Christian Care Assisted Living-cottonwood

Based on record review and interview, the manager failed to ensure a written notice of termination of residency included the policy for refunding fees, charges, or deposits, and the deposition of a resident's fees, charges, or deposits, for two of four residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed the following: In R1's medical record, a 14-day notice to vacate, the notice was missing the policy for refund fees, charges, or deposits, and the deposition of the resident's fees, charges, and deposits; and R2's medical record contained a 14-day notice to vacate, which was missing the policy for refund fees, charges, or deposits, and the deposition of the resident's fees, charges, and deposits. 2. In an interview, E1 reported that both R1's and R2's 14-day notices should contain all information required. 3. In an exit 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 resident had a written service plan that was established, documented, and implemented, which, when updated, was signed and dated by the resident or resident’s representative, the manager, and by the medical practitioner who reviewed the service plan, for one of two residents sampled. This posed a health and safety risk if the resident or the resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. A review of R2's medical record did not include documentation that the resident's service plan was signed and dated by the resident or the resident's representative, manager, nurse, or medical practitioner for the service plan dated April 19, 2025. Based on R2's admission date, this documentation was required to be complete. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 3. This is a repeat deficiency from the compliance inspection conducted on May 21, 2024.

Based on record review and interview, the manager failed to ensure the assisted living center maintained a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted, for three of three residents sampled. Findings include: 1 . A review of R1's, R2's, and R3's personnel records revealed documentation of a standardized emergency medical services (EMS) form was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E2 and no additional information was added.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113, for three of three residents sampled. Findings include: 1 . A review of R1's, R2's, and R3's medical records revealed documentation of negative TB skin tests. However, documentation of a TB screening questionnaire was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E2 and no additional information was added.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed an unattended cleaning cart in the hallway. The cart had the following chemicals unsecured and accessible to residents: -A bottle of "Lysol" toilet bowl cleaner; -A bottle of "Simple Green" disinfectant spray; and -A bottle of "Zep" all-purpose cleaner. 2 . In an exit interview, the findings were discussed with E2 and no additional information was added.

Based on record review and interview the health care institution failed to develop policies and procedures for a training program regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program policy and procedure as required in A.R.S. \'a7 36-420.01. 2. During an interview, E2 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a plan is implemented for an ongoing quality management program that includes a method to make changes or take actions as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. Review of the monthly facility quality management reports revealed that the reports did not include a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care. 2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management documentation.

Based on record review and interview, the manager failed to ensure that three of three sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled. Findings include: 1. During an interview, E1 indicated that R1 self-administered some of their medications and stored the medications in their room. 2. The record for R1 contained a service plan dated April 19, 2024 that did not include how the resident's medication would be stored and controlled. 3. During an interview, E1 indicated that R2 self-administered some of their medications and stored the medications in their room. 4. The record for R2 contained a service plan dated February 23, 2024 that did not include how the resident's medication would be stored and controlled. 5. During an interview, E1 indicated that R3 self-administered some of their medications and stored the medications in their room. 6. The record for R3 contained a service plan dated April 8, 2024 that did not include how the resident's medication would be stored and controlled. 7. During an interview, E1, acknowledged the service plans did not indicate how the residents' medications would be stored and controlled in their rooms.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of a service plan that when initially developed and updated, was signed and dated by the nurse or medical practitioner who reviewed the service plan. Findings include: 1. The record for R1 (personal care, receiving medication administration services), contained service plans dated April 19, 2024 and October 19, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan. 2. The record for R2 (personal care, receiving medication administration services), contained service plans dated February 23, 2024 and August 23, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan. 3. During an interview, E1 acknowledged that the service plans did not reflect the dated signature of the nurse or medical professional.

Based on documentation review and interview, the manager failed to ensure that daily social, recreational, or rehabilitative activities are planned. Findings include: 1. Review of 12 months of activity calendars revealed there were no activities noted for Saturdays and Sundays for June through September of 2023. 2. During an interview E1 acknowledged documentation failed to reflect that daily activities were planned and available.

Based on documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. The facility medication administration policies and procedures failed to reveal evidence that the policies had been reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. During an interview, E1 acknowledged that facility residents receive medication administration services. 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. No toxicology guide was available for review. 2. During an interview, E1 stated, "I just ordered that."

Based on documentation review and interview, the manager failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that include policies and procedures for subsections a. through f. of this rule. Findings include: 1. Review of facility policies and procedures failed to reveal documentation indicating that the health care institution had established and documented tuberculosis infection control policies and procedures that include subsections a. through f. of this rule. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.