Country Grove LLC

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, both forms were missing the following information: primary care doctor's name and contact information; 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. 2. A review of R2's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, both forms were missing the following information: 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. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the health care institution failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of the facility's documentation records revealed no facility risk assessment for infectious TB was documented and available during the inspection. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 3. Technical assistance was provided on this rule during the inspection conducted on September 28, 2023.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility’s policies and procedures revealed there was no documentation showing they were reviewed at least once every three years. 2. 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 that medication administered to a resident was administered in compliance with a med order for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order dated October 31, 2025. The order included a prescription for the medication Jardiance, 10mg, 1 tablet by mouth daily, hold for SBP less than 110 or HR less than 60. 3. A review of R1’s medication administration record revealed Jardiance, also known as Empagliflozin, was given at 8am on November 1-3, 2025. There was no documentation of doses administered to R1 after November 3, 2025. The verbiage, "no supply" was written next to the dates for the missed doses. 4. A review of R2’s medical record revealed R2’s current service plan dated July 26, 2025. The service plan revealed R2 received medication administration. 5. A review of R2’s medical record revealed a medication list signed and dated by a physician on October 31, 2025. This medication list prescribed the following medications: Metoprolol Tartrate 25 mg 1 tablet by mouth daily. Hold for SBP less than 100 or HR less than 60; Losartan Potassium 25 mg take 1 tablet by mouth daily at bedtime. Hold for SBP less than 110 or HR less than 60. 6. A review of R2’s Medication Administration Record (MAR) revealed R2 received Metoprolol once a day at 8 am, November 1st - present. Their MAR also revealed R2 received Losartan once a day at 8pm, November 1-present. However, there was no documentation of R2's blood pressure or heart rate available for review. 7. In an interview, when the CO asked the facility about the checks for R2's systolic blood pressure (SBP) E1 replied, "they did not do them." 8. 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 that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the caregiver immediately notified the resident’s emergency contact and primary care provider. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R1's medical record revealed an incident report dated October 18, 2025 showing R1 was taken to the hospital. The documentation did not include documentation of immediately notifying the resident’s primary care provider. 2. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the caregiver documented the names of individuals who observed the accident, emergency, or injury. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R1's medical record revealed an incident report dated October 18, 2025 showing R1 was taken to the hospital. The documentation did not include the names of individuals who observed the accident, emergency, or injury. 2. In an interview, E5 reported E5 and E2 both witnessed the incident. 3. In an exit interview, the findings were reviewed with E1 and E2 and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a resident was provided a diet that met the resident's nutritional needs as specified in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as diet orders were not followed. Findings include: 1. The Compliance Officers observed the lunch meal. R1 and R2 were served quarter sized Italian sausage medallions, large chunks of baked potato, and coleslaw. 2. A review of R1's service plan revealed a "Regular PUREE texture, THIN LIQUIDS consistency, Aspiration precaution" diet was required. 3. A review of R2's service plan revealed a "Mechanical Soft" diet was required. 4. A review of the facility's policies and procedures revealed a policy titled "Dining Services" that stated, "A resident is provided a diet that meets the resident's nutritional needs as specified in the resident's service plan". 5. In an interview, E1 acknowledged that the meal served to R1 and R2 was not the appropriate diet requirements according to the service plans.

Based on observation, documentation review, and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officers observed the following hazards: \'b7 In the backyard there was a tile pathway that had broken and cracked tiles. These tiles had sharp edges. \'b7 The sidewalk leading from the back door was uneven and had a large gap. \'b7 The two showers lacked a nonslip mat. \'b7 In the front bathroom there was a yellow towel/throw rug on the floor in front of the shower. 2. A review of the facility's policies and procedures revealed a policy titled "37. Environmental Safety" that stated, "Potentially hazardous situations like cracks in the sidewalk, torn or curling carpet or linoleum, plants, bushes or trees growing over and in common traffic areas should be reported to the manager immediately for correction", "Showers and tubs will have slip proof devices on their floors before any resident may use them", and "Throw rugs are not allowed in the facility". 3. In an interview, E1 and E2 acknowledged the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation, documentation review, and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, in the backyard, the Compliance Officers observed the following toxins unlocked: \'b710 gallons paint \'b71 red container of gasoline \'b71 gallon of Moxie carpet cleaner \'b71 container Armor All tire foam \'b71 container Irwin Straightline Marking Chalk \'b71 container AMS synthetic motor oil \'b71 container Krylon spray paint \'b71 container DAP ready mixed concrete patch \'b71 container Paint thinner 2. A review of the facility's policies and procedures revealed a policy titled "37. Environmental Safety" that stated, "All poisonous or toxic materials will be stored in a labeled containers, locked area and separate from food preparation and storage, dining areas, medications such that they are inaccessible to residents". 3. In an interview, E1 and E2 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

Based on observation, documentation review, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as E3 and E4 were assistant caregivers, and E6, E7, and E8 were not present on the premises and accountable when the manager was not present on the premises. Findings include: 1. The Compliance Officer observed E3 and E4 on the premises alone and working when the Compliance Officer arrived at approximately 12:00 PM. 2. The Compliance Officer observed E1 and E2 arrive on the premises at approximately 12:35 PM. 3. The Compliance Officer observed a document titled "DELEGATION OF AUTHORITY" (dated January 3, 2021) located near the front door. The document stated "...I, [E5] manager of Country Grove LLC...do hereby delegate my authority to the following individual(s)...[E8]...[E7]...[E6]...who are trained caregiver(s), at least 21-years of age..." However, E6, E7, and E8 were not present on the premises and accountable when E5 was not present on the premises. 4. In a joint interview, E1 and E2 acknowledged a designated individual was not present on the premises when the manager was not present on the premises.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, including a demonstration of the employee's ability to perform CPR. The deficient practice posed a risk if E4 was unable to perform CPR. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation and First Aid Requirements" (dated July 3, 2022). The policy stated "...Obtain CPR training specific to adults which includes a demonstration of the individual's ability to perform CPR. (On-line programs do not meet this requirement unless they include a demonstration of the individual's ability to perform CPR)..." 2. A review of E4's (hired in 2023) personnel record revealed E4 was hired as an assistant caregiver. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued June 26, 2022). 3. A review of the NationalCPRFoundation website revealed courses were conducted online. The NationalCPRFoundation website stated, "Help Save Lives Today with Your Online CPR Certification Training!" 4. In a joint interview, E1 and E2 acknowledged E4's online CPR training did not include a demonstration of E4's ability to perform CPR.

Based on observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as E3 and E4 were not qualified to provide the required services. Findings include: A.R.S. \'a7 36-401.A.42. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 1. The Compliance Officer observed E3 and E4 on the premises alone and working when the Compliance Officer arrived at approximately 12:00 PM. 2. The Compliance Officer observed E1 and E2 arrive on the premises at approximately 12:35 PM. 3. The Compliance Officer observed seven residents on the premises. 4. A review of E3's and E4's personnel records revealed E3 and E4 were hired as assistant caregivers. 5. In a joint interview, E1 and E2 acknowledged E3 and E4 were working at the facility and were not supervised by a manager or caregiver.

Based on observation, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for one of two assistant caregivers sampled. The deficient practice posed a risk if E3 was unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E3 and E4 on the premises alone and working when the Compliance Officer arrived at approximately 12:00 PM. 2. A review of E3's (hired in 2023) personnel record revealed E3 was hired as an assistant caregiver. However, documentation of the verification of E3's skills and knowledge was not available for review. 3. In a joint interview, E1 and E2 acknowledged E3's skills and knowledge was not verified and documented prior to E3 providing physical health services.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked cabinet used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed seven residents on the premises. 2. The Compliance Officer observed the following medication on a desk located in the kitchen for R5: -Tramadol HCL 50mg. 3. In a joint interview, E1 and E2 acknowledged the medication was not stored in a separate locked room, closet cabinet, or self-contained unit used only for medication storage.