Brookdale Camino Del Sol

Based on documentation review, record review, 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, and monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R2's medical record revealed a document titled "Resident Incident Report" dated September 18, 2025. This document stated "R1 was seen walking on the sidewalk on Aleppo and N 138th Ave at 8 am this morning, about .5 miles from the building by an off-duty caregiver, E4. It was found that the resident was able to get out through an unlocked door and gate at our community that were left unlocked by a staff member yesterday after her lunch break...." 3. In an interview, E1 reported R1 eloped from the facility through the door connecting the living room to the courtyard. At the time of the elopement, the door that was exited and the courtyard gate were unlocked; therefore, the alarm did not activate. 4. A review of an internal investigation document revealed R1 was last seen around 0755. E4 was off duty and recognized R1. E4 called the facility and stayed with R1. R1 was returned to the facility around 0810. R1 was fully assessed, and all parties were notified. The doors and gates were checked and locked. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. A review of facility documentation revealed an incident report. The report detailed an incident which occurred between R1 and R2 at 8:30 PM on August 27, 2025. The report stated the incident was “Reported to APS.” The review further revealed a printout of an email confirmation sent to E2. The email stated, “Thank you for contacting Adult Protective Services on 8/28/25.” 4. In an interview, E1 reported E2 reported the suspected abuse at approximately 11:00 AM on August 28, 2025, the morning after the incident. When the Compliance Officer asked why the suspected abuse was not reported immediately, E2 reported facility personnel were supervising R2 for several hours to help control R2’s behavior. E2 reported R2 finally went to bed at approximately 11:00 PM. E2 reported E2 worked on the incident report and report to A.P.S. for several hours the next morning.

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled, “Medication & Treatment,” which stated, “11. Administration of opioid medications requires assessment of resident pain with the use of the 0-10 verbal pain scale or faces scale as applicable. a. The assessment of pain is conducted prior to administration. b. Within an hour after administration the resident should be assessed for response and effectiveness of the opioid administration. c. documentation of the resident’s pain before administration of the opioid and the effect of the opioid administration should be documented on the MAR or eMAR.” 2. Review of R4’s medical record revealed a current service plan indicating R4 was at the directed level of care and received medication administration. The service did not indicate R4 was on hospice, was receiving treatment for an active malignancy, or had an end-of-life condition. 3. Review of R4’s medical record revealed a medication administration record (MAR), which revealed R4 received Tramadol HCI oral tablet 50 MG three times a day for the entire month of July 2025. 4. Review of R4’s medical record revealed a medication order for Tramadol HCI 50 MG, the start date was listed as November 2024. 5. Review of R4’s medical record did not reveal documentation of R4’s pain level or the effectiveness of the Tramadol HCI 50 MG. 6. In an interview, E5 reported E5 did not know scheduled opioid documentation was to also include the resident’s pain scale and the effectiveness of the opioid medication. 7. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that policies and procedures were implemented in response to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings Include: 1. During the complaint inspection, E1 showed a video to the Compliance Officer regarding the incident that included E2, E3, and R1. The video showed no signs of the staff attempting to de-escalate the situation with R1. 2. A review of policies and procedures revealed a document title: "Response to Aggressive Behavior". It provided steps on how to manage a resident who showed aggressive behaviors: "attempt to move the resident away from the immediate situation, while attempting to calm the resident", "remain with the resident in the area in a non threatening manner". 3. In an interview, E1 acknowledged that policies and procedures were not implemented by E2 and E3 in response to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R5’s medical record revealed an incident report dated April 29, 2025, that stated, “On 04/25/25 [E2] notified [E3] of [E2’s] med error. [E2] gave LANTIS in the PM for at least 10 days prior to 4/25/25 since it was d/c.” 2. Review of R5’s current service plan dated March 8, 2025, revealed R5 received medication administration. 3. Review of R5’s medical record revealed a signed medical order dated March 28, 2025, which stated, “Discontinue: effective 3/28/25 insulin glargine 100 units/mL Subcutaneous solutions; inject 5 units subcutaneous once a day (in the evening) for diabetes…” 4. In an interview, R5 was unable to provide an interview statement. 5. In an interview, E1 acknowledged E2 administered medication that was not in compliance with a medication order.