Cest Lavie Home

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411. The deficient practice posed a risk if E1 was a danger to a vulnerable population. Findings include: 1. A review of E1’s personnel record, revealed no documentation of the Adult Protective Services (APS) Central Registry check completed as required. 2. Review of https://des.az.gov/APSRegistry revealed that E1 did not appear to be on the APS Central registry. 3. In an interview, E1 acknowledged the manager failed to ensure that E1's personnel record was in compliance with the APS central registry requirements.

Based on record review, documentation review and interview, the manager terminated a resident without notice who was not exhibiting behaviors that were an immediate threat to the health and safety of the resident or other individuals in the assisted living facility. Findings include: 1. A review of the residency agreement signed by R1 on May 9, 2025 revealed that the residency agreement could be terminated by the facility without notice "the resident's behavior poses a threat to the health or safety of others in the facility". 2. A review of R1's "Communication Log"', revealed that the resident was not exhibiting out-of-control behaviors when the facility had the resident transported to the hospital on June 6, 2025. 3. A documentation review of the facility's Policies and Procedures titled, "Termination of Residency" stated that "a residency may be terminated without notice for out-of-control behaviors, 14 days notice for non payment, and 30 days notice for any other reason. 4. In an interview, E1 revealed that R1 should have been given a 14 days notice of termination for non payment. There was no written documentation to show that the resident was given a 14-day notice for non payment. E1 acknowledged that R1 was terminated without notice but not exhibiting out-of-control behaviors.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for R2. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident. Findings include: 1. A review of R2's medical records revealed no written service plan. Based on R2's date of admission, a written service plan was required. 2. In an interview, E1 acknowledged that there was no service plan completed within 14 days after R2's date of acceptance.

Based on record review, documentation review, and interview, the manger failed to ensure that a caregiver immediately notified a resident’s emergency contact, primary care provider, and document the date and time of the accident or emergency, a description of the accident, emergency, or injury, actions taken by the caregiver, the individuals notified by the caregiver, and action taken to prevent the accident, emergency or injury from occurring in the future. Findings include: 1. A review of R1's medical record revealed progress notes which reported that R1 sustained a bloody face from scratching wounds. EMS was called because the resident was in pain. The resident was transported to the hospital. 2. A review of the facility's Policies and Procedures revealed a policy titled, " Accident, Incident, or Injury", which included a standardized 'Incident Report Form" that was to be completed following an incident. 3. A review of R1’s medical records revealed no incident report made regarding R1's need to be transported to the hospital. 4. In an interview, E1 acknowledged that there was not an incident report regarding R1's injuries and transportation by EMS to the hospital.

Based on observation and interview the manager failed to ensure that food was obtained, prepared, served, and stored with potentially hazardous food being refrigerated at a temperature maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection, the Compliance Officer observed that a package of raw ground beef on the kitchen counter. 2. In an interview, E1 revealed that the food was thawing in preparation for dinner. E1 acknowledged that potentially hazardous food was not maintained at 41° F or below.

Based on record review and interview, the manager failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review R2's medical records revealed no prefilled Emergency Medical Services (EMS) Face Sheet readily available. 2. In an interview, E1 acknowledged that the facility did not maintain a standardized form for R2 that included the information as prescribed.