Avondale Assisted Living Home

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility, and if an individual was expected to receive supervisory care services, personal care services, or directed care services, the documentation included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for two 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 R1’s and R2’s medical record revealed there was no admitting documentation to indicate R1's and R2’s expected level of care that included whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints, and that was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E4 reported that R1 and R2 did not have documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided at the time of the inspection.

Based on observation, record review and interview, the manager failed to terminate residency in a manner compliant with R9-10-807(G)(3), for one of three residents sampled. Findings include: 1. The Compliance Officer observed the R3 was not in the facility at the time of the inspection. 2. A review of R3’s medical record revealed a signed residency agreement for the facility. 3. In an interview, E4 reported R3 was living in the facility and then was transferred to a sister facility. E4 reported R3 did not receive a 30 day termination letter. E4 was not aware residents needed a 30 day termination letter to transfer to a sister facility. 4. A review of R3’s medical record revealed R3’s transfer date on the manila folder that contained R3’s records. A further review revealed no 30 day termination letter. 5. In an exit interview, the findings were reviewed with E4 and no additional information was provided at the time of the inspection.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of three residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. A review of R1’s medical record revealed no documented service plan for R1. Based on R1’s acceptance date this documentation was required. 2. In an interview, E4 was asked to find R1’s service plan. E4 was unable to find R1’s service plan. E4 acknowledged that R1 did not have a service plan. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided at the time of the inspection. 4. This is a repeat deficiency from the complaint investigation conducted on October 7, 2025.

Based on the record review and interview, the manager failed to ensure that a caregiver documented the services provided in the residents' medical records, for two of three sampled residents. Findings include: 1. A review of R2’s medical record revealed a signed service plan dated November 28, 2025. The service plan indicated R2 received the following services: Maintenance of room; and Laundry service. 2. A review of R2’s medical record revealed activities of daily living (ADL) documentation for March 2026, which did not indicate R2 was provided maintenance of room and laundry service. 3. A review of R3’s medical record revealed a signed service plan dated May 14, 2025. The service plan indicated R3 received the following services: Maintenance of room; and Laundry service. 4. A review of R3’s medical record revealed ADL documentation for January 2026, which did not indicate R3 was provided maintenance of room and laundry service. 5. In an interview, E4 reported that R2 and R3 received laundry and maintenance of room services; however, the services provided were not documented in the ADLs. 6. In an exit interview, the findings were reviewed with E4, and no additional information was provided at the time of the inspection. 7. This is a repeat deficiency from the compliance inspections conducted on June 21, 2023, May 29, 2024, and the complaint investigation on October 7, 2025.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for five of seven residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R2, R3, R5, R6 and R7 medical records revealed no documentation of a residency agreement. 2. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was available, for five of seven residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. A review of R2, R3, R5, R6, and R7's medical records revealed no documentation of a service plan. Based on the acceptance dates, a service plan was required. 2. In an exit interview, findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. A review of E2's personnel record revealed E2 had a hire date of August 17, 2025. 3. A review of E2's personnel record revealed no documentation of a fingerprint clearance card. A receipt titled 'Aloha Fingerprints,' dated October 3, 2025, stated that fingerprints were completed. 4. An interview with an Arizona Department of Public Safety representative revealed E2 applied for E2’s fingerprint card on October 03, 2025, and the card was issued to E2 on October 20, 2025. 5. A review of the facility's personnel scheduled dated September 28, 2025 - October 04, 2025, revealed E2 worked Sunday through Saturday, on the day shift from 6 am to 6 pm, and the night shift from 6 pm to 6 am. 6. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. During the inspection, the Compliance Officers observed E2 providing services to residents, preparing medication, bathing, and providing incontinence care. 2. A review of E2’s personnel record revealed no documentation of completing a caregiver training program approved by the Department or the NCIA Board. 3. A review of the facility document titled Employee work scheduled dated September 28, 2025- October 04, 2025, revealed E2 was scheduled to work Sunday through Saturday, on the day shift from 6 am to 6 pm, and the night shift from 6 pm to 6 pm. 4. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E2. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid (FA) and cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed no documentation of FA and CPR training. 2. A review of the facility's personnel scheduled dated September 28, 2025 - October 04, 2025, revealed E2 worked Sunday through Saturday, on the day shift from 6 am to 6 pm, and the night shift from 6 pm to 6 am. 3. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one 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 R2’s medical record revealed no documentation of any service provided. 2. In an interview, E1 reported R2 received assisted living services from the caregivers. 3. In the exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on June 21, 2023 and May 29, 2024.

Based on observation, record review, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified and false or misleading information was provided to the Department. Findings include: 1. Upon arrival at the facility, the Compliance Officers (COs) were greeted by E2. E2 escorted the COs to the dining room table. The Compliance Officers asked for the residents' Medication Administration Records (MARS). At that time, E2 took a binder out of the kitchen cabinet and walked into the caregiver’s room. The CO walked back to the same room as E2. The CO observed E2 in the process of writing on a document in the binder that was labeled “MARS & ADLs”. The CO asked E2 if E2 was backfilling the documents; E2 confirmed backfilling the documents. 2. A review of R1’s medical record revealed a September 2025 MAR. The MAR listed the following medications: "Alendronate Sodium 35mg Tablet. 1 tablet with plain water by mouth 30 minutes before 1st food/ drink/medicine of the day once a week" and indicated this medication was administered on September 13th and 20th at 7 AM "Trulicity Solutions auto injector (dulaglutide injection) 0.75MG /0.5 ML. Give as directed subcutaneously every week" and indicated the medication was administered on September 13th and 20th at 8 AM "Lantus Solostar Solution Pen – Injector 100 Units/ML as directed. 20-30 Units subcutaneously every 12 hours for 3 doses for 90 days" and indicated the medication was administered on September 13th-20th at 8 AM - 8 PM "HumaLOG Kwiken Solution Pen Injector 100 units/ML as directed, 10-20 units subcutaneously. Take medicine 3 times a day for 90 days" and indicated the medication was administered on September 13th-20th at 7 AM, 3 PM, and 11 PM "Metformin HCI 100MG Tablet. Take 1 Tablet orally twice a day for 90days" and indicated the medication was administered on September 12th - 20th at 8 AM and 8 PM "Atorvastatin 40MG Tablets, USP, for calcium. Take 1 tablet by mouth every day for 90 days" and indicated the medication was administered on September 13th-20th at 8 AM "Fluoxetine HCI 20MG Capsule. Take 1capsule by mouth every day" and indicated the medication was administered on September 13th-20th at 8 AM "Trazodone 50MG Tablet. Take 1 tablet by mouth at bedtime as needed" and indicated the medication was administered on September 13th, 14th, 17th, and 18th at 8 PM "Farxiga 10 MG Tablet. Take 1 tablet by mouth every day for 90 days" and indicated the medication was administered on September 13th-20th at 8 AM "Lisinopril 10MG tablet. Take 1 tablet by mouth every day" and indicated the medication was administered on September 13th-20th at 8 AM "Aspirin EC 81MG tablet. Take 1 tablet by mouth every day for 30 days" and indicated the medication was administered on

Based on record review, observation, and interview, the manager failed to ensure that the assistant caregiver interacted with residents under the direct supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A review of E3’s personnel record revealed E3 was hired as an assistant caregiver. 2. During a tour of the facility with E2, the Compliance Officers observed E3 assisting with toileting services and showering a resident alone. 3. In an interview, E2 reported E3 was assisting R3 with showering. 4. In an interview, E3 reported E3 was assisting R3 with showering. 5. In an interview, E2 acknowledged that E3 was an assistant caregiver and interacted with R3 without the supervision of a manager or caregiver.

Based on record review and interview, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two 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 R1’s service plan dated March 03, 2025, revealed that R1 received personal care. 2. A review of R1’s service plan revealed no documentation of a description of R1's medical or health problems. 3. A review of R2’s service plan dated February 10, 2025, revealed that R2 received personal care. 4. A review of R2’s service plan revealed no documentation of a description of R2's medical or health problems. 5. In an interview, E2 acknowledged the R1's and R2's service plans 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 included the amount, type, and frequency of assisted living services provided for one of two residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings Include: 1. A review of R1’s service plan dated March 03, 2025, revealed that R1 was bed-bound and required personal care. 2. A review of R1’s service plan dated March 03, 2025, revealed R1 required repositioning. However, the frequency of the repositioning was not included on the service plan. 3. In an interview, E1 acknowledged R1's service plan did not include the frequency of repositioning.

Based on observation and interview, a manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings: 1. During a tour of the facility with E2, the Compliance Officers observed R1's room with no means to alert employees to a resident's needs or emergencies. 2. In an interview, E2 reported E2 used a baby monitor at night to monitor the residents. When asked how residents were monitored during the day, E2 replied that R1 had a loud voice and yelled for assistance. 3. In an interview, E2 reported that the baby monitor was in the room. When the Compliance Officers asked to see the baby monitor, E2 was unable to locate it. 4. In an interview, E2 acknowledged a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available and accessible in a bedroom being used by the resident. 5. This is a repeat deficiency from the inspection conducted on May 29, 2024.

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. During a tour of the facility with E2, the Compliance Officers observed one ambulatory resident. 2. During a tour of the facility with E2, the Compliance Officers observed the backyard. The backyard had open window wells for egress from the basement. Window screens were observed lying across the window wells. 3. In an interview with E2, E2 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. 4. Technical Assistance was provided on this Rule during an inspection conducted on May 29, 2024.

Based on observation and interview, the manager failed to ensure an oxygen container was secured. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility with E2. The Compliance Officers observed R4's room with an oxygen tank stored in an upright position in a closet, but not secured. 2. In an interview with E2, E2 acknowledged the oxygen container was not secured.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed toxic materials stored in an unlocked kitchen drawer and cabinet. The following items were accessible to residents and included warning labels: - A bottle of Ajax Ultra Soap - A tube of Locktite Super Glue 2. The Compliance Officers observed ambulatory residents in the facility. 3. In an interview, E2 acknowledged the unlocked materials in the kitchen were accessible to residents and should have been locked.

Based on observation and interview, the manager failed to ensure a bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. The Compliance Officers observed two bathrooms that were accessible from a common area did not contain paper towels or a mechanical air hand dryer. 2. In an interview, E2 acknowledged a bathroom accessible from a common area did not contained paper towels in a dispenser or a mechanical air hand dryer. 3. Technical assistance was provided on this Rule during the compliance inspection conducted June 21, 2023.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a window that opened or another means of ventilation. Findings include: 1. The Compliance Officers observed a hallway bathroom, used by residents, did not contain a window or other means of ventilation. 2. In an interview, E2 acknowledged the bathroom did not have a window or other means of ventilation. E2 reported the exhaust fan must be broken. 3. Technical assistance was provided during the compliance inspection conducted on June 21, 2023.

Based on record review and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of five employees reviewed. The deficient practice posed a TB exposure risk to residents. 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E3's personnel record revealed no documentation of freedom from infectious TB. Based on E3's hire date, this documentation was required. 4. A review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required. 5. A review of E5's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E5's hire date, this documentation was required. 6. In an interview, E2 reports E4 lived at the facility. 7. In an interview, E2 acknowledged E2 did not understand the TB rules and acknowledged E3, E4, and E5 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on observation, interview, and record review, the manager failed to ensure an individual residing in an assisted living home, who was not a resident, a manager, a caregiver, or an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a TB exposure risk to residents. Findings include: 1. The Compliance Officers observed O1 alone in a bedroom not used for residents. 2. In an interview, E2 reported O1 to be an assistant caregiver that worked at another facility. E2 reported O1 did not work at this home but resided at the home. 3. Documentation was not available for O1 that showed freedom from infection TB. 4. In an interview, E2 acknowledged documentation of freedom from infectious TB was not maintained for an individual residing in the assisted living home who was not a resident, a manager, a caregiver, or an assistant caregiver.

Based on record review and interview the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of four residents sampled. The deficient practice posed a TB exposure risk to residents. 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: . . . iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R3's medical record revealed no documentation of freedom from infectious TB. Based on R3's acceptance date, this documentation was required. 3. A review of R4's medical record revealed a chest x-ray. However, documentation was not available indicating R4 had a previous positive TB skin test or blood test and without such documentation a chest x-ray is not acceptable as documentation of freedom from TB. No additional documentation of freedom from infectious TB was available for review. Based on R4's acceptance date, this documentation was required. 4. In an interview, E2 acknowledged R3 and R4 did not provide current documentation of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of four residents sampled. 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 service plan dated December 21, 2023. The plan stated R1 was to receive the following services: - Combing hair daily - Shaving twice a week 2. A review of R1's medical record revealed an activities of daily living (ADL) log that revealed no documentation of combing hair daily and shaving twice a week for the month of May 2024. 3. During an interview, E2 acknowledged R1's medical record did not include documentation of the above listed services and reported the services were provided. 4. This is a repeat deficiency from the compliance inspections conducted June 21, 2022 and June 21, 2023.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. The Compliance Officers observed the hot water temperature was above 120\'b0 F in two bathrooms and in the kitchen. - A bathroom sink in a hallway read 125.7\'b0 F - A bathroom sink in a residential unit read 126.3\'b0 F - The kitchen sink read 127.1\'b0 F 2. In an interview, E2 acknowledged the water temperatures were not maintained between 95\'b0 F and 120\'b0 F. 3. This is a repeat deficiency from the compliance inspection conducted June 21, 2023.

Based on record review and interview the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), for two of four residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed R1 refused the flu and pneumonia vaccination in June 2022. However, current documentation was not available that showed the flu and pneumonia vaccinations were received or refused. Based on R1's acceptance date, this documentation was required. 3. A review of R2's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R2's acceptance date, this documentation was required. 4. In an interview, E2 acknowledged R1's and R2's medical records did not include current documentation showing the flu and pneumonia vaccinations were received or refused. E2 reported E2 was unaware that flu and pneumonia vaccinations were supposed to be offered and documented once every year.

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed no bell, intercom, or other mechanical means to alert the caregivers and the assistant caregivers to the residents needs or emergencies in R1's room. 2. In an interview, E2 acknowledged R1 did not have a bell, intercom, or other means to alert employees to needs or emergencies. 3. In an interview, R1 reported R1 does not have a call bell.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of three residents reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R3's medical record revealed a current written service plan for directed care services dated May 12, 2024. This service plan revealed no documentation of R3's weight. In addition, R3's medical record revealed no documentation of R3's weight or documentation from a medical practitioner stating weighing R3 was contraindicated. 2. A review of R4's medical record revealed a current written service plan for directed care services dated April 18, 2024. This service plan revealed no documentation of R3's weight. In addition, R3's medical record revealed no documentation of R3's weight or documentation from a medical practitioner stating weighing R3 was contraindicated. 3. During an interview, E2 acknowledged R3's and R4's service plans did not include documentation of weight and documentation was not available in R3's and R4's medical records from a medical practitioner stating weighing R3 and R4 was contraindicated. 4. This is a repeat deficiency from the compliance inspection conducted June 21, 2023.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed no bell, intercom, or other mechanical means to alert the caregivers and the assistant caregivers to the residents needs or emergencies in R3 and R5's rooms. 2. A review of R3's and R5's medical records revealed R3 and R5 received directed care services. 3. In an interview, E2 acknowledged R3 and R5 did not have a bell, intercom, or other means to alert employees to needs or emergencies.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officers observed the medication closet did not have an appropriate lock on the door. A key was not needed to unlock the closet door to access the stored medication. The door was opened with a fingernail by a Compliance Officer. 2. The Compliance Officers observed ambulatory residents walking around the facility. 3. During an interview, E5 acknowledged the lock on the door did not need to be opened with a key and E5 was able to unlock the door with a fingernail. 4. During an interview, E2 acknowledged the lock on the medication door was not sufficient.

Based on observation and interview, the manager failed to ensure a fire alarm system was in working order. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. The Compliance Officers observed the tag on the fire alarm box was last inspected in November 2020. 2. During an interview, E2 reported E1 made an appointment to get the fire alarm box checked, but no one came out. 3. Technical assistance was provided on this Rule during the compliance inspection conducted June 21, 2023.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of the two residents sampled. Findings; 1. Review of R1's directed care service plan dated March 21, 2023, identified the following service: "Check fingernails daily and clean as needed, tub bath 2 x weekly on days when complete bath is not given partial bedside bath." However, R1's medical record for June 2023 revealed no documentation of R1's partial bedside bath or nail care services provided. 2. Review of R2's personal care service plan dated March 7, 2023, identified the following service: "Check fingernails daily and clean as needed, bed bath 2 x weekly." However, R2's medical record for June 2023 revealed no documentation of R2's bed bath or nail care services provided. 3 During an interview with E1, E1 reviewed R1 and R2's medical records. E1 acknowledged that R1 and R2's medical records revealed no documentation of the identified services. E1 reported R1 and R2 receive the services daily as identified on the service plan. E1 acknowledged the manager failed to ensure a caregiver documented the services provided in the resident's medical record. This is a repeat deficiency from the compliance inspection conducted June 21, 2022.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for one of two residents reviewed receiving directed care services. Findings include: 1. Review of R1's record revealed a current written directed care service plan dated March 21, 2023 and a previous service plan dated December 21, 2022. These service plans revealed no documentation of R1's weight. A review of R1's record revealed no documentation from a medical practitioner stating weighing R1 was contraindicated. 2. During an interview, E1 acknowledged R1's directed care service plans did not include R1's weight and R1's record did not include documentation weighing R1 was contraindicated. E1 acknowledged the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the compliance officer observed the back patio door contained an alarm to alert employees of the egress of a resident however the alarm was not functioning. The compliance officer observed the back door, allowed residents to be a least 30 feet away from the facility and led to a gate that was unlocked and accessed the city street. The gate had a padlock that was not locked. 3. During an interview, E1 acknowledged the alarm on the patio door was not working and required a battery change. E1 acknowledged the lock on the gate allowing access to the city street was unlocked. E1 reported E3 recently took the garbage out and forgot to lock the gate. E1 acknowledged the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. .

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of R1's medical record revealed signed medication orders for the following medications; Escitalopram 10 mg tablet take one tablet by mouth daily, Oxcarbazepine 300 mg take three tablets by mouth twice daily, Senna 8.6 mg tablet take one tablet by mouth twice daily, and Topiramate 100 mg tablet take one tablet by mouth twice daily. A review of R1's medical record revealed no documentation the identified medications were administered to R1 on June 21, 2023, a.m. A review of R1's medical record revealed R1 receives medication administration. 2. A review of R2's medical record revealed signed medication orders for the following medications; Hiprex 1 gram tab take twice a day, Apixaban 5 mg tab twice a day, and Protonix 40 mg tab take one tab once a day. A review of R2's medical record revealed no documentation the identified medications were administered to R2 on June 21, 2023, a.m. A review of R2's medical record revealed R2 receives medication administration. 3. The compliance officer observed R1 and R2's identified medications were available at the facility. 4. In an interview, E2 reported E2 provided medication administration to R1 and R2 at 7 a.m. on June 21, 2023. E2 acknowledged E2 did not document the medication administration in R1 and R2's medical record. 5. In an interview. E1 acknowledged the manager failed to ensure medication administered to a resident was documented in the resident's medical record.

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. Findings include: 1. During the facility tour with E1, the Compliance Officer observed an unlocked box and a plastic Tupperware container located in the facility's refrigerator. The refrigerator contained the following medications unlocked and accessible to residents; Lantus Solostar Pens, Lorazepam Intensol Oral Concentrate, and Morphine Sulfate Oral Solution. 2. During an interview, E2 reported E2 returned the reported medications to the fridge unlocked. 3. During an interview, E1 the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. Findings include: 1. During the facility tour with E1, the surveyor observed the water temperature at 138\'b0 F in a resident shared bathroom. 2. In an interview, E1 reviewed the hot water temperature reading. E1 acknowledged the resident shared bathroom temperature was not maintained between 95\'b0 F and 120\'b0 F in the area of a facility used by residents.