Brookdale Central Chandler

Based on record review and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1's medical record revealed a progress note dated February 17, 2026, that stated, "The fall occurred in the shower...[E4] witnessed the resident fall...[R1] slid from the shower chair...Resident is not able to move all extremities compared to normal (pre-fall) baseline. The resident's left knee was swollen...The resident was taken to the hospital for evaluation." 2. A review of R1's medical record revealed a service plan dated February 16, 2026, that indicated R1 was a two-person transfer assist. 3. In an interview, E1 reported that E4 was unaware that R1 was a two-person assist before attempting to transfer R1 out of the shower by themselves. As a result, R1 slipped on the way out of the shower and fell. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for two of four employees sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled “Skills & Competency Policy” The policy stated, “Upon hire and as needed, the skills sets or competencies will be assessed/evaluated through a variety of methods, including but not limited to: Proof of certifications, proof of licensure, attendance of required state specific trainings with passing of examinations (if required), demonstration and documentation of required competencies prior to providing resident care. The assessment/evaluation may include skills, tasks, or competencies identified in the associate's job description (e.g. bathing, handwashing, ambulation, transfer, etc.)” 2. A review of E3’s personnel record revealed E3 was hired as a caregiver on February 4, 2026. Evidence of documentation indicating E3’s skills and knowledge were verified was unavailable for review. 3. A review of E4’s personnel record revealed E4 was hired as a caregiver on September 27, 2018. Evidence of documentation indicating E4’s skills and knowledge were verified was unavailable for review. 4. A review of facility staff documentation revealed E3 and E4 worked numerous shifts in February 2026. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy, as stated in R9-10-113 for three of seven 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: 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. A review of R4, R6, and R7's medical records revealed no documentation of assessing risks of prior exposure to infectious TB and a determination of whether R4, R6, and R7 had signs or symptoms of TB. Based on R4, R6, and R7's date of acceptance, this documentation was required. 3. A record review of R6 and R7's medical records revealed no documentation of R6 and R7's freedom from infectious TB. Based on R6 and R7's date of acceptance, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was completed no later than 14 calendar days after the resident’s date of acceptance. for one out of seven residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R7's medical record revealed there was no service plan available. Based on R7's date of acceptance, this documentation was required. 2. In an exit 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 facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one residents reviewed who was confined to a bed or chair. 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 medical record revealed documentation from a doctor that indicated R1 was unable to ambulate even with assistance and was confined to a bed or chair. The document was signed by a doctor and dated in 2024. 2. Review of R1's medical record revealed no documentation indicating R1's medical practitioner had examined R1 at least once every six months, signed and dated a determination that stated R1's needs could be met by the facility, and reviewed the facility's scope of services after 2024. 3. In an interview, E1 reported that R1 was confined to a bed or chair and could not ambulate with assistance. 4. 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 if pets or animals were allowed in the assisted living facility, pets or animals were licensed consistent with local ordinances. Findings include: 1. In an interview, E1 reported that there were three pets currently living at the facility, which included two dogs and one cat. 2. A review of both dogs' records revealed no documentation of a current license from Maricopa County. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of five caregivers sampled. The deficient practice posed a potential 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. A review of E5's personnel record revealed a hire date of February 19, 2025. The record included a positive test result for infectious TB dated after E5's date of hire. Documentation of freedom from infectious TB was not available. 3. In an 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 February 4, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of five employees 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 E2's personnel record revealed a documentation of CPR training dated April 11, 2025, however, this training was conducted by the National CPR Foundation, which was a CPR and first aid training program available exclusively online. Documentation was not available showing a demonstration of the individual's ability to perform CPR 2. A review of the facility’s documentation/policies and procedures revealed a document titled "CPR Policy-States Requiring Certification" with the following verbiage, "Nurses, caregivers, managers or volunteers who provide direct care to residents will be required to complete CPR and first aid training as required by Arizona regulations. This training will be provided by an approved trainer through American Red Cross, American Heart Association, or National Safety Council." 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.