Cerbat House Assisted Living LLC

Based on a record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for two out of three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's service plan revealed various services, such as Oral Care Twice Daily, Dressing Daily and PRN, and Incontinence Checks every 2-3 hours. A review of the activities of daily living revealed missing documentation of services listed above for December 2025: Oral Care PM - 24th, 25th, 26th, 27th, and 28th Dressing PM - 26th Incontinence Checks -26th 2. A review of R2's service plan revealed various services, such as Offer Fluids with snack and meals, Oral Care Twice Daily, Shave, Toileting Full Assist Daily and PRN, Bladder Total Incontinence, Bowel Total Incontinence, and Incontinence Checks every 2-3 hours. A review of the activities of daily living revealed missing documentation of services listed above for December 2025: Dinner: 26th Snack 3 pm and 8 pm: 26th Offer Fluid: 26th Oral Care: 24th, 26th and 28th Dressing: 26th Full Assist: 26th Incontinence Checks: 26th 3. In an interview, R4, R5, and R6 reported that, as far as they know, services were being provided. 4. In an interview, E1 acknowledged that there was some missing documentation of services provided for December.

Based on document review, record review and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the report made to a peace officer or to the adult protective services central intake unit. The deficient practice posed a potential safety risk for residents and a potential rights violation if alleged abuse, neglect, or exploitation was not documented as required. Findings include: 1. A review of facility documentation incident reports revealed three incident reports dated May 14, 2025, and one dated May 15, 2025. The incident reports revealed E2 being physically abusive to several residents. The incident reports also revealed that several staff members reported the incidents after the incident occurred. However, the facility manager failed to report to a peace officer or the adult protective services’ central intake unit. 2. In an interview, E1 acknowledged the facility manager failed to report the incident to a peace officer or the adult protective services’ central intake unit.

Based on document review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a resident rights violation if the resident was subjected to abuse. Findings include: 1. A review of facility documentation incident reports revealed three incident reports dated May 14, 2025, and one dated May 15, 2025. The incident reports revealed E2 had verbally and physically abused several residents. The incident reports also contained reports from several staff members who reported the incidents to management at the facility. 2. In an interview, E1 acknowledged residents were not treated with dignity, respect, and consideration by E2. E1 also reported E2 was immediately terminated from the facility.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for two of three sampled personnel. The deficient practice posed a risk if personnel did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation staffing schedules revealed staffing schedules for the previous three months. The schedules revealed E2 and E3 worked at the facility as a caregiver and/or assistant caregiver on multiple shifts. 2. A review of E2's personnel records revealed no documented verification of E2's skills and knowledge. 3. A review of E3's personnel records revealed no documented verification of E3's skills and knowledge. 3. In an interview, E1 acknowledged E2's and E3's personnel records did not contain documented verification of skills and knowledge before E2 and E3 provided physical health services on behalf of the facility.

Based on record review, documentation review, and interview, the manager failed to ensure a manager, caregiver, or assistant caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for two of three personnel reviewed. The deficient practice posed a risk if a manager, caregiver, or assistant caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed E2 worked as a caregiver. The personnel record revealed an online first aid and CPR card with a completion date of July 2023. 2. A review of E3's personnel record revealed E3 worked as a caregiver. The personnel record revealed an online first aid and CPR card with a completion date of November 2023. 3. A review of facility documentation revealed a First Aid and CPR policy which required personnel to have "current CPR and First Aid cards, specifically for adults, which includes a demonstration of the employee's ability to perform cardiopulmonary resuscitation from a valid/qualified trainer of programs such as:" 4. In an interview, E1 acknowledged current documentation of first aid and CPR training before providing assisted living services was not provided for E2 and E3.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and signed 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, for three of three sampled residents. 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 no documentation indicating whether R1 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. 2. A review of R2's medical record revealed documentation indicating whether R2 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. 3. A review of R3's medical record revealed no documentation indicating whether R3 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. 2. In an interview, E1 acknowledged that a manager failed to ensure R1, R2, and R3 submitted documentation dated within 90 calendar days before R1, R2, and R3 were accepted by the assisted living facility.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of notification of the availability of vaccination for influenza and pneumonia offered to residents on a yearly basis, according to A.R.S. \'a7 36-406(1)(d), for three of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R1's medical record did not contain documentation for 2021-2024 tow show that notification of the availability of vaccination for influenza and pneumonia was offered to R1 on a yearly basis based on R1's date of acceptance. 2. A review of R2's medical record did not contain documentation for 2024 to show that notification of the availability of vaccination for influenza and pneumonia was offered to R2 on a yearly basis based on R2's date of acceptance. 3. A review of R3's medical record did not contain documentation for 2024 to show that notification of the availability of vaccination for influenza and pneumonia was offered to R3 on a yearly basis based on R3's date of acceptance. 4. In an interview, E1 acknowledged R1's, R2's, and R3's medical records did not contain documentation of notification of the availability of vaccination for influenza and pneumonia on a yearly basis.

Based on observation, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of three sampled resident who received medication administration. Findings include: 1. A review of R1's medical record revealed R1 received supervisory care and medication adminstration services. 2. A review of R1's medical record revealed a medication order dated October 25, 2024 for: Quetiapine Fumarate 25 mg oral tablet, two times a day 3. A review of R1's medication administration record (MAR) for December 2024 revealed Quetiapine Fumarate 25 mg was not documented as administered on December 17, 2024 at 8:00 a.m. 1. A review of R2's medical record revealed R2 received directed care and medication adminstration services. 2. A review of R2's medical record revealed a medication order dated January 7, 2025 for: Tramadol HCL 50 mg oral tablet, every eight hours for pain 3. A review of R2's medication administration record (MAR) for January 2025 revealed Tramadol HCL 50 mg was not documented as administered on January 17th and 20th of 2025 at 2:00 p.m. A sticky note was on R2's MAR reminding staff to document administration for these two dates. 4. In an interview, E1 reported that the medications were administered to R1 and R2; however, staff forgot to document the MAR. 5. In an interview, E1 acknowledge E1 failed to ensure a medication administered to a resident was documented in the resident's medical record.