Casa Del Rey Assisted Living Care Home LLC

Based on record review and interview, the manager failed to ensure a medication was administered to a resident 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. Review of R2’s medical record revealed a current service plan dated May 6, 2025. This service plan indicated R2 received medication administration. 2. Review of R2’s medical record revealed a signed medication order dated July 11, 2025, that stated, “Cetirizine 10 MG BID” (twice a day). 3. Review of R2’s medical record revealed the medication administration record (MAR) for the month of August 2025. This MAR revealed Cetirizine 10 MG was administered once a day from August 1st to present. 4. In an interview, E1 reported that Cetirizine 10 MG was administered once a day. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on July 11, 2023.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s medical record revealed a current service plan dated July 21, 2025. This service plan indicated R1 received medication administration. 2. Review of R1’s medical record revealed signed medication orders dated June 27, 2025. These orders stated, “Donepezil 10 MG two tablets PO HS” and “Gabapentin 300 MG one tablet PO QD”. 3. Review of R1’s medical record revealed R1’s medication administration record (MAR) for August 2025. This MAR showed Donepezil 10 MG was not documented as administered on the 14th and Gabapentin 300 MG was not documented as administered on the 12th, 13th, and 14th. 4. In an interview, E1 reported E1 administered the medications, however E1 did not document it. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on July 11, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed medical records for all residents were stored in an office room in the back of the facility. However, the office was not locked and provided access to the door leading to the backyard from this office room. The Compliance Officer observed medical records scattered all over the office room. The Compliance Officer also observed two ambulatory residents walking through this office room to the backyard several times. 3. In an interview, E2 and E3 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use. 4. In an telephonic interview, E1 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled 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 records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed four ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the front door leading to the street from the facility. However, the door was not secured and the door chime was not functioning. 4. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility. 5. In an telephonic interview, E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, 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 provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility and controlled 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 records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed four ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 4. During the environmental tour, the Compliance Officer observed a gate in the back yard leading to the front yard. The gate was locked and did not allow an exit to a location at least 30 feet away from the facility. This gate was not equipped with a device that alerted caregivers of the egress of a resident. 5. In an interview, E2 and E3 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility. 6. In an telephonic interview, E1 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.

Based on observation, documentation review, and interview, the manager failed to ensure pets were licensed consistent with local ordinances. Findings include: 1. The Compliance Officer observed O1 freely roaming in the facility. 2. A review of facility documentation for O1 revealed no documented evidence to indicate O1 was licensed consistent with local ordinances. 3. In an interview, E3 reported being unable to provide documentation of a pet license for O1. 4. In an telephonic interview, E1 reported being unable to provide documentation of a pet license for O1.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies. Findings include: 1. The Compliance Officer observed O1 freely roaming in the facility. 2. A review of facility documentation for O1 revealed no documented evidence to indicate a current rabies vaccination for O1. 3. In an interview, E3 reported being unable to provide documentation of a current rabies vaccination for O1. 4. In an telephonic interview, E1 reported being unable to provide documentation of a current rabies vaccination for O1.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance the individual submitted documentation, dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three residents sampled. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R2's date of admission, to include whether R2 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. In an interview, E1 acknowledged R2's documents were not submitted before or at the time of their acceptance by the assisted living facility.

Based on record review, documentation review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of three residents sampled. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a service plan dated in May 2023. The plan revealed R1 was to receive the following service: -Complete bath 2x per week 2. A review of facility documentation revealed a binder with Activities of Daily Living (ADL) documents. The binder included an ADL document for July 2023 for R1 and revealed R1 received a complete bath on the following day: -July 1, 2023 3. A review of R3's (admitted in 2021) medical record revealed a service plan dated in February 2023. The plan revealed R3 was to receive the following service: -Complete bath 2x per week 4. A review R3's (admittined in 2021 and discharged in 2023) medical record revealed ADL documents. The record included an ADL document for March 2023 for R3 and revealed R3 did not receive a full bath between March 1 and March 14. 5. In an interview, E1 reported residents only receive one full bath a week. E1 acknowledged R1's and R3's service plans indicated R1 and R3 were to receive two full baths a week. E1 reported this seemed excessive and reported the facility only provide one full bath per week, regardless of what the service plan indicated.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's needs required in R9-10-807(B), for one of three residents sampled. Findings include: 1. A review of R3's (admitted in 2021) medical record revealed documentation dated in March 2021, signed and dated by a physician. However, the document was not signed and dated prior to or within 90 calendar days before R3's date of admission. 2. In an interview, E1 acknowledged the manager failed to ensure before or at the time of R3's acceptance, R3 submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation, record review and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. Findings include: 1. The Compliance Officer observed a shared bedroom belonging to R1 and R4. However, the bedroom did not contain a bell, intercom or other mechanical means to alert employees to R4's needs or emergencies. 2. A review of R4's (admitted in 2022) medical record revealed a service plan, dated in June 2023, for personal care services. 3. The Compliance Officer observed a bedroom belonging to R5. However, the bedroom did not contain a bell, intercom or other mechanical means to alert employees to R5's needs or emergencies. 4. A review of R5's (admitted in 2022) medical record revealed a service plan, dated in February 2023, for personal care services. 5. In an interview, E1 acknowledged R4's and R5's bedrooms did not have a bell, intercom or other mechanical means to alert employees of R4's or R5's needs or emergencies.

Based on observation, record review and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving directed care services. Findings include: 1. The Compliance Officer observed a shared bedroom belonging to R1 and R4. However, the bedroom did not contain a bell, intercom or other mechanical means to alert employees to R1's needs or emergencies. 2. A review of R1's (admitted in 2022) medical record revealed a service plan, dated in May 2023, for directed care services. 3. In an interview, E1 acknowledged R1's and R4's shared bedroom did not have a bell, intercom or other mechanical means to alert employees R1's needs or emergencies.

Based on record review, documentation review, and interview, the manager failed to ensure a medication administered to a resident was administered compliance with a medication order, for two of three 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 R1's (admitted in 2022) medical record revealed a service plan dated in May 2023. The service plan stated R1 received "administration of medication." 2. A review of facility documentation revealed a medication administration record (MAR) for R1 dated July 2023. The MAR indicated R1 received the following medications from July 1, 2023 - July 6, 2023: -Buspirone 15 MG - 8 pm -Depakote 125 MG - 8 am and 8 pm -Lasix 20 MG - 8 am -Acetaminophen 500 MG - PRN -Trazodone HCL 100 MG - 8 pm -Quetiapine 25 MG - 8 pm -Potassium 20 MEQ 3. A review of R1's medical record revealed the following medication orders: Signed on July 7, 2023: -Stop Quetiapine 25 MG -Start Quetiapine 50 MG PO BID -Start Amlodipine 5 MG PO daily (Hold if SBP <110 mmHg) -Start Metformin 500 MG PO BID, Signed on May 22, 2023 -Start Lasix 40 MG PO BID -Stop Lasix 20 MG PO Daily -Start Miralax 17 g daily PRN -Start Quetiapine 25 MG PO Daily at HS, and Signed on January 31, 2023: -Change Lasix 20 MG tab to take 1 tab PO PRN for swelling, once a day -Change Potassium to 20 MEQ oral packet, take 1 packet PRN daily PRN only is using Lasix -Change Acetaminophen 500 MG oral liquid, take 15 mL PO BID PRN However, medication orders for Buspirone, Depakote, Lazix 20mg and Trazadone were not available for review. 4. A review of R2's (admitted in 2023) medical record revealed a service plan was not available for review. 5. A review of facility documentation revealed a MAR for R2 dated July 2023. The MAR indicated R2 received the following medications from July 1, 2023 - July 6, 2023:: -Levothyroxine 75 MG - 8 am -Lithium Carbonate 300 MG - 9 AM -Pregablin 150 MG - 8 am, 4 pm and 11 pm -Diazepam 25 MG - 11 pm -Quetiapine Fumarate 50 MG - 11 pm -Morphine 25 MG - 9 am and 6 pm 6. A review of R2's medical record revealed the following medication orders: Signed on June 22, 2023: -Morphine Sulfate 15 MG - One tablet by mouth twice a day (1 in AM, 1 in PM) -Diazepam 2 MG - One tablet at bedtime, Signed on April 26, 2023: -Lidocaine 5% cream - Topical PRN, Signed on April 25, 2023: -Loperamide HCL 2 MG - 1 tablet PRN, Signed on April 22, 2023: -Levothyroxine 75 mcg -1 T QAM -Lithium Carbonate 300 MG - 1 T QD -Pregablin 150 MG - 1 T Q8hrs -Sumatruptan 25 MG - 1 T Q8 hr PRN -Ondasetron HCL 4 MG - 1 T Q6 hr PRN -Quetiapine Fumarate 50 MG - 1 T QHS -Diphenhydramine HCL 25 MG - PRN, and Signed on April 10, 2023: -Seroquil 50 MG - 1 tablet in evening However, medication orders for Diazepam 25mg and Morphine 25mg were not available for review. 7. In an interview, E1 reported all residents, including R1 and R2, received medication administ

Based on record review, documentation review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of three residents sampled. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a service plan dated in May 2023. The service plan stated R1 received "administration of medication." 2. A review of facility documentation revealed a medication administration record (MAR) for R1 dated July 2023. The MAR indicated R1 received the following medications from July 1, 2023 - July 6, 2023: -Buspirone 15 MG - 8 pm -Depakote 125 MG - 8 am and 8 pm -Lasix 20 MG - 8 am -Acetaminophen 500 MG - PRN -Trazodone HCL 100 MG - 8 pm -Quetiapine 25 MG - 8 pm -Potassium 20 MEQ However, medications were not documented as administered to R1's from July 7 - July 11, 2023. 3. A review of R2's (admitted in 2023) medical record revealed a service plan was not available for review. 4. A review of facility documentation revealed a MAR for R2 dated July 2023. The MAR indicated R2 received the following medications from July 1, 2023 - July 6, 2023: -Levothyroxine 75 MG - 8 am -Lithium Carbonate 300 MG - 9 AM -Pregablin 150 MG - 8 am, 4 pm and 11 pm -Diazepam 25 MG - 11 pm -Quetiapine Fumarate 50 MG - 11 pm -Morphine 25 MG - 9 am and 6 pm However, medications were not documented as administered to R2's from July 7 - July 11, 2023. 5. In an interview, E1 acknowledged R1's and R2's MAR had not been initialed to indicate medications had been administered since July 6, 2023. E1 reported all residents had received their medications.

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 the staffing schedule, dated July 2023, revealed the facility maintained the following shifts: -8 am-8 pm (1st shift) -8 pm-8 am (2nd shift) 2. A review of the facility's documented disaster drills revealed the following: -March 3, 2022 - 2nd shift (7:30 pm) -March 3, 2023 - 2nd shift (7:30 pm) 3. In an interview, E1 reported the facility had two shifts. E1 acknowledged the facility had not conducted a disaster drill on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a health and safety risk to residents. Findings include: 1. The Compliance Officer observed an unlocked laundry room that led to an unlocked garage. The following items were accessible to residents and included warning labels: -Lysol liquid cleanser -Great Value multi-purpose cleanser -Laundry detergent -Gain -Comet -Dishwasher pods -Fabric softener -Raid 2. The Compliance Officer observed four ambulatory residents on premises. 3. In an interview, E1 acknowledged the unlocked poisonous or toxic materials were accessible to residents.