Cogir of Gilbert

Based on documentation review and interview, the health care institution failed to develop a training program for all staff which included initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of facility documentation revealed a program which included when staff would receive initial training and when staff would receive competency training in fall prevention and fall recovery was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E4, E5, and E6, and no additional information was provided.

Based on documentation review and interview, the assisted living center failed to provide a written document which covered A.R.S § 36-420.04.A.1-9, when the assisted living center contacted an emergency responder on behalf of the resident, for four of five residents sampled. Findings include: 1 . A review of R1's medical record revealed an incident where R1 was sent to the hospital by the facility on April 25, 2025. However, documentation of a written document presented to emergency medical services (EMS) that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of incident was not available for review at the time of inspection. 2 . A review of R2's medical record revealed an incident where R2 was sent to the hospital by the facility on September 10, 2025. However, documentation of a written document presented to EMS that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of incident was not available for review at the time of inspection. 3 . A review of R3's medical record revealed an incident where R3 was sent to the hospital by the facility on August 24, 2025. However, documentation of a written document presented to EMS that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of incident was not available for review at the time of inspection. 4 . A review of R4's medical record revealed an incident where R4 was sent to the hospital by the facility on May 2, 2025. However, documentation of a written document presented to EMS that included all items covered under A.R.S § 36-420.04.A.1-9 at the time of incident was not available for review at the time of inspection. 5 . In an exit interview, the finding was discussed with E4, E5, and E6, and no additional information was provided.

Based on documentation review and interview, the assisted living center failed to maintain 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, for five of five residents sampled. Findings include: 1 . A review of R1's, R2's, R3's, R4's, and R5's medical records revealed no documentation of an emergency medical services (EMS) standardized form available for review at the time of inspection. 2 . In an interview, E5 reported the facility was currently working on a standardized form. 3 . In an exit interview, the findings were discussed with E4, E5, and E6 and no additional information was provided.

Based on record review and interview, the healthcare institution failed to document in the patient’s medical record an identification of the patient’s need for the opioid before the opioid was administered, for two of nine residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R2's medical record revealed a signed medication order, dated February 23, 2025, for Tramadol HCl 50 milligrams (mg), 2 tablets by mouth (po) three times a day (tid). 2. A review of R2's medication administration record (MAR), for March 2025, revealed R2 was administered Tramadol HCl 50 mg, 2 tablets po, at 6:00 AM, 12:00 PM, and 6:00 PM, March 1, 2025 - present. However, the MAR did not include documentation of the facility's assessment of R2's need before the Tramadol HCL 50 mg was administered. 3. A review of R6's medical record revealed a signed medication order, dated February 21, 2025, for Tramadol HCl 50 mg, 0.5 tablet po twice a day (bid). 4. A review of R6's MAR, for March 2025, revealed R6 was administered Tramadol HCl, 0.5 tablet po, at 8:00 AM and 7:00 PM on March 1, 2025 - present. However, the MAR did not include documentation of the facility's assessment of R6's need before the Tramadol HCL 50 mg was administered. 5. In an interview, E2 acknowledged R2's and R6's medical records did not include documentation of R2's and R6's need for the opioid before the opioid was administered to R2 and R6.

Based on observation, documentation review, and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the facility’s refrigerator used for resident food storage on the third floor memory care kitchen area to have a temperature reading of 57° F displayed on a digital thermometer on the outside of the refrigerator. 2. A review of the refrigerator’s internal thermometer revealed a reading of 49° F. 3. In an interview, E1 reported that the facility had ordered a new refrigerator on March 17, 2025, to replace the faulty refrigerator. 4. A review of facility documentation revealed that a replacement refrigerator was ordered on March 17, 2025. However, at the time of inspection resident's food was stored in the old refrigerator. 5. In an interview, E2 acknowledged that foods requiring refrigeration were not maintained at 41° F or below. Technical assistance was provided regarding this rule during the compliance and complaint inspection conducted on February 22, 2024 - February 23, 2024.

Based on documentation review and interview, the assisted living center failed to maintain a copy of the document provided to the emergency responder for a period of two years after the date of the emergency. Findings include: 1. A review of Department documentation revealed a resident suffered an accident, illness, or injury that resulted in the resident needing emergency medical services on the following dates: December 15, 2024; and December 29, 2024. 2. A review of the facility emergency responder information revealed a standardized form for each resident to be provided to emergency medical services in the case of an emergency. However, the documentation provided was not maintained for a period of two years following the date of the emergency. 3. In an interview, E2 reported the facility provided the required documentation to emergency medical services; however, E2 acknowledged the documentation provided was not maintained for a period of two years after the date of the emergency.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of the facility's documentation revealed an evacuation drill that was conducted on October 18, 2023 during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during the past 12 months. 2. In an interview, E1 acknowledged there was no documentation of an evacuation drill for employees and residents conducted at least every six months, as required, during the past 12 months.

Based on observation and interview, the manager failed to ensure that soiled linens stored by the assisted living facility were stored in a closed container away from food storage, kitchen, and dining areas which posed a health risk. Findings included: 1. During a tour of the facility's central kitchen, E2 and the compliance officer observed an uncovered bin one-quarter full of soiled linen sitting in the kitchen. 2. In an interview, E2 acknowledged the facility was storing uncovered soiled linen in the kitchen which could pose a health risk.

Based on observation, record review, and interview, the manager failed to ensure two sampled dogs residing at the facility were licensed consistent with local ordinances. Finding include: 1. During a facility tour, E2, E3 and the compliance officer observed two dogs residing at the facility, O1 and O2. 2. The compliance officer requested and was not provided with any documentation that O1 and O2 had a current license from Maricopa County Animal Care and Control. 3. In an interview, E2 acknowledged there was no record that O1 and O2 had a current license, as required.

Based on record review and interview, the manager failed to ensure one of eight sampled residents' service plans was updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition which posted a health and safety risk in the care of the resident. Findings include: 1. Review of R6's current service plan dated January 30, 2024 stated the resident was now unable to ambulate even with assistance. 2. R6's medical record contained a documented determination dated January 4, 2024 indicating R6's needs could be met even though unable to ambulate even with assistance. 3. In an interview, E3 reported R6 prior to the end of December 2024 was able to ambulate with assistance, however, at the end of December R6 could no longer could walk even with assistance and a determination was completed. E3 acknowledged that R6's service plan had not been updated within 14 calendar days of this significant change in R6's condition, as required.

Based on document review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. During the review of the facility's documents, the compliance officer requested and was not provided documentation of the current disaster plan review for the past 12 months. There was documentation of an annual disaster plan review that was dated January 27, 2023. 2. In an interview, E2 acknowledged there was no documentation available that the disaster plan was reviewed during the past 12 months, as required.