Cascades of Tucson

Based on observation and interview, a licensee failed to ensure the center did not implement a modification described in subsection (C) until an approval or amended license is issued by the Department. Findings include: 1. During a tour of the facility, the Compliance Officers observed the dining room was being renovated. The dining room was closed to residents and not being used, though the remodel was almost complete. However, upon leaving the dining room, residents were observed eating in an enclosed hallway, or breezeway, which connected the dining room with the lobby area. 2. In an interview, E1 reported the construction of the breezeway was included in the renovation and was new construction. E1 reported the facility did have permits for the work being completed. 3. A review of Department documentation revealed no evidence of a modification application or notification to the Department of the modification of the licensed property, prior to implementing the breezeway as usable space. 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 governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for three of ten personnel records reviewed. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: … 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459…” 2. A review of E4's personnel record revealed E4 was hired before January 1, 2025. The review revealed no documentation the governing authority checked the Adult Protective Services (APS) Registry for E4. 3. A review of E7’s personnel record revealed E7 was hired before March 31, 2025. The review revealed no documentation the governing authority checked the (APS) Registry for E7. 4. A review of E8’s personnel record revealed E8 was hired after March 31, 2025. The review revealed no documentation the governing authority checked the APS Registry for E8. 5. A review of the Arizona Department of Economic Security, Adult Protective Services (APS) Registry at https://hsapps.azdhs.gov/ls/sod/SearchAPS.aspx?type=APS revealed E4, E7, and E8 were not on the APS registry. 6. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for four of ten resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R4's medical record revealed R4 received directed care level services. Further review of R4's medical record revealed a document titled "Care Tracking Sheet" for August 2025. The document recorded the service provided and initials of the person who provided the service. 2. A review of R4's Care Tracking Sheet revealed the following spots with a dash mark. According to the key, a dash mark indicates, “Care Scheduled but not Recorded”: - “Activity Reminder”, on August 9, 2025; - “Assurance Checks”, on August 9, 24, 25, and 26, 2025; - “Cognitive Assistance”, on August 9, 2025; - “Dressing Assistance”, on August 9, 2025; - “Escorts”, on August 9 and 25, 2025; - “Grooming Reminders”, on August 9, 2025; and - “Oral Care Reminders”, on August 9, 2025. 3. A review of R6's medical record revealed R6 received directed care level services. A review of R6's Care Tracking Sheet revealed the following spots with a dash mark. According to the key, a dash mark indicates, “Care Scheduled but not Recorded”: - “Activity Reminder”, on August 9, 2025; - “Assistive Device Assistance”, on August 9, 2025; - “Assurance Checks”, on August 9, 24, 25, and 26, 2025; - “Cognitive Assistance”, on August 9, 2025; - “Device Reminders”, on August 9, 2025; - “Dressing Reminders”, on August 9, 2025; - “Escorts”, on August 9 and 25, 2025; - “Grooming Reminders”, on August 9 and 25, 2025; - “Hydration Assistance”, on August 9, 2025; - “Oral Care Reminders”, on August 9, 2025; and - “Toileting – Light Assistance”, on August 9, 2025. 4. A review of R7's medical record revealed R7 received directed care level services. A review of R7's Care Tracking Sheet revealed the following spots with a dash mark. According to the key, a dash mark indicates “Care Scheduled but not Recorded”: - “Assurance Checks”, on August 24 and 25, 2025 5. A review of R8's medical record revealed R4 received personal care level services. A review of R8's Care Tracking Sheet revealed the following spots with a dash mark. According to the key, a dash mark indicates “Care Scheduled but not Recorded”: - “Activity Reminder”, on August 9, 2025; - “Assistive Device Assistance”, on August 9, 2025; - “Assurance Checks”, on August 9, 25, and 26, 2025; - “Catheter Assistance”, on August 9, 2025 - “Cognitive Assistance”, on August 9, 2025; - “Depression Monitoring”, on August 9, 2025; - “Dressing Assistance”, on August 9, 2025; - “Escorts”, on August 9, 2025; - “Fall Risk Intervention”, on August 9, 2025 - “Grooming - Cueuing”, on August 9, 2025; - “Hearing Aid Assistance”, on August 9, 2025; - “Meal Assistance”, on August 9, 25, and 26, 2025; - “Mobility Assistance”, on August 9, 2025; -

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility incident reports revealed an incident report for R2, dated June 26, 2025, and documented how R2 was treated without dignity or respect. The report indicated the incident occurred on June 14, 2024, involving a skin tear to the upper arm of R2. 2. The investigation of the incident documented, on June 26, 2025, E13 approached E1 to report additional information on the incident that occurred on June 14, 2025. E13 reported E11 was providing care to R2 when a skin tear occurred. According to the investigation, E12 and E13 reported providing first aid to R2, when R2 reported to E12 and E13 that E11 caused the skin tear. The documentation further reported E12 was unsure if E12 was supposed to put in an incident report that E11 caused the skin tear, and did not include the information in the initial incident report. 3. The investigation included an interview with R2’s medical provider who reported the injury appeared to be a skin tear with bruising in the shape of a hand, and possibly the skin tear occurred in the course of providing care, as R2 had very fragile skin, and someone was too scared to report the incident. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for two of ten resident records reviewed. 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 R2's medical record revealed a signed medication order dated June 18, 2025 for "Midodrine HCI Oral Tablet 5 MG… Give one tablet (5 mg) by mouth twice daily for low systolic blood pressure. Hold if SBP is more than 130.” 2. A review of R2’s Medication Administration Record (MAR) dated August 2025 revealed the following administration of Midodrine: - Midodrine was held on August 2, 2025. R2’s blood pressure was recorded as 111/68; - Midodrine was held on August 4, 2025. R2’s blood pressure was recorded as 92/48; - Midodrine was held on August 5, 2025. R2’s blood pressure was recorded as 104/78; - Midodrine was held on August 6, 2025. R2’s blood pressure was recorded as 112/49; - Midodrine was held on August 7, 2025. R2’s blood pressure was recorded as 122/79; - Midodrine was held on August 8, 2025. R2’s blood pressure was recorded as 117/67; - Midodrine was held on August 10, 2025 in the morning. R2’s blood pressure was recorded as 97/56; - Midodrine was held on August 10, 2025 in the evening. R2’s blood pressure was recorded as 123/67; - Midodrine was held on August 11, 2025. R2’s blood pressure was recorded as 90/55; - Midodrine was held on August 12, 2025. R2’s blood pressure was recorded as 99/65; - Midodrine was held on August 13, 2025. R2’s blood pressure was recorded as 82/48; - Midodrine was held on August 14, 2025 in the morning. R2’s blood pressure was recorded as 127/73; - Midodrine was held on August 14, 2025 in the evening. R2’s blood pressure was recorded as 120/69; - Midodrine was held on August 15, 2025. R2’s blood pressure was recorded as 92/61; - Midodrine was held on August 17, 2025. R2’s blood pressure was recorded as 95/54; - Midodrine was held on August 18, 2025. R2’s blood pressure was recorded as 107/69; - Midodrine was held on August 20, 2025. R2’s blood pressure was recorded as 98/57; - Midodrine was held on August 21, 2025. R2’s blood pressure was recorded as 101/58; - Midodrine was held on August 25, 2025. R2’s blood pressure was recorded as 106/60; - Midodrine was held on August 26, 2025. R2’s blood pressure was recorded as 92/56; - Midodrine was given on August 3, 2025. R2’s blood pressure was recorded as 137/77; - Midodrine was given on August 11, 2025. R2’s blood pressure was recorded as 132/80; - Midodrine was given on August 17, 2025. R2’s blood pressure was recorded as 136/78; - Midodrine was given on August 20, 2025. R2’s blood pressure was recorded as 135/77; and - Midodrine was given on August 25, 2025. R2’s blood pressure was recorded as 137/78. 3. A review of R8's medical record revealed a medication order dated August 8, 2025, that ordered “Fu