80... BP was 79/43, pulse 125. Writer called 911 to have the resident further assessed. Upon arrival of paramedics, when checking ... BP, it was raised to 90/70, when having resident stand, BP dropped to 50/40. Paramedics advised resident to be taken to the nearest hospital... R1's .../POA insisted [R1] to be taken to a different hospital where... has an infectious disease specialist... The paramedic stated that as long as they were aware of the risks of a further drive, they would accommodate... Call 911, Emergency Room..." 2. In record review, R3's medical record (received personal care and medication administration services) included documentation R3 required emergency medical services (EMS) on September 5, 2024 for low heart rate. 3. In record review, R1 and R3's medical record did not include a copy of the document provided to the emergency responders, which included the items listed in A.R.S. \'a7 36-420.04(A)(1) through (9). 4. During an interview, E1 reported the emergency responders were provided a copy of the required documentation listed in A.R.S. \'a7 36-420.04(A)(1) through (9); however, the facility did not maintain a copy of the documentation provided to the emergency responders.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident which included how an employee may submit a complaint related to resident care. Findings include: 1. During an interview, the Compliance Officer requested to review the facility's policy on how an employee may submit a complaint related to resident care. 2. In documentation review, a review of the facility's policies and procedures provided for review revealed the facility did not have a policy which covered how an employee may submit a complaint related to resident care. 3. During an interview, E1 and E2 acknowledged the policies and procedures provided for review did not include documentation policies and procedures were established, documented, and implemented to protect the health and safety of a resident and included how an employee may submit a complaint related to resident care.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented, which covered the requirements in A.R.S. Title 36, Chapter 4, Article 11. The deficient practice posed a risk if a health professional was unable to submit a complaint confidentially and without fear of retaliation. Findings include: 1. A.R.S. Title 36, Chapter 4, Article 11 states: "36-450.01.A. Each health care institution licensed pursuant to this chapter shall adopt a procedure for reviewing reports made in good faith by a health professional concerning an activity, policy or practice that the health professional reasonably believes both: 1. Violates professional standards of practice or is against the law. 2. Poses a substantial risk to the health, safety or welfare of a patient. B. The procedure shall include reasonable measures to maintain the confidentiality of the identity of a health professional providing information to a health care institution pursuant to this section." 2. A.R.S. Title 36, Chapter 4, Article 11 states: "36-450.02.A. Each health care institution that is licensed pursuant to this chapter shall adopt a policy that prohibits retaliatory action against a health professional who in good faith: 1. Makes a report to the health care institution pursuant to the requirements of section 36-450.01..." 3. In documentation review, the facility's policies and procedures provided for review, did not include documentation which covered procedures for reviewing reports made in good faith by a health professional, and included reasonable measures to maintain confidentiality of the identity of a health professional (as indicated in paragraph #1), and prohibited retaliatory action against a health professional (as indicated in paragraph #2). 4. During an interview, E1 and E2 acknowledged the facility did not provide documentation to indicate policies and procedures were established, documented and implemented to protect the health and safety of a resident, and included procedures identified in A.R.S. Title 36, Chapter 4, Article 11.

Based on documentation review, and interview, for one resident death, the manager failed to provide written notification to the Department of a resident's death, which was unexpected, according to A.R.S. \'a7 11-593. Findings include: 1. In documentation review, the Compliance Officer inquired on the death of R1, and was provided documentation of the recent death of R1. 2. In documentation review, a review of Department records revealed the Department was not notified of the death of R1. 3. In record review, R1's medical record (received personal care and medication administration services) included documentation of a medication order, dated October 5, 2023, for Metoprolol Succ ER 25 mg, take one tablet by mouth at bedtime for hypertension/AFIB, Hold for SBP (systolic blood pressure) less than 100 or HR (heart rate) less than 60. R1's record did not include documentation the caregivers followed the medication order and took blood pressure and pulse readings, per the order, during the months of October 2023 - April 2024, and did not immediately report abnormal vital signs to the Health & Wellness Director and the resident's physician. The resident's medication administration record (MAR) included documentation of abnormal vital signs as follows, with no indication of notification to the Health & Wellness Director and the resident's physician: October 20, 2023: SBP 99, October 31, 2023: SBP 99, September 4, 2023: SBP 99, November 4, 2023: SBP 99, November 16 - 18, 2023: SBP 99, December 2, 2023: SBP 99, December 10, 2023: SBP 94 January 8, 2024: SBP 93, January 15, 2024: SBP 99, January 30, 2024: SBP 99 February 2, 2024: SBP 99, February 4, 2024: SBP 89, February 12, 2024: SBP 99, February 19, 2024: SBP 98 April 13, 2024: SBP 88, April 14, 2024: SBP 88 4. In record review, R1's MARs revealed the following: - September 2023 - R1 was administered Metoprolol on September 21 - 30, 2023; however, the facility had no documentation of R1's HR September 21 - 30, 2023, and of R1's SBP September 25 - 30, 2023. - October Mar 2023 - R1 was administered the Metoprolol medication on October 1 - 12, 16 - 19, 21 - 23, and 29 - 30, 2023; however, the facility had no documentation R1's heart rate was monitored and documented on these days. On October 24, 2023, R1's SBP was 105, and HR was 84 bpm; however, the MAR indicated the medication was held (DNG - drug not given). - November Mar 2023 - R1 was administered the Metoprolol medication on November 5, 11, 16, 19, - 30, 2023; however, the facility had no documentation R1's heart rate was monitored and documented on these days. The Metoprolol medication was administered on November 9-10; however, the facility had no documentation of R1's SBP or HR. - December MAR 2023 - R1 was administered the Metoprolol medication on December 1, 3 - 9, and 11 - 31; however, the facility had no documentation R1's heart rate was monitored and documented on these days. - January MAR 2024 - R1 was administered the Metoprolol medication o

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. Findings include: 1. A review of the facility's policy and procedure manual dated January 1, 2024, revealed a policy titled, "Quality Improvement Program Reporting," which stated, "The QI program gathers data from acute transfer log, MARs, incident reports, QA data sheets...The QI program tracks falls, hospitalizations, pressure injuries, weight changes...completed data sheet is submitted by the 5th of each month for the previous month." 2. The Compliance Officer requested the quality management forms and the quality management reports from August 2023 through August 2024. However, there were no reports available for review from August 2023 through December 2023. 3. In an interview, E1 acknowledged the facility's ongoing quality management program had not been implemented and documented as required in the facility's policy and that there was no further documentation available for review.

Based on record review, documentation review, and interview, for one of eight residents reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk as the service plan directs resident care. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. In record review, R1's medical record (received personal care and medication administration services) included documentation R1 obtained an injury on the right leg on or around January 9, 2024. The record documented the following: - A "Skin Injury Report," dated January 9, 2024, indicated R1 had bruising on the right lower leg, and documented "... bruise.". - A "Skin Injury Report," dated January 12, 2024, indicated R1 had bruising on the right lower leg, and documented "... notified HWD, stated [R1] got it from running into ... bench from practicing with ... motorized power chair with ... O4." - A "Skin Injury Report," dated January 16, 2024, showed a circle around the right lower leg of a body diagram. - A "Progress Note," dated January 17, 2024, documented, "Received resident ABT treatment, ordered TID for 5 days... Writer also notified the provider that the resident went to the ER yesterday due to ... wound... LE (late entry) - "1/16 was informed by the caregiver regarding the wound on ... right leg. Had informed the hwd (Health and Wellness Director) couple of times prior this and was informed that home health will be taking care of the wound." 2. In record review, R1's record included an unsigned service plan dated September 24, 2023, and March 13, 2024; however, the record did not include an updated service plan which showed [R1's] change in condition for the wound infection on the right leg. 3. In documentation review, a facility policy, titled, "AS05 - Service Plans," on page 61, documented, ..."Assessments and Service Plans will be developed and updated as frequently as necessary to ensure they reflect current resident care needs and preferences... 3. Service Plans are created/updated.... Whenever there is significant change in resident status..." 4. During an interview, E1 reported R1 received an injury to the right lower leg when testing a motorized scooter with O4. The injury initially appeared as a bruise, and then appeared to be infected. R1 was taken to the Urgent Care by O4. E1 and E2 acknowledged the resident's service plan was not reviewed and updated with R1's change of condition and services provided.

Based on record review and interview, for five of eight residents reviewed, the manager failed to ensure a written service plan was updated, signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner, as required. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements regarding the care and services provided for a resident. Findings include: 1. During an interview, the Compliance Officer (CO) requested to review R1's complete medical record, including R1's service plans. 2. In record review, R1's medical record indicated R1 received personal care services and medication administration services. The record included written service plans through January 19, 2023, and did not include documentation R1's service plan was updated, and signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner. 3. During an interview, the findings were reviewed with E1 and E2, who reported having additional service plans for R1, which were located in the facility's electronic medical record system. Additional service plans were printed and provided for the CO's review. 4. Additional service plans were provided for review, and were dated August 3, 2023, (Personal Care), September 24, 2023, (Personal Care - change of condition), March 13, 2024 (Personal Care - change of condition), March 18, 2024 (Personal Care - change of condition). The service plans were not signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner, as required. 5. During an interview, the findings were reviewed with E1, E2, and O1, who acknowledged the resident's service plans were not signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner, as required. 6. In record review, R3's medical record contained a service plan dated May 25, 2024. The service plan indicated R3 received personal care services, and medication administration services. The service plan did not include documentation R3's service plan was signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner. 7. In record review, R6's medical record contained a service plan dated March 27, 2024. The service plan indicated R6 received personal care services, and medication administration services. The service plan did not include documentation R6's service plan was signed and dated by the resident or the resident's representative, the manager, and the nurse or medical practitioner. 8. In record review, R7's medical record contained a service plan dated April 29, 2024. The service plan indicated R7 received personal care services, and medication administration services. The service plan did not include documentation R7's service plan was signed and dated by the resident or the resident's represen

Based on record review and interview, the manager failed to ensure caregivers were only assigned to provide the assisted living services the caregiver had the documented skills and knowledge to perform, for one of three caregivers sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs. Findings include: 1. A review of R6's medical record contained documentation dated May 7, 2024 of an incident where E9 reported R6 "slid out of bed onto the floor" while E9 was transferring R6 to the wheelchair. 2. A review of R6's medical record revealed a service plan dated April 2024 that revealed the following assistance needed with transfers: -Care staff will assist in moving from one surface to another with the aid of a gait belt -uses a wheelchair 3. In review of the personnel file for E9 there was documentation of a skills/knowledge checklist dated March 2023 that identified a training area of "safety transport with wheelchair using foot rest and brakes." 4. An email dated May 8, 2024 to E2 from R6's POA stated "Upon reflection of the incident that transpired on May 7, 2024...appears to have had a guided fall...further inquiry revealed that an improper transfer may have been a factor in the situation." 5. In an interview with E1 and E2, E1 indicated being made aware of an improper transfer that lead to the aforementioned incident for R6. There was no further documentation available to review that demonstrated the skills and knowledge for proper gait belt and wheelchair training.

Based on documentation review, record review and interview, for one of eight residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk as services could not be verified as provided. Findings include: 1. In documentation review, a facility policy, titled, "MP39 - Continuous Positive Airway Pressure (CPAP), on page 319-320, documented, "... Any resident using CPAP must have a current physician's order... The physician order must include whether the resident is able to self-administer, or staff must administer treatments... Residents who self-administer CPAP use must be capable of self-administration, plus safe CPAP handling and storage... Residents unable to self-administer CPAP use will be assisted by trained care staff... The Health & Wellness Director or designee monitors the resident's on-going ability to self-administer CPAP use according to physician's orders." 2. In record review, R1's medical record included an order dated September 12, 2023, for "CPAP Resmed (7-12 cm H2O) every night shift for Sleep Apnea... Store mask in bag while not in use... Resmed CPAP cleaning instructions: Hand wash mask/headgear.... using warm water and mild soap. Rinse well with drinking quality water. Allow to air dry out of direct sunlight every day shift." R1's record did not include documentation of whether R1 was able to self administer the CPAP or required assistance, and did not include documentation of CPAP services provided. 3. During an interview, E1 and E2 acknowledged R1's record did not include documentation CPAP services were provided for R1, as ordered.

Based on documentation review and interview, for one of eight residents reviewed and receiving medication administration services, the facility failed to implement their policies and procedures on vital sign readings to determine the need for a medication. The deficient practice posed a health and safety risk if the caregivers did not implement the facility's policy on vital sign readings, and did not report an abnormality, as indicated in the policies and procedures. Findings include: 1. In documentation review, the facility's policy, titled, "MP35 - Vital Sign Readings to Determine the Need for Medication," on pages 310-311, documented, "... Resident vital signs (blood pressure and pulse readings) are taken to determine the need for medication... 3. Parameters based on vital signs for giving a medication must be indicated on the MAR. a. A written record recording the vital signs is documented on the MAR. 4. Any abnormal vital signs are immediately reported to the Health & Wellness Director and the resident's physician. a. The Physician Communication form may be used to communicate with the resident's physician. b. Abnormal vital signs include: i. Blood Pressure: > 180/100 or 100 or < 60. 2. In record review, R1's medical record (received personal care and medication administration services) included documentation of a medication order, dated October 5, 2023, for Metoprolol Succ ER 25 mg, take one tablet by mouth at bedtime for hypertension/AFIB, Hold for SBP (systolic blood pressure) less than 100 or HR (heart rate) less than 60. R1's record did not include documentation the caregivers followed the medication order and took blood pressure and pulse readings, per the order, during the months of October 2023 - April 2024, and did not immediately report abnormal vital signs to the Health & Wellness Director and the resident's physician. The resident's medication administration record (MAR) included documentation of abnormal vital signs as follows, with no indication of notification to the Health & Wellness Director and the resident's physician: October 20, 2023: SBP 99, October 31, 2023: SBP 99, September 4, 2023: SBP 99, November 4, 2023: SBP 99, November 16 - 18, 2023: SBP 99, December 2, 2023: SBP 99, December 10, 2023: SBP 94 January 8, 2024: SBP 93, January 15, 2024: SBP 99, January 30, 2024: SBP 99 February 2, 2024: SBP 99, February 4, 2024: SBP 89, February 12, 2024: SBP 99, February 19, 2024: SBP 98 April 13, 2024: SBP 88, April 14, 2024: SBP 88 3. In record review, R1's MARs revealed the following: - September 2023 - R1 was administered Metoprolol on September 21 - 30, 2023; however, the facility had no documentation of R1's HR September 21 - 30, 2023, and of R1's SBP September 25 - 30, 2023. - October Mar 2023 - R1 was administered the Metoprolol medication on October 1 - 12, 16 - 19, 21 - 23, and 29 - 30, 2023; however, the facility had no documentation R1's heart rate was monitored and documented on these days. On October 24, 2023, R1'

Based on documentation review, record review, and interview, for two of eight residents reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to a resident who was not administered a medication, as prescribed. Findings include: 1. In documentation review, the facility's policy, titled, "MP35 - Vital Sign Readings to Determine the Need for Medication," on pages 310-311, documented, "... Resident vital signs (blood pressure and pulse readings) are taken to determine the need for medication... 3. Parameters based on vital signs for giving a medication must be indicated on the MAR. a. A written record recording the vital signs is documented on the MAR. 4. Any abnormal vital signs are immediately reported to the Health & Wellness Director and the resident's physician. a. The Physician Communication form may be used to communicate with the resident's physician. b. Abnormal vital signs include: i. Blood Pressure: > 180/100 or 100 or < 60. 2. In record review, R1's medical record (received personal care and medication administration services) included documentation of a medication order, dated October 5, 2023, for Metoprolol Succ ER 25 mg, take one tablet by mouth at bedtime for hypertension/AFIB, Hold for SBP (systolic blood pressure) less than 100 or HR (heart rate) less than 60. 3. In record review, R1's medication administration records (MAR) revealed the following: - September 2023 - R1 was administered Metoprolol on September 21 - 30, 2023; however, the facility had no documentation of R1's HR monitoring September 21 - 30, 2023, and no documentation of R1's SBP reading September 25 - 30, 2023. - October MAR 2023 - R1 was administered the Metoprolol medication on October 1 - 12, 16 - 19, 21 - 23, and 29 - 30, 2023; however, the facility had no documentation R1's heart rate was monitored and documented on these days. On October 24, 2023, R1's SBP was 105, and HR was 84 bpm; however, the MAR indicated the medication was held (DNG - drug not given). - November MAR 2023 - R1 was administered the Metoprolol medication on November 5, 11, 16, 19, - 30, 2023; however, the facility had no documentation R1's heart rate was monitored and documented on these days. The Metoprolol medication was administered on November 9-10; however, the facility had no documentation of R1's SBP or HR reading. - December MAR 2023 - R1 was administered the Metoprolol medication on December 1, 3 - 9, and 11 - 31; however, the facility had no documentation R1's heart rate was monitored and documented on these days. - January MAR 2024 - R1 was administered the Metoprolol medication on January 1, 2024; however, R1's SBP and HR was not documented. The medication was administered January 4 - 7, 9 - 14, 16 - 29 and 31, 2024; however, the facility had no documentation R1's heart rate was monitored and documented on these days. On January 30, 2024, R1's SBP was 99; howev

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the identification of residents needing assistance for evacuation. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the evacuation drills revealed evacuation drills conducted on September 20, 2023 and March 13, 2024. However, the drills did not include the identification of residents needing assistance for evacuation. 2. During an interview, E1 reported some of the residents would need assistance during an evacuation. E1 and E2 acknowledged the evacuation drill did not include the identification of residents needing assistance for evacuation.

Based on record review, documentation review, and interview, for three of eight residents who had an emergency resulting in the need for medical services, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a risk if the facility did not take action to prevent an accident, emergency, or injury from occurring in the future to ensure the health and safety of residents. Findings include: 1. In record review, R1's medical record (received personal care and medication administration services) included documentation R1 required emergency medical services (EMS) on February 21 and April 15, 2024: - February 21, 2024 ... "resident was in bed and stated that ... was having a hard time breathing... Call 911, Hospitalization..." R1's record did not include documentation of action taken to prevent the accident, emergency, or injury from occurring in the future. - April 15, 2024 - "... notified by resident services coordinator... to check vitals for resident... Systolic BP was below 80... BP was 79/43, pulse 125. Writer called 911 to have the resident further assessed. Upon arrival of paramedics, when checking ... BP, it was raised to 90/70, when having resident stand, BP dropped to 50/40. Paramedics advised resident to be taken to the nearest hospital... R1's .../POA insisted [R1] to be taken to a different hospital where... has an infectious disease specialist... The paramedic stated that as long as they were aware of the risks of a further drive, they would accommodate... Call 911, Emergency Room..." R1's medical record did not include documentation of action taken to prevent the accident, emergency, or injury from occurring in the future. 2. In record review, R1's medical record included documentation R1 received emergency medical services on the following dates, and the facility did not complete the required documentation: - January 17, 2024: Progress note... "Writer also notified the provider that [R1] went to the ER yesterday due to ... wound. Requested HH referral. Order was sent out today. Notified MPOA. LE (Late Entry) 1/16 Was informed by the caregiver regarding the wound on [R1's] right leg. Had informed the hwd (Health and Wellness Director) couple of times prior this and was informed that home health will be taking care of the wound." R1's record did not include the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or inj

Based on observation, record review, and interview, the manager failed to ensure the premises were kept clean. Findings include: 1. During the facility tour with E2, the Compliance Officer observed an odor coming from outside of R8's residential unit. Upon entry, the odor was very strong of feces and urine. R8 was not in the unit at the time of the observation. 2. In review of R8's medical record, the service plan dated April 2024 identified that R8 had a colostomy bag and maintains the bag independently. 3. During an interview, E2 acknowledged the odor in R8's residential unit. E2 acknowledged the premises were not kept clean.

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that could pose a hazard. The deficient practices posed a safety risk to residents, who resided in the facility. Findings include: 1. During an environmental inspection with E2, the Compliance Officer observed the inside of the facility was in the midst of a remodel. The open space across from the movie theatre located on the first floor, contained several electrical fixture plates with exposed wires hanging out around the built-in cabinetry and above baseboards. Throughout the facility, there were multiple light fixture plates with electrical wiring exposed. Several "workers" were observed inside the facility. 2. Additionally, in the "Bogart Room" located on the second floor that was accessible to the residents, there was a floor outlet that protruded above the carpet approximately two inches which could impose a tripping hazard. 3. During an interview, E2 acknowledged the facility was in the midst of a remodel, and had several ambulatory residents. E2 acknowledged there was construction going on with tools and equipment in the facility, which could pose a hazard.

Based on observation, and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents. Findings include: 1. During an environmental inspection, the Compliance Officer observed a hallway near the facility entrance and foyer, which had an unlocked unit under remodel. Room 107 had a can of Paint and Epoxy Remover on the floor, and five gallon paint containers (open). 2. Additionally, a bottle of Pledge and Breakdown-XC Odor Eliminator was found in an unlocked cabinet located on the first floor unlocked laundry room. 3. During an interview, E1 and E2 acknowledged the unit was unlocked and contained toxic materials which were accessible to residents. 4. This is a repeat deficiency from the compliance inspection conducted on July 18, 2023.

Based on record review, documentation review, and interview, for two of two residents reviewed, and receiving opioid medication as part of treatment; without an active malignancy or an end of life condition, an individual authorized to administer an opioid failed to monitor and document the patient's response to the opioid. Findings include: 1. In record review, R1's medical record included documentation R1 received opioid medication administration as follows: - Hydrocodone-Acetaminophen 5-325 mg "take 1 tablet by mouth every 8 hours as needed," was administered on June 7, 2023, July 14, 21, 22, 23, 27, 28, 29, 30, 2023, August 1, - 14 and August 25, 2023, October 22, 23, 27, 2023, and November 2, 5, 2023. - Oxycodone HCL 5 mg "take one tablet by mouth once daily in the morning," was administered on January 10 - 31, 2024, and February 1 - 8, 2024, March 21, 2024, March 13 - 16, 19 - 21, 2024, and April 5 - 11, 2024. 2. In record review, R1's medical record did not include documentation of the monitoring of the patient's response to the opioid. R1's medical record did not indicate R1 had an active malignancy or an end of life condition. 3. In record review, R7's medical record included documentation R7 received opioid medication administration as follows: - Morphine 20 mg oral solution prefilled syringe daily from May 15, 2024 through September 11, 2024. 4. In record review, R7's medical record did not include documentation of the monitoring of the patient's response to the opioid. 5. In documentation review, a facility policy, titled, "MP29 - Pain Management and Opioid Medications," on page 296, documented, "... f. Opioid Administration... must include: ii. Monitoring resident's response to medication iii. Documenting the effectiveness of medication forty-five (45) minutes after administration in resident's record. g. Document on the MAR the resident's need, monitoring, and response to the medication. This documentation shall include: ... iv. How the resident's response was monitored including the time and person(s) responsible for monitoring, and v. The resulting effect of the medication on the resident." 6. During an interview, the findings were reviewed with E1, E2, and O1, who acknowledged the resident's response to the opioid was not monitored and documented by staff. 7. This is a repeat deficiency from the compliance inspection conducted on July 18, 2023.

Based on documentation review, record review, and interview, for five of seven staff reviewed, 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. In documentation review, the facility provided documentation of a fall prevention and fall recovery training program. 2. In record review, the personnel records for E2, E3, E4, E5, and E7, did not include documention staff received training on fall prevention and fall recovery. 3. During an interview, E1 and E2 reported the staff received training on Relias; however, the Relias training included Fall Prevention training only. E1 and E2 acknowledged the facility did not have documentation the staff received training which included fall recovery training.

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure the 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 health and safety risk to residents, if staff were unaware of the skin maintenance services needed by a resident. Findings include: 1. In record review, R2's service plan, dated March 13, 2024, (received personal care services), documented "Overall skin condition normal, resident requires skin checks with bathing, RLE skin tear..." 2. R2's record included documentation: - "01/18/2024... Resident fell next to ... recliner... had an abrasion on ... left side of back..." - "02/04/2024... Res was bleeding from ... right hand... got the skin tear... tried to get of the commode and scratch arm..." - "02/15/2024... Trying to transfer ... to recliner and ... lost balance and fell..." - "02/19/2024... resident injured ...self on ... right leg, sustaining a skin split..." 3. During an interview, E1 and E2 acknowledged R2 had falls and skin injuries, and acknowledged R2's service plan did not include skin maintenance services provided for R2.

Based on record review and interview, for two of five caregiver records reviewed, the manager failed to ensure a caregiver' skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services. Findings include: 1. In record review, the personnel record for E5 (hired January 18, 2023, in a different capacity, and then transitioned to a caregiver position) did not include documentation the caregiver's skills and knowledge were verified before the caregiver provided services. In record review, the personnel record for E11 (a caregiver from a staffing agency) did not include documentation the caregiver's skills and knowledge were verified before the caregiver provided services. 2. During an interview, E1 and O2 acknowledged the personnel records for E5 and E11 did not include documentation of the verification of the caregiver's skills and knowledge.

Based on record review, documentation review, and interview, for one of five caregivers reviewed, the manager failed to ensure a personnel record included documentation of cardiopulmonary resuscitation training. Findings include: 1. In record review, E11's (a caregiver from a staffing agency) personnel record did not include documentation of cardiopulmonary resuscitation training. 2. In documentation review, the staffing schedule for the week of July 9, - 15, 2023, revealed E11 worked shifts at the facility. 3. During an interview, E1 and O1 acknowledged the required documentation was not in E11's personnel record. O1 reported being unaware a personnel record was required to be maintained by the facility, for staffing agency personnel.

Based on record review and interview, for eight of eight residents reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: A.R.S. \'a7 36-401.38 defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.38 defines " Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. 1. In record review, residents R1, R2, R3, R4, R5, R5, R7, and R8 had written service plans in the medical records. However, the residents' services plans did not include documentation of the level of service each resident was expected to receive. 2. During an interview, E1 reported the residents received either personal or supervisory care services, and acknowledged the service plans did not include documentation of the level of service to be provided.

Based on observation, record review, documentation review, and interview, for two residents who stored medications in their residential units, the manager failed to ensure the service plan included how the medication was stored and controlled. The deficient practice posed a health and safety risk if medications were not stored in a safe manner. Findings include: 1. During an environmental inspection with E1 and E11, R4's residential unit had medications stored in the unit. Medications were observed to be stored on the kitchen countertop and in a kitchen drawer and included: Tylenol, Senna, Potassium Chloride, Losartan, Xarelto, Dilitiazem and L-Thyroxine. 2. In record review, R4's service plan, dated June 28, 2023, documented, "... Medications provided by outside pharmacy. community to manage medication needs through pharmacy other than primary pharmacy..." R4's service plan did not include documentation of how the medications were stored and controlled in the residential unit. 3. During an environmental inspection with E1, R6's residential unit was observed to have two bottles of Tylenol, and 2 pills by the telephone in the bedroom 4. In record review, R6's service plan, dated April 6, 2023, documented, "... Medications provided by outside pharmacy. Community to manage medication needs through pharmacy other than primary pharmacy. Resident is independent with medication management..." R6's service plan did not include documentation of how the medications were stored and controlled in the residential unit. 5. In documentation review, a facility policy, titled "Securing Medications,... page 88, updated September 2021," documented, ... "Meds kept in resident's rooms must be kept in the locking cabinet unless the resident's service plan specifies that the resident may keep a specific medication unsecured at bedside (e.g., nitroglycerin)... Residents with medications in their apartment must keep their apartment door locked when resident is not in view of medication..." 6. During an interview, E1 and E11 acknowledged medications were stored the medications in R4 and R6's residential units. E1 acknowledged the residents' service plans did not include documentation of how the medications were stored and controlled.

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. In record review, R2's medical record revealed a medication order for Oxycodone HCL 10 mg tablet, take 1 tablet by mouth twice daily in the morning and evening. R2's medical record included documentation R2 received the medication daily, as ordered. 3. In an interview, E1 reported the facility did not have documented policies and procedures for administering opioid medication.

Based on record review, interview and documentation review, for one resident receiving transportation, the manager failed to ensure an evaluation of the resident was conducted before and after the transport, information from the resident's medical record was provided to a receiving health care institution, and if applicable, any communication with an individual at a receiving health care institution, the date and time of the transport and if applicable, the name of the caregiver accompanying the resident during a transport. Findings include: 1. During an interview, E12 reported R5 was transported to a Dialysis clinic, by E12, weekly on Mondays and Wednesdays. 2. In record review, R5's medical record did not include the required documentation. 3. In documentation review, a facility policy titled, "Resident Transport/Transfer" documented "Transportation for a resident must have at least 1 additional person for the ride to ensure resident safety when using company transportation. [Facility] is not liable .... Any facility employee who transports residents... have received training ..." The facility's policy did not include documentation of the required procedures: an evaluation of the resident was conducted before and after the transport, information from the resident's medical record was provided to a receiving health care institution, and if applicable, any communication with an individual at a receiving health care institution, the date and time of the transport and if applicable, the name of the caregiver accompanying the resident during a transport. 4. During an interview, E1 reported the facility implemented the required transportation documentation procedures through the year 2022, in accordance with the rules. E1 reported having no documentation, as required, for R5's transportation in 2023.

Based on record review, and interview, for three of eight residents reviewed, the manager failed to ensure a resident's medical record contained a copy of the health care power of attorney (POA). The deficient practice posed a risk if the facility did not obtain and adhere to a resident's POA documentation. Findings include: 1. In record review, the medical records for R3, R7, and R8, did not include a copy of the resident's POA documentation. Based on the residents' acceptance dates, this documentation was required to be in the residents' records. 2. In record review, R3's medical record documented R3's son was R3's POA. R7's medical record included a Face Sheet, which documented "POA on File." R8's medical record included a Face Sheet which documented "POA on File," and R8's residency agreement was signed by R8's POA. 3. During an interview, E1 acknowledged the medical records for R3, R7, and R8 did not include a copy of the residents' POA documentation.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster. Findings include: 1. In documentation review, the facility's disaster plan did not include documentation the disaster plan was reviewed in the last 12 months. 2. In an interview, E1 reported being unaware if the disaster plan had been reviewed, and acknowledged the facility did not have documentation the disaster plan was reviewed, as required.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a health and safety risk to residents if the employees were not trained to implement the disaster plan. Findings include: 1. In documentation review, the facility had documentation of disaster drills conducted on November 30, 2022, on the first and second shift, on January 18, 2023, on the first shift and on January 26, 2023, on the second shift. 2. During an interview, E1 reported the facility had three shifts: 6:00am - 2:00pm, 2:00pm - 10:00pm, 10:00pm - 6:00am. E1 provided documentation of disaster drills conducted; however, the documentation was not dated, and E1 and E10 did not know the dates the drills were conducted. E1 acknowledged a disaster drill was required to be conducted on each shift at least once every three months.

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. The deficient practice posed a health and safety risk to residents and employees, if the employees were not prepared to implement the evacuation plan. Findings include: 1. In documentation review, the facility did not have documentation of evacuation drills conducted within the last year. 2. During an interview, E1 and E10 reported being unable to locate documentation of evacuation drills conducted within the last year. E10 reported an evacuation drill was conducted; however, was unable to locate the documentation.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a health and safety risk to residents if garbage and refuse were not stored in a covered manner. Findings include: 1. During an environmental inspection with E1 and E11, the compliance officer observed two "Refuse" closets located on resident hallways. The closets contained partially filled garbage containers, which were uncovered. Three garbage containers did not have covers. Two garbage containers had attached lids; however, the lids were folded behind the containers. 2. During an interview, E1 acknowledged garbage is required to be stored in a covered manner.

Based on observation, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection with E1 and E11, the compliance officer observed a closet located on the third floor resident hallway was unlocked, labeled "Roof Access," and contained Asphalt Primer, SPA Water Defoamer, Xylol Xylene Paint Thinner, Cans of Red hot blue Glue Cement, and Pipe Wrap Primer. The Physical Therapy room was unlocked and had a container of "Ready Kleen" on a counter top. 2. During an interview, E1 and E11 acknowledged the roof access closet and physical therapy room were unlocked and contained poisonous or toxic materials. E1 and E11 acknowledged poisonous or toxic materials were required to be maintained in a locked area and inaccessible to residents.

Based on documentation review, record review, and interview, for one of two residents reviewed, and receiving opioid medication, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. In documentation review, the facility's policies and procedures revealed no documented Opioid policies and procedures. 2. In record review, R2's medical record revealed a medication order for Oxycodone HCL 10 mg tablet, take 1 tablet by mouth twice daily in the morning and evening. R2's medical record included documentation R2 received the medication daily, as ordered. However, R2's record did not include documentation of the identification of the resident's need for the opioid, and documentation of the effect of the opioid administered. R2's medical record did not include documentation to show that R2 had an active malignancy or an end-of-life condition. 3. During an interview, E11 reported having documented a resident's need for the opioid and the effect of the opioid administered when opioid medication is ordered as a PRN (as needed), and did not document a resident's need for the opioid and the effect of the opioid administered, when an opioid medication was ordered as scheduled medication. E1 and E11 acknowledged all opioid medication administration is required to include documentation of the identification of the resident's need for the opioid, and the effect of the opioid administered.