Assisted Living of Mesa

Based on record review and interview, the manager failed to ensure that staff obtain a certificate of completion, as specified in R9-10-126, including the minimum eight hours of initial memory care services training. Findings include: 1 . A review of E3's employee records revealed no certificate of memory care services training. E3 had a hire date of April 1, 2024. 2 . In an exit interview, E1 acknowledged that E3 had not completed the required memory care services training.

Based on observation and interview, the manager failed to ensure that a resident was not subject to a restraint. Findings include: 1 . During a tour of the facility the Compliance Officer observed a resident in their bed with full bed rails. E1 reported that the bed rails were prescribed by Hospice and E1 was told that they did not have a half rail available. 2 . In an interview, E1 acknowledged that a restraint was being used for a resident, in the facility.

Based on observation 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 used by a resident receiving personal care services. Findings include: 1 . During a tour of the facility, the Compliance Officer observed two of three residents sampled, without a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies. 2 . In an exit interview, E1 acknowledged that there were two rooms without a bell, intercom or other mechanical means to alert employees to a resident's needs or emergencies.

Based on record review and interview the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that was completed no later than 14 calendar days after the resident's date of acceptance. Findings include: 1 . A review of R3's record revealed a service plan, however, the service plan was created more than 14 days after R3's date of admission 2 . In an interview, E1 acknowledged a service plan was not established, documented, and implemented within 14 calendar days after the R3's date of acceptance. This is a repeat deficiency from compliance inspection conducted on June 24, 2023.

Based on document review, record review and interview, the administrative officer failed to ensure that the health care institution annually assessed the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1 . During a review of facility documents, the Compliance Officer reviewed the blank documents use to assess the facility for it's risk of exposure to infectious tuberculosis, however, there was not a completed document to show that the facility was assessed for the exposure to infectious tuberculosis. 2 . In an interview, E1 acknowledged that there was not an annual assessment for the facility's risk of exposure to infectious tuberculosis.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed a medicine cabinet with a child latch on the drawer. The Compliance Officer was able to unlock the drawer without a use of a key. Inside of the drawer revealed the following prescribed medications: - Three bottles of Levothyroxine 25 MCG, 25MCG, and 137 MCG - Omeprazole 20 MG 2. In an interview, E1 acknowledged medications stored by the facility were not stored in a locked area.