Cedar Pastures

Based on documentation review, record review, and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs and the Department was provided false and misleading information. Findings include: 1. The Compliance Officer arrived at the facility around 10:00 AM. The Compliance Officer observed E2 and E3, who identified themselves as caregivers, 2. A review of the facility documentation of staff schedule from December 1, 2025, to December 23, 2025, revealed that E2 worked at the facility from 6:00 am to 6:00 pm by themselves. 3. A review of the facility documentation of staff schedule from May 4, 2025, to August 7, 2025, revealed that E3 worked at the facility on shift 6:00 am to 6:00 pm or 6:00 pm to 6:00 am by themselves. 4. A review of the facility documentation of staff schedule for December 2025 revealed no record of E4 working at the facility. 5. A review of E2's personnel record revealed that E2 had been hired in December 2025, and it also revealed a caregiver certificate dated December 28, 2011. However, in an interview, E2 reported that they had arrived in Arizona in 2016, and eventually admitted to the Compliance Officer that they had not taken the caregiver's training program that was in the file. 6. A review of E3's personnel record revealed that E3 had been hired in May 2025. It also revealed that E3 completed a caregiver training program on August 8, 2025. However, in an interview, E3 reported that from May 4, 2025, to August 7, 2025, they had worked at the facility alone and had not completed a caregiver program until August 8, 2025. 7. A request for E4's personnel record revealed no personnel file for E4. The Compliance Officer was unable to confirm if E4 had completed a caregiver’s training program due to no staff at the facility knowing any information about E4. 8. In separate interviews, E2 and E3 reported that E4 had worked at the facility alone on December 20, 2025, and December 21, 2025. 9. In an exit interview, the findings were reviewed with E2, and no additional information was provided. This is a repeat citation from an inspection conducted on January 31, 2025.

Based on observation, record review, and interview, the manager failed to ensure a personnel record was established and maintained for each employee as required for one of four employees sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer arrived at the facility around 10:00 AM. The Compliance Officer observed E2, and E3 identified themselves as caregivers. E1 and E4 were not at the facility at the time of inspection. 2 A request for E4's personnel record revealed no personnel file for E4. 3. In separate interviews, E2 and E3 reported that E4 had worked at the facility alone from December 20, 2025, to December 21, 2025. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record for one of three residents sampled. Findings include: 1. A review of R2’s medical record revealed a November and December 2025 MAR. The MAR listed the following medications: · "Aspirin EC 81mg Take 1 tablet by mouth every day." The medication, however, was only given from November 1st to the 19th, 2025, and no marks were on the MAR to show if this medication was given from November 20 to November 31. 2025. The medication was not given in December 2025, and the reason indicated on the MAR was medication was that the medication was “x - medication out.” 2. A review of R2’s medical record revealed a medication order for: · Aspirin EC 81mg oral capsule: 3. In an interview, E2 reported the did not give the medication to R2 during December 2025. 4. In an interview, E3 reported the did not give the medication to R2 from November 20 to November 31. 2025. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of two residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a written service plan for directed care services dated September 20, 2024. However, a service plan after September 2024 was not available for review. 2. In an interview, E1 acknowledged R1's service plan was not updated at least once every three months.

Violation cited

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster. Findings include: 1. A review of the facility's disaster plan did not indicate the plan was reviewed at least once every 12 months, as required. 2. During an interview, E1 acknowledged the facility did not have documentation the disaster plan was reviewed at least once every 12 months.

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9) for two of two sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review R1's and R2's medical records revealed a standardized form, however the form did not include a copy of the resident's health insurance portability and accountability act (HIPAA) release. 3. In an interview, E1 acknowledged the facility failed to maintain a standardized form for R1 and R2 that included the information required in A.R.S. 36-420.04.A.

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management" reviewed and signed by E1 dated November 3, 2022. This policy stated "a. An Assurance checklist will be performed by manager/caregiver/designee on a regular basis for at least once every 3 month. b. A Quarterly report will be compiled for residents having falls, medication errors, calling 911, weight loss, pressure sores, and residents admitted with C-Diff or MRSA". 2. Review of facility documentation revealed no documentation of a quality management report. 3. During an interview, E1 acknowledged a quality management report was not available for review. This is a repeat deficiency from the inspection conducted on March 3, 2022 and December 8, 2022.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three individuals sampled who was working as a caregiver. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. A review of Department documents revealed the facility was licensed to provide directed care. 2. In an interview, E1 reported E2 was a caregiver. 3. A review of facility documentation revealed a series of personnel schedules which revealed E2 worked regularly as a caregiver between November 2024 and January 2025. 4. A review of E2's personnel record revealed a "CERTIFICATE OF TRAINING" from "Assisted Living Trainers...ALTP 0050" dated as issued on March 1, 2000. Further review revealed E2's certificate stated "Has satisfactorily demonstrated competency in Supervisory Care Level". No other documentation of completing a caregiver training program approved by the Department or the NCIA Board up to the directed care level was available. In addition, E2's record did not include documentation that showed an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. 5. A review of the caregiver certificate verification website (azch.tmutest.com) revealed no valid caregiver certificate under E2's name. 6. In an interview, E1 acknowledged E2 did not have documentation of completing a caregiver training program approved by the Department or the NCIA Board up to the directed care level.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse (RN), 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. A review of R1's medical record revealed a document titled "Determination for Admission." This document was signed by a registered nurse practitioner and dated three days after R1's admission date. Further review revealed the document did not include R1's name. 2. In an interview, E1 acknowledged R1's medical record did not contain the required documentation that was dated within 90 days before R1 was accepted by the facility.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two residents. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of R1's date of occupancy. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged R1's residency agreement did not include the date of occupancy. This is a repeat deficiency from the inspection completed on December 8, 2022.

Violation cited