Azalea Villa Assisted Living Center

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a water temperature of 162.3º F in the shared laundry room for residents. 2. In an interview, E2 acknowledged the hot water temperatures were not maintained between 95º F and 120º F in areas used by residents.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record revealed E1 completed training on recognizing the signs and symptoms of TB on March 21, 2024. However, documentation of additional training was not available for review. 2. A review of E2's personnel record revealed E2 completed training on recognizing the signs and symptoms of TB on March 21, 2024. However, documentation of additional training was not available for review. 3. In an interview, E2 acknowledged training and education related to recognizing the signs and symptoms of TB was not provided initially and annually to individuals employed by the health care institution.

Based on record review and interview, the manager failed to ensure that an entry in a resident's medical record was not changed to make the entry illegible. Findings include: 1. A review of R2's activities of daily living (ADL) documentation for July 2025 revealed multiple entries were made illegible with correction fluid. 2. In an interview, E2 acknowledged the entries on R2's ADL were made illegible. Technical assistance was provided regarding this rule during the compliance and complaint inspection conducted on August 2, 2024.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication list dated April 4, 2025, signed by a registered nurse (RN) for: Aspirin 81 milligrams (mg), 1 tablet by mouth (po) daily (qd); Citalopram 10 mg, 1 tablet po qd; Colace 100 mg, 1 capsule po qd; Levothyroxine 100 micrograms (mcg), 1 tablet po Monday, Tuesday, Wednesday, Thursday, and Friday; Levothyroxine 100 mcg, 1/2 tablet po Saturday and Sunday; Propafenone HCl 225 mg, 1 tablet po twice a day (bid); Olanzapine 5 mg, 1 tablet po at bedtime (qhs); and Trazodone 50 mg, 1 tablet po qhs. However, the medication list was not signed by a medical practitioner as required. 3. A review of R1's medical record revealed a medication order for Midodrine HCl 5 mg, 1 tablet po qd, dated June 3, 2025. However, the medication order was not signed by a medical practitioner as required. 4. A review of R1's medication administration record (MAR) for July 2025, revealed R1 was administered the following medications July 1, 2025 - present: Aspirin 81 mg, 1 tablet po qd at 8:00 AM; Citalopram 10 mg, 1 tablet po qd at 8:00 AM; Colace 100 mg, 1 capsule po qd at 8:00 AM; Levothyroxine 100 mcg, 1 tablet po Monday, Tuesday, Wednesday, Thursday, and Friday at 8:00 AM; Levothyroxine 100 mcg, 1/2 tablet po Saturday and Sunday at 8:00 AM; Propafenone HCl 225 mg, 1 tablet po bid at 8:00 AM and 8:00 PM; Olanzapine 5 mg, 1 tablet po at 8:00 PM; Trazodone 50 mg, 1 tablet po at 8:00 PM; and Midodrine HCl 5 mg, 1 tablet po qd at 8:00 AM. 5. In an interview, E2 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed a medication order dated June 15, 2025, for Levothyroxine 175 micrograms (mcg), 1 tablet by mouth (po) daily (qd). 2. A review of R2’s medication administration record (MAR) for July 2025 revealed R2 was administered Levothyroxine 112 mcg, 1 tablet po qd, July 1, 2025 - present. 3. A review of R2's medical record revealed a medication order signed by a registered nurse (RN) on June 21, 2025, for Levothyroxine 112 mcg, 1 tablet po qd. However, the medication order was not signed by a medical practitioner as required. 4. The Compliance Officer observed Levothyroxine 112 mcg stored at the facility for administration to R2. 5. In an interview, E2 reported R2’s medications were changed by R2's provider following the signed order on June 15, 2025. However, E2 acknowledged that medication administered to R2 was not administered in compliance with a medication order.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan, with a review date of June 1, 2023. However, documentation of an additional review was not available for review. 2. In an interview, E2 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on record review and interview, the manager failed to ensure that a caregiver documented the time of the accident, emergency, or injury, the names of the individuals who observed the accident, emergency, or injury, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R2's medical record revealed R2 had an emergency on June 19, 2025, that resulted in R2 needing medical services.. However, the documentation did not include the following required elements: the time of the accident; the names of individuals who observed the accident; the actions taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident from occurring in the future. 2. In an interview, E2 acknowledged that when R2 had an accident, emergency, or injury that required medical services, a caregiver did not document all required elements per R9-10-818.D.2

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed two shifts; an AM shift and a PM shift. 2. A review of the facility's disaster drills revealed a drill conducted as follows: January 3, 2024 on the AM shift; January 4, 2024 on the PM shift; and April 4, 2024 on the AM shift. No other employee disaster drills were available for review. 3. In an interview, E3 acknowledged the disaster drills were not conducted on each shift at least once every three months.

Based on documentation review, observation, record review, and interview, a person established, conducted and maintained a health care institution without a current and valid license issued by the Department. The deficient practice posed a risk as unlicensed operation or maintenance of a health care institution is declared a nuisance inimical to the public health and safety, per Arizona Revised Statutes (A.R.S.) \'a7 36-430. Findings include: 1. A review of Department documentation revealed AL12593 was previously licensed as AL11377 (Azalea Villa Assisted Living Center LLC). However, AL11377 was closed on April 11, 2023 for failure to pay annual licensing fees. 2. During the environmental inspection of the facility, the Compliance Officer observed 16 residents on the premises. The Compliance Officer also observed the following conspicuously posted documents: -A "Delegation of Manager's Authority" document, which showed E3 as manager's designee; -A list of "Resident Rights" and "Home Rules"; -An assisted living manager's license for E1; -A document displaying "Current Telephone Numbers" pursuant to A.A.C. R9-803(D)(3)(a)-(d); -A "Weekly Menu" dated October 9-15, 2023; and -An assisted living facility license for AL11377. 3. A review of facility documentation revealed a resident roster. The roster indicated 16 residents were currently receiving assisted living services at the facility. 4. A review of resident records revealed full medical records for R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16. The Compliance Officer sampled records for R1 and R2 which contained service plans, medication administration records (MARs), and activities of daily living (ADL) sheets. The documentation was dated and maintained after the license for AL11377 was closed on April 11, 2023. 5. In an interview, E1 reported licensing fees for AL11377 were not paid on time, which led to the closure of the facility. However, E1 stated E1 applied for a new license right away. E1 acknowledged AL12593 conducted and maintained a health care institution without a current and valid license issued by the Department.