Bethesda Gardens

Based on record review, documentation review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide the emergency responders with a written document that included all information required in A.R.S. § 36-420.04, for one of four residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings Include: 1. A review of R2's medical record revealed an incident that occurred on August 4, 2025. The incident report stated, “During morning medication pass at 5 am, staff went into the R2 room to let R2 know that R2's morning medication wasn’t available. When the staff walked in, they found R2 lying motionless in bed. Staff checked R2, and R2 was pale, cold, and R2's feet were turning purple. The staff checked vital signs, and there wasn’t any reading. The nurse and 911 were called.” 2. A review of Department documentation revealed an intake report dated August 3, 2025, which included sworn testimony that stated, “Staff/facility insufficient to meet patient need for safety and wellbeing as patient left unattended for extended period of time. Staff failed to provide a patient care report (DNR) per ARS 36-420.04, A9. Inappropriate utilization of the 911 system (deceased patient with known DNR). Bethesda Gardens-Phoenix's assisted living staff explains to the fire department that they have a DNR. When asked for it, the assisted living staff left to retrieve it and were notified that it must be present and would be an orange form. The fire department waited approximately 15 minutes until the staff admitted they were unable to find it. The fire department cleared the scene and returned to service.” 3. In an interview, E3 acknowledged that the documentation the fire department requested wasn’t given to the fire department. 4. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on the documentation review and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. 1. A review of facility documentation revealed an incident report dated March 24, 2025. The incident report revealed that R1 suffered burns from a bathroom circulation fan that caught on fire. 2. A review of facility documentation revealed no documentation showing how often the premises and equipment used at the assisted living facility were maintained. 3. In an interview, E1 acknowledged that the premises were not free from conditions or situations that may cause a resident or other individual to suffer physical injury.

Based on the documentation review and interview, the manager failed to ensure that the equipment used at the assisted living facility was maintained in working order. 1. A review of facility policies and procedures revealed a policy titled “Deep cleaning of residents' apartments.” The policy stated that cleaning the bathroom would include cleaning the vents. However, no documentation showed how often the vents were cleaned in the residents' apartments. 2. A review of facility documentation revealed an incident report dated March 24, 2025. The incident report revealed that a bathroom vent caught fire and burned R1. 3. In an interview, E1 reported that the facility does not check bathroom vents to ensure they are in working order. This is a repeat deficiency from a compliance and complaint inspection conducted on February 15, 2024.

Based on documentation review, video review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. A review of department documentation revealed a complaint intake dated February 12, 2025, which reported that resident was not treated well. “The staff who assisted the resident back into bed after a fall pulled the covers over resident and completely covered resident head.” 2. A review of video evidence revealed E5 helping R10 back into the bed and throwing a blanket over R10’s head. 3. In an interview, E1 reported that E5's action was not acceptable behavior, and acknowledged that R10 was not treated with dignity, respect, and consideration. This is a repeat deficiency from a complaint inspection conducted on February 18, 2025.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident covering how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "At Risk Behaviors" which detailed how caregivers should follow up after a resident exhibits intense or out of control behavior, however, the policy did not cover how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. 2. In an interview, E1 acknowledged a policy and procedure was not available covering how a caregiver would respond in the moment to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual.

Based on interview and observation, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. In an interview, R4 stated "the staff look at me like I am dirt." 2. In an interview, E2 stated "Maybe [R4] wasn't the best person to have you speak to, we all hate [R4]." 3. The Compliance Officer observed that R4 was only a few steps away, and within earshot, when the interview with E2 took place. 4. In an interview, E1 reported that E2's statement was not acceptable behavior, and acknowledged that R4 was not treated with dignity, respect, and consideration.