Avana Assisted Living

Based on record review, documentation review, and interview, the manager failed to ensure the residency agreement for three of three sampled residents included a termination policy that complied with the requirements for a manager to terminate residency as indicated in R9-10-807(G). Findings include: 1. A review of R1's medical record revealed a residency agreement dated December 23, 2024. The residency agreement stated, “the facility reserves the right to transfer of discharge a resident with a 14-day written notice for the following reasons: … (2) Documentation of Resident’s non-compliance with the residency agreement or internal facility requirements (House Rules). 2. A review of R2's medical record revealed a residency agreement dated February 20, 2024. The residency agreement stated, “the facility reserves the right to transfer or discharge a resident with a 14-day written notice for the following reasons: … (2) Documentation of Resident’s non-compliance with the residency agreement or internal facility requirements (House Rules). 3. A review of R3's medical record revealed a residency agreement dated October 1, 2025. The residency agreement stated, “the facility reserves the right to transfer of discharge a resident with a 14-day written notice for the following reasons: … (2) Documentation of Resident’s non-compliance with the residency agreement or internal facility requirements (House Rules). 4. A.A.C. R9-10-807(G) states: "A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14-day written notice of termination of residency: a. For nonpayment of fees, charges, or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason." Review of subsection (C) revealed, "1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The assisted living services needed by the individual are not within the assisted living facility's scope of services; 3. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 4. The individual requires restraints, including the use of bedrails." 5. In an interview, E1 acknowledged that R1’s, R2’s, and R3’s residency agreements did not include the required termination terms in R9-10-807(G). The facility received technical assistance on February 27, 2020, and August 9, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental tour, the Compliance Officer unlocked an unlocked bedroom labeled room 5. The bedroom contained patch and paint, all-purpose joint compound, and super paint acrylic 124 oz. 2. In an interview, E1 acknowledged that the aforementioned poisonous or toxic materials were not stored in a locked area inaccessible to residents.

Based on observation and interview, the manager failed to ensure that a list of resident rights were conspicuously posted. Findings include: 1. During a facility tour, the compliance officer observed 22 resident rights conspicuously posted. However, the posted list of rights was not the current resident rights listed in R9-10-810.C. 2. In an interview, E1 reported being unaware that the 22 resident rights were outdated and did not cover the current resident rights listed in R9-10-810.C.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. Findings include: 1. A review of R2’s medical record revealed a medication order dated July 7, 2025, which reflected Losartan 100mg one tablet daily, hold if SBP is less than 110. 2. A review of R2’s October 2025 medication administration recorded reported R2 was not administered Losartan 100mg on October 8, 2025, due to R2’s “Med out of stock”. 3. The compliance office observed R2’s Losartan prescription bottle with a pharmacy filled date of September 2, 2025. 4. In an interview, E3 reported being unable to find R2’s Losartan medication, and it was misplaced and later found. 5. In an interview, E1 acknowledged that R2’s medication was not administered in compliance with a medication order.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a documented training program for all staff regarding fall prevention and fall recovery was not available for review. 2. A review of E1's, E2's, and E3's personnel records revealed initial training or continued competency training in fall prevention and fall recovery training was not available for review. 3. In an interview, E1 and E2 reported the facility had not developed or administered a training program for all staff regarding fall prevention and fall recovery.