Az Senior Living Management, LLC

Based on the record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults for one of three personnel records sampled. 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 E4’s personnel record revealed a hire date of December 2024 2. A review of E4's personnel record revealed a CPR and First Aid certification with an expiration date of August 12, 2024. No other documentation of E4's CPR and First Aid certification was provided for review. 3. In an interview, E1 acknowledged that E4's personnel record did not contain current CPR and first aid training certification documentation.

Based on documentation review and interview, the manager failed to ensure policies and procedures were available to employees and volunteers of the assisted living facility. The deficient practice posed a risk as policies and procedures reinforce and clarifly standards expected of employees and volunteers. Findings include: 1. A review of Department documentation revealed the perpetual license for AL12449 was effective March 30, 2023. 2. The Compliance Officer requested to review the facility's policies and procedures. However, the polices and procedures were not provided for review. 3. In an interview, E1 reported to be unaware of where the policies and procedures were located. 4. In an interview, E1 acknowledged the policies and procedures were not available to employees and volunteers of the assisted living facility.

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility to include the manager's signature and date signed, for one of four current residents and one of one discharged resident sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R4's (admitted in 2023) medical record revealed a documented residency agreement. However, the residency agreement was signed and dated by E2 and not the manager. 2. A review of R5's (admitted in 2023) medical record revealed a documented residency agreement. However, the residency agreement was signed and dated by E2 and not the manager. 3. In an interview, E1 acknowledged R1's and R3's residency agreements did not include the manager's signature or the date signed.

Based on documentation review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10), for three of four current residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of Department documentation revealed the facility's perpetual license was effective on March 30, 2023. 2. A review of R1's (admitted before AL12449 was licensed) medical record revealed a residency agreement dated in December 2021. However, a residency agreement with AL12449 was not available for review. 3. A review of R2's (admitted before AL12449 was licensed) medical record revealed a residency agreement dated in October 2021. However, a residency agreement with AL12449 was not available for review. 4. A review of R3's (admitted before AL12449 was licensed) medical record revealed a residency agreement dated in July 2022. However, a residency agreement with AL12449 was not available for review. 5. In an interview, E1 acknowledged R1's, R2's and R3's residency agreements were not completed for AL12449.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the resident or resident's representative, for two of four current residents and one of one discharged resident sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed a current service plan (dated in May 2023) for directed care services. However, the service plan was not signed and dated by the resident's representative. 2. A review of R4's medical record revealed a current service plan (dated in March 2023) for directed care services. However, the service plan was not signed and dated by the resident's representative. 3. A review of R5's medical record revealed a current service plan (dated in March 2023) for personal care services. However, the service plan was not signed and dated by the resident. 4. In an interview, E1 acknowledged R1's, R4's, and R5's written service plans did not include a signature and date from the resident or resident's representatives.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for one of four current residents sampled. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. A review of R3's (admitted before AL12449 was licensed) medical record revealed a service plan was not available for review. 2. In an interview, E1 acknowledged R3's medical record did not contain R3's service plan and updates.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed ambulatory residents on the premises. 2. The Compliance Officer observed an unlocked medication box in the unlocked refridgerator located in the kitchen with the following medications: -Lantus Solostar 100 units/ml; -Oxycodone Hyrdochloride 100mg; -Bisacodyl 10mg; -Prevnar 13 Syringe .5ml; -Biscolax 10mg; and -Lorazapam 2mg/ml. 3. In an interview, E1 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit.