Aspire Care Home LLC

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a current written service plan for directed care services dated December 8, 2025. This service plan stated the following services were needed: "Oral/denture care per day 2" "Nail care per week 2" "Shaving per week 2" 2. A review of R1's medical record revealed a document titled "Activities Of Daily Living Chart" dated February 2026. This document revealed the following: "Oral Care (2X/ day)" however, documentation was not available showing this service was provided at 8am on February 18th and at 8pm on February 12th-present "Nail Care (PRN X/week)" however, documentation was only available showing this service was provided on February 2nd, 6th, and 10th "Shave (PRN X/week)" however, documentation was only available showing this service was provided on February 11th 3. A review of R2's medical record revealed a current written service plan for directed care services dated January 15, 2026. This service plan stated the following services were needed: "Resident requires full assistance with dressing and undressing." 4. A review of R2's medical record revealed a document titled "Activities Of Daily Living Chart" dated February 2026. This document revealed the following: "Dressing (1X/day and PRN)" however, documentation was not available showing this service was provided at 8am on February 2nd, 5th, 12th-present and at 8pm February 2nd, 4th, 6th-present 5. In an interview, E1 reported that sometimes R1's family assisted with care. E1 reported that the services were provided and acknowledged that the medical records did not include documentation of these services as stated in the service plan. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. The Compliance Officer observed a desk next to the kitchen table. When R1's and R2's medical records were requested, the records were retrieved from an unlocked drawer in the desk. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the inspection, the Compliance Officer observed two medication organizers full of medication sitting on top of a desk next to the kitchen table. When the Compliance Officer arrived, R1 was sitting at the kitchen table, and E2, the only personnel member onsite, was observed leaving the immediate area. The medication organizers remained in this location throughout the duration of the inspection. 2. During an observation, the caregivers were not accessing the medications during the duration of the inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. 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 dated "Feb 15th THRU Feb 21st 2026". The Thursday, February 19th breakfast menu stated: "Eggs Meat Toast or Tortilla Beverage" Documentation was not available showing any substitutions. 2. In an interview, R2 reported that R2 received cereal, banana, and milk for breakfast that morning. 3. In an interview, E1 reported that the menu wasn't always followed, as E1 worked with the residents' preferences. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.