Care With Compassion Assisted Living

Based on observation and interview, the manager failed to ensure that the residents' medical records were protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed the residents' medical records were sitting out in an open area and were easily accessible, subject to unauthorized usage, loss or damage. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

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 R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a medication list for the following medications: Alprazolam 0.5 milligrams (mg), 1 tablet by mouth (po) twice a day (bid); Acetaminophen 325 mg, 2 tablets po bid; Trazodone HCl 100 mg, 1 tablet po at bedtime (qhs); Tramadol HCl 50 mg, 1 tablet po bid; Aspirin 81 mg, 1 tablet po daily (qd); Sennosides 8.6 mg, 1 tablet po bid; Carvedilol 12.5 mg, 2 tablets po bid; Amlodipine Besylate 5 mg, 2 tablets po qd; and Clopidogrel Bisulfate 75 mg, 1 tablet po qd. However, the medication list was not signed by a medical practitioner as required. 3. A review of R2's medication administration record (MAR) for July 2025 revealed R2 was administered the following medications; Alprazolam 0.5 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present; Acetaminophen 325 mg, 2 tablets po bid, and indicated 2 tablets were administered at 8:00 AM and 8:00 PM July 1, 2025- present; Trazodone HCl 100 mg, 1 tablet po qhs, and indicated 1 tablet was administered at 8:00 PM July 1, 2025- present; Tramadol HCl 50 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present; Aspirin 81 mg, 1 tablet po qd, and indicated 1 tablet was administered at 8:00 AM July 1, 2025- present; Sennosides 8.6 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00 AM and 8:00 PM July 1, 2025- present; Carvedilol 12.5 mg, 2 tablets po bid, and indicated 2 tablets were administered at 8:00 AM and 8:00 PM July 1, 2025- present; Amlodipine Besylate 5 mg, 2 tablets po qd, and indicated 2 tablets were administered at 8:00 AM July 1, 2025- present; and Clopidogrel Bisulfate 75 mg, 1 tablet po qd, and indicated 1 tablet was administered at 8:00 AM July 1, 2025- present. 4. In an exit interview, the finding was 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's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed R1 was offered the flu and pneumonia vaccines on February 1, 2024. However, documentation of an additional offering was not available for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated February 1, 2025) revealed R1 received personal care services, and was confined to a bed or chair. 3. A review of R1's medical record revealed a determination for continued residency dated February 1, 2024. However, no further documentation was available for Compliance Officer review. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of the facility’s license revealed that the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the back door had an alarm. However, it was not turned on at the time of inspection. 3. In an exit interview, the finding was reviewed with E1 and no additional information was provided.

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 to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed insulin was stored in an unlocked mini fridge and on the kitchen counter. Additionally, the Compliance Officers observed the facility's medication cart that held medication for all five residents, unlocked and accessible to residents. 3. In an exit interview, the finding was reviewed with E1 and no additional information was provided. Technical assistance was provided regarding this regulation during the abbreviated inspection conducted on June 12, 2024.

Based on observation and interview, the manager failed to ensure the premises of the facility was free from a condition or situation that may cause a resident or another individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a glass table outside sitting next to the back yard door with a large, broken shard of glass lying on top in a way that was accessible to residents and/or staff. 2. In an exit interview, the finding was reviewed with E1 and no additional information was provided.