Country Oaks LLC

Based on record review and interview, the assisted living home failed to maintain a copy of documentation provided to an emergency responder for two of six residents reviewed. The deficient practice posed a risk if the Department was unable to verify the required documentation was provided during a resident emergency. Findings include: 1. A.R.S. § 36-420 requires: Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. 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. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives. 2. A review of R4's medical record revealed a document titled "Incident/Accident Report" that revealed the facility contacted emergency medical services (EMS) on May 5, 2025, and R4 was transported to the hospital. 3. A review of R6's medical record revealed a document titled "Incident/Accident Report" that revealed the facility contacted EMS on January 22, 2025, and R6 was transported to the hospital. 4. A review of faci

Based on observation, documentation review, and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a kitchen refrigerator where an unlocked medication storage container held the following medications: -Lorazepam Oral Concentrate; 2mg/mL; and -Morphine Sulfate Oral Solutions; 100mg per 5 mL (20 mg/mL). 2. A review of facility documentation revealed a policy titled "Medications." The policy stated, "...A. All resident medications must be secured in a locked storage area...D. Medications requiring refrigeration need to be kept in a lock container in the refrigerator...E. Controlled Substances... a. Some facilities elect to have narcotic medication double locked..." 3. In an exit interview, the findings were reviewed with E4 and E5 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the names of individuals who observed the accident, emergency, or injury and any action taken to prevent the accident, emergency, or injury from occurring in the future when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, for two of six residents sampled. Findings include: 1. A review of R2's medical record revealed an incident report dated February 2, 2026. The incident report revealed R2 had an accident, emergency, or injury and was taken to the hospital. However, the document did not include the names of individuals who observed the accident, emergency, or injury and any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. A review of R6's medical record revealed an incident report dated January 22, 2025. The incident report revealed R6 had an accident, emergency, or injury and was taken to the hospital. However, the document did not include any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. In an exit interview, the findings were reviewed with E4 and E5, and no additional information was provided.

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9), for three of three sampled residents. Findings include: 1. A review of R1's, R2's and R3's medical records revealed standardized emergency responder forms were not available for review. 2. In an interview, E1 and E2 acknowledged medical records for R1, R2, and R3 did not contain standardized emergency responder forms as required by this statute.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of four personnel members sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E4's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 3. In an interview, E1 and E2 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E4 was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three personnel records sampled. The deficient practice posed a risk if the employee was unable to meet the needs of a resident. Findings include: 1. A review of facility documentation revealed a policy titled "Staffing Documentation and Recordkeeping." The policy stated " ...1. A facility manager shall ensure that a file is maintained on the premises for each employee containing the following ...the individual's completed orientation..." 2. A review of E5's personnel record revealed E5 worked as a facility caregiver and had a hire date of September 2024. The personnel record revealed no documentation that showed E5 received orientation specific to the duties to be performed. 3. In an interview, E1 and E2 acknowledged E5's personnel record did not include documentation showing E5 received orientation that was specific to the duties to be performed.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a risk of a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental tour of the facility with O1, the Compliance Officer observed an unlocked outdoor storage shed. Inside the storage shed, the Compliance Officer observed an unsecured oxygen container that was not in an upright position. 2. In an interview, O1 acknowledged that an oxygen container was not secured in an upright position.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility with O1, the Compliance Officer observed a shed in the backyard. The Compliance Officer observed the shed door was left ajar and unlocked. Inside the shed, the Compliance Officer observed containers of Glidden Interior Paint and Glidden Premium Interior Paint and Primer. 2. In an interview, O1 acknowledged combustible or flammable liquids stored by the assisted living facility were not stored in a locked area inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual dated March 15, 2019. However, documentation to indicate the facility's policies and procedures were reviewed and updated at least once every three years was not available for review. 2. In an interview, E4 acknowledged the facility's policies and procedures had not been reviewed at least once every three years. This is a repeat deficiency from the compliance inspection completed on June 20, 2022.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's education and experience applicable to the individual's job duties, for one of three caregivers sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs. Findings include: 1. A review of E2's (hired in 2022) personnel record revealed E2 was hired as a caregiver. However, documentation of E2's education and experience to work as a caregiver was not available for review. 2. In an interview, E4 reported E2 had documentation of E2's education and experience. However, the documentation was not provided for review during the inspection or during the exit interview.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed in-service education, for one of three caregivers sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed an undated policy and procedure titled "Fall Prevention and Fall Recovery." The policy and procedure stated "...3. All staff will now be required to have an ongoing training that will cover Fall Prevention and Recovery at least once every 12 months ..." 2. A review of E4's personnel record revealed documentation of initial training in fall prevention and fall recovery dated in January 2022. However, documentation to indicate training in fall prevention and fall recovery was completed at least once every 12 months was not available for review. 3. In an interview, E4 acknowledged E4 had not completed training in fall prevention and recovery at least once every 12 months.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit 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 four ambulatory residents on the premises. 2. The Compliance Officer observed an unlabeled medication bottle in an unlocked caregiver's sleeping quarters belonging to E3. 3. The Compliance Officer observed an unlocked refrigerator in the kitchen. The refrigerator contained unlocked Morphine Sulfate Oral Solution belonging to R4. 4. In an interview, E4 acknowledged the medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.