Crossroads Assisted Living

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. Findings include: A review of the facility's policies and procedures, last reviewed and approved February 6, 2025, revealed a policy titled "Fall and Injury Policy and Procedure." This policy stated, "The manager or her Designee will ensure that all caregivers at the time of their employment will review the Fall and Injury Policy and Procedure before providing services to the residents." However, the policy did not cover all staff and did not include continued competency training. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure compliance with A.R.S. § 36-411(C)(4), for two of two sampled personnel. A.R.S. § 36-411(C)(4) states: "4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee." Findings include: A review of E1's and E3's personnel records revealed documentation of verification each employee was not on the adult protective services registry, dated on or before March 31, 2025, was not available for review. Based on E1's and E3's dates of hire, this documentation was required. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

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, for one of two sampled residents. Findings include: A review of R1's medical record revealed a baseline TB screening form dated 9 months prior to R1's date of occupancy. However, the baseline screening form included a TB skin test read 15 months prior to R1's date of occupancy. A TB skin test dated within 12 months prior to R1's date of occupancy was not available for review. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, for two of two sampled residents who required behavioral care, the manager failed to ensure a resident's service plan included the psychosocial interactions or behaviors for which the resident requires assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. Findings include: 1. A review of R1's medical record revealed a signed list of medication orders, dated January 2, 2026. The list included orders for Depakote, Klonopin, Naltrexone, and Risperidone, and listed the following diagnoses: 1. Moderate alcohol inducted major neurocognitive disorder, nonamnestic confabulatory type, without use disorder. Onsite: 12/09/2025; 2. Bipolar disorder, in full remission, most recent episode depressed, onset: 12/09/2025." 2. A review of R1's medical record revealed a service plan, dated October 29, 2025, for personal care services including medication administration. The service plan stated R1's medical diagnosis and history included, "bipolat 1, moderate alcohol induced major neurocognition" (sic). However, the service plan did not include the psychosocial interactions or behaviors for which R1 required assistance, psychotropic medications ordered for R1, planned strategies and actions for changing R1's psychosocial interactions or behaviors, and goals for changes in R1’s psychosocial interactions or behaviors. 3. A review of R2's medical record revealed a signed list of medication orders, dated December 3, 2025. The list included the following orders : "Divalproex, 250 mg 24 hr ER, taken seven tablets by mouth at bedtime for mood"; "Hydroxyzine, 25MG, take one tablet by mouth twice a day for anxiety"; "Risperidone, 4mg Tab, take one tablet by mouth at bedtime for clear thinking related to schizophrenia and psychosis"; and "Sertraline, 100MG tab, take two tablets by mouth every day for obsessive compulsive disorder." 4. A review of R2's medical record revealed a service plan, dated October 20, 2025, for personal care services including medication administration. The service plan stated R2's medical diagnosis and history included "schizophrenia." However, the service plan did not include the psychosocial interactions or behaviors for which R2 required assistance, psychotropic medications ordered for R2, planned strategies and actions for changing R2's psychosocial interactions or behaviors, and goals for changes in R2’s psychosocial interactions or behaviors. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure the service plan for a resident who required behavioral care was reviewed by a medical practitioner or behavioral health practitioner, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a signed list of medication orders, dated January 2, 2026. The list included orders for Depakote, Klonopin, Naltrexone, and Risperidone, and listed the following diagnoses: 1. Moderate alcohol inducted major neurocognitive disorder, nonamnestic confabulatory type, without use disorder. Onsite: 12/09/2025; 2. Bipolar disorder, in full remission, most recent episode depressed, onset: 12/09/2025." 2. A review of R1's medical record revealed a service plan, dated October 29, 2025, for personal care services including medication administration. The service plan stated R1's medical diagnosis and history included "bipolat 1, moderate alcohol induced major neurocognition" (sic). However, the service plan had not been reviewed or signed by a medical practitioner or behavioral health professional. 3. A review of R2's medical record revealed a signed list of medication orders, dated December 3, 2025. The list included the following orders: "Divalproex, 250 mg 24 hr ER, taken seven tablets by mouth at bedtime for mood"; "Hydroxyzine, 25MG, take one tablet by mouth twice a day for anxiety"; "Risperidone, 4mg Tab, take one tablet by mouth at bedtime for clear thinking related to schizophrenia and psychosis"; and "Sertraline, 100MG tab, take two tablets by mouth every day for obsessive compulsive disorder." 4. A review of R2's medical record revealed a service plan, dated October 20, 2025, for personal care services including medication administration. The service plan stated R2's medical diagnosis and history included "schizophrenia." However, the service plan had not been reviewed or signed by a medical practitioner or behavioral health professional. 5. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a service plan which was reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f) no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition, for one of two sampled residents. Findings include: A review of R2's medical record revealed R2 had entered hospice services and signed a DNR order on December 12, 2025. A review of R2's medical record revealed a current service plan, dated October 20, 2025, for personal care services. R2's service plan indicated R2 was "full code" and did not include documentation of home health or hospice services. However, based on the date of the on-site inspection, more than 14 days had elapsed since R2 began hospice services. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager retained two of two sampled residents who required behavioral care without meeting the requirements, to include documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. Findings include: 1. A review of R1's medical record revealed a signed list of medication orders, dated January 2, 2026. The list included orders for Depakote, Klonopin, Naltrexone, and Risperidone, and listed the following diagnoses: 1. Moderate alcohol inducted major neurocognitive disorder, nonamnestic confabulatory type, without use disorder. Onsite: 12/09/2025; 2. Bipolar disorder, in full remission, most recent episode depressed, onset: 12/09/2025." 2. A review of R1's medical record revealed a service plan, dated October 29, 2025, for personal care services including medication administration. The service plan stated R1's medical diagnosis and history included, "bipolat 1, moderate alcohol induced major neurocognition" (sic). 3. A review of R1's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of R1's bipolar disorder; reviewed the facility's scope of services; and signed and dated a determination stating the R1's needs were being met at the facility, was not available for review. 4. A review of R2's medical record revealed a signed list of medication orders, dated December 3, 2025. The list included the following orders : "Divalproex, 250 mg 24 hr ER, taken seven tablets by mouth at bedtime for mood"; "Hydroxyzine, 25MG, take one tablet by mouth twice a day for anxiety"; "Risperidone, 4mg Tab, take one tablet by mouth at bedtime for clear thinking related to schizophrenia and psychosis"; and "Sertraline, 100MG tab, take two tablets by mouth every day for obsessive compulsive disorder." 5. A review of R2's medical record revealed a service plan, dated October 20, 2025, for personal care services including medication administration. The service plan stated R2's medical diagnosis and history included "schizophrenia." 6. A review of R2's medical record revealed documentation to demonstrate a behavioral health professional or medical practitioner had examined the resident at least once every six months throughout the duration of R2's bipolar disorder; reviewed the facility's scope of services; and signed and dated a determination stating the R2's needs were being met at the facility, was not available for review. 7. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan included an accurate description of a resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated May 16, 2025 for personal care services. However, the service plan did not document R1's skin conditions or wound care orders, additionally, the service plan included a condition and related service which was not possible due to R1's gender. 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 a caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 4, 2025 for personal care services, which detailed the services the facility would provide to R2. 2. A review of R2's medical record revealed a document titled, "Crossroads Monthly ADL Chart," (ADL) dated August 2025. The ADL documented the services provided to R2 on each day in August 2025. However, the ADL had been left blank for all services provided on both shifts on August 9 and August 10, 2025. 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's medical record contained the date of termination of residency, for one of one sampled residents who no longer resided at the facility. Findings include: 1. A review of R2's medical record revealed a Medical Administration Record (MAR) dated August 2025. The MAR indicated medication had been administered to R2 on the "morning" and "evening" of August 14, 2025, and no medication had been administered after August 14, 2025. 2. A review of R2's medical record revealed a document titled, "Crossroads Monthly ADL Chart," dated August 2025. The ADL indicated services were provided to R2 on the first and second shifts on August 14, 2025 and no services had been provided after August 14, 2025. 3. A review of R2's medical record revealed a date of termination of residency was not available for review. 4. During the on-site inspection, E1 showed the Compliance Officer a document on E1's phone. This document was titled, "Resident Check Out form," and indicated R2's, "Date of Check Out," was August 13, 2025. 5. In an interview, E1 reported this date of discharge was incorrect. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk as the resident was able to elope a second time after their high risk of elopement had been established by a successful elopement. Findings include: 1. A documentation review of facility incident reports revealed an incident report dated July 29, 2025, which stated, "[R1] scape from the facility [R1] jumped out of the window around 4:02. Somebody from police department call [E2] (owner and caregiver on duty) to let [E2] know that [R1] was on Los Lomitos and La Canada, [E2] went there to pick [R1] up. 2. A documentation review of facility incident reports revealed an incident report dated August 5, 2025 at 2:55 PM, which stated, "[E1] went to check [R1]. [E1] notice that [R1] wasn't in [R1's] room and [R1] find the way to open the window and take the alarm off. [E1] start driving on Las Lomitas to see if [E1] can find [R1]. [E1] find [R1] across Las Lomitas and La Canada, [R1] was already with the Sherriff. [E1] transport [R1] back to the facility. We checked on [R1], gave [R1] water and [R1] was fine, we explained the situation to the family, prior this they did 30 day notice. 8/6/2025 We spoke to [R1's representative] we decided to give [R1] 15 day notice. 3. The Compliance Officer observed R1 was present in the facility during the on-site inspection and was going back and forth from R1's room to the living room periodically. The Compliance Officer observed R1's window was secured and could no longer be opened without a tool. 4. In an interview, E1 reported R1 occasionally becomes agitated and wants to leave the facility and threatens to break the windows to get out, but has not yet attempted to break the windows. E1 reported R1 is moving to another facility on August 12, 2025, the day after the on-site inspection. E1 reported R1 had disabled the window alarm because the alarm had not sounded when R1 eloped. E1 reported all exit doors lead to a secured fenced area, but some bedroom windows, including R1's window, lead to an unfenced area. 5. 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 establish, document, and implement tuberculosis (TB) infection control activities. Findings include: A review of E3's personnel record revealed a two-step skin test series. However, a baseline screening questionnaire including a symptom screen and risk assessment was not available for review. A review of R1's medical record revealed documentation of evidence of freedom from TB was not available for review. Based on R1's admission date, TB clearance was required. A review of R2's medical record revealed documentation of a negative skin test. However, a baseline screening questionnaire including a symptom screen and risk assessment was not available for review. Based on R2's admission date, TB clearance was required. In an interview, E1 acknowledged E3's, R1's and R2's records did not contain complete documentation of evidence of freedom from TB.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a water temperature of 131.4º F in a shared bathroom. 2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95º F and 120º F in areas used by residents.