Davis Place

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of four employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. ARS § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to:[...](3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee. (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." 2. A review of E1's, E2's, E3’s, and E4's personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. In an interview, E1 acknowledged that good faith efforts were not made to verify that each employee was not on the adult protective services registry.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for a caregiver included current documentation of first aid (FA) and cardiopulmonary resuscitation (CPR) training for three of three caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation staff schedules for May 2025 through July 2025 revealed E2 and E4 worked numerous shifts throughout the month. 2. A review of E1's personnel record revealed CPR certification; however, no FA. 3. A review of E2's personnel record revealed E2 was hired in July 2024 until July 18, 2025. E2’s personnel record revealed no FA. E2’s personnel record also revealed CPR in the personnel record; however, the CPR had expired on May 17, 2025. (E2 worked from July 2024 until July 18, 2025.) 4. A review of E4's personnel record revealed no current documentation of FA and CPR training. (E4 worked from May 2025 until July 22, 2025.) 5. In an interview, E1 reported that E2 worked from July 2024 until July 18, 2025. E1 reported that E4 worked from May 2025 until July 22, 2025. 6. In an interview, E1 acknowledged that E1 had no FA. E1 acknowledged E2 had no FA, and E2’s CPR had expired on May 17, 2025. E1 also acknowledged E4 had no CPR or FA. This is a repeat citation from an inspection conducted on June 13, 2024.

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for one of four caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E2's personnel record revealed no documented verification of E2's skills and knowledge. 2. In an interview, E1 acknowledged that E2’s personnel record did not include documented verification of skills and knowledge at the time of the inspection.

Based on record review and interview, the manager failed to ensure a written service plan included how medication would be stored and controlled, for one resident reviewed who stored medication in the bedroom. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's record revealed a service plan dated February 19, 2025. This service plan stated "Self Admin..." However, this service plan did not indicate how the medication would be stored and controlled. 2. In an interview, E1 reported R1 manages R1's own medications and acknowledged that R1's service plan did not indicate how the medications would be stored and controlled.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for three of seven sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of a resident. Findings include: 1. A review of R3's medical record revealed a current service plan for personal care services dated April 17, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. A review of R6's medical record revealed a current service plan for personal care services dated April 17, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. A review of R7's medical record revealed a current service plan for personal care services dated January 08, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 4. In an interview, E1 acknowledged that R3's, R6's, and R7's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services, included offering sufficient fluids to maintain hydration, for two of seven residents sampled who received personal care services. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated February 19, 2025. However, the service plan did not include offering sufficient fluids to maintain hydration. 2. A review of R5's medical record revealed a service plan for personal care services dated April 23, 2025. However, the service plan did not include offering sufficient fluids to maintain hydration. 3. In an interview, E1 acknowledged R1's and R5's service plans for personal care services did not include offering sufficient fluids to maintain hydration.

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 Officers observed a water temperature of 132.9º F in R6’s room. 2. In an interview, E1 acknowledged that the hot water temperatures were not maintained between 95º F and 120º F in the area used by the resident.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the inspection of the facility, the Compliance Officer observed R1 at the front desk located at the front of the facility. The Compliance Officer and E2 walked R1 back to R1’s room. During the inspection, O1 entered the facility with R1 through a secured door. O1 reported O1 had tracked R1 by R1’s phone when O1 noticed R1 was not in R1’s room via a camera that was placed in R1’s room to monitor R1 by O1. O1 reported R1 was about half a mile away from the facility when O1 located R1. R1 had scrapes on the right knee and left palm of R1’s hand. R1 was provided first aid by a caregiver to clean the wounds. 2. In an interview, E2 reported the facility front door alert had not alerted to notified staff of R1's egress from the facility. E2 acknowledged the staff was unaware of R1’s egress due to the front door alerts not sounding when R1 opened the front door of the facility.

Based on documentation review and interview, the manager failed to ensure that a food menu is maintained for at least 60 calendar days after the last date noted on the menu. Findings include: 1. Two months of menus were requested. No menus were available for review. 2. During an interview, E2 stated, "I don't have that." 3. During an interview, E2 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure a current therapeutic diet manual was available for use by employees when the assisted living facility offered therapeutic diets. Findings include: 1. During an interview, E2 indicated that the facility offered therapeutic diets and that R6 was currently on a therapeutic diet. 2. The record for R6 contained a physician's order indicating the resident required a diabetic diet. 3. The facility therapeutic diet manual was the Becky Dorner Diet manual with a copyright date of 2008. Internet review of the manual's web site revealed that there was a more current edition available for use. 4. During an interview, E2 acknowledged a current therapeutic diet manual was not available for use by employees.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E2 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility documentation failed to reflect that disaster drills had been conducted. 2. During an interview, E2 acknowledged that no documentation of employee disaster drills was available for review.

Based on record review and interview the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of the record for E1 (hired November 1, 2023), failed to reveal documentation that fall prevention and fall recovery training had been administered. 2. This is an uncorrected deficiency from the survey conducted on June 15, 2024. 3. During an interview, E2 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on record review and interview, the governing authority failed to ensure that three of five sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety (DPS), or an application for a fingerprint clearance card completed, within 20 working days of employment. Findings include: 1. The record for E5 (start date October 29, 2022) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the DPS. 2. The record for E2 (start date November 8, 2023) contained a DPS fingerprint clearance card, however, there was no documentation present in the record reflecting that DPS was contacted to verify that the fingerprint clearance card remained valid. 3. Review of the DPS web site revealed that the card was valid. 4. The record for E1 (start date November 1, 2023) contained a DPS fingerprint clearance card, however, there was no documentation present in the record reflecting that DPS was contacted to verify that the fingerprint clearance card remained valid. 5. Review of the DPS web site revealed that the card was valid. 6. During an interview, E2 acknowledged the required documentation was not in the records.

Based on documentation review and interview, the manager failed to ensure that quality management reports included changes made or actions taken 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 changes made or actions taken as a result of the identification of a concern about the delivery of services related to resident care. 2. During an interview, E2 acknowledged the required documentation was not included in the facility quality management documentation. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Based on record review and interview, the manager failed to ensure that one of five sample employee records for staff who were providing caregiver services, contained documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Findings include: 1. The record for E5 (hired October 29, 2022) did not contain documentation reflecting that the employee had completed a caregiver training program. 2. During an interview, E2 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that three of five sample personnel records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. The record for E1 (Manager, hired November 1, 2023) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review. 2. The record for E5 (Assistant Caregiver, hired October 29, 2022) contained no documentation indicating that a TB test with negative results, was administered on or before the date the individual began providing services to residents. No other TB test documentation conducted within the past 13 months was provided for review. 3. The record for E3 (Caregiver, hired March 13, 2023) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 4. During an interview, E2 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure for two of five sample records, that before providing services to a resident, a manager or caregiver provided documentation of first aid training certification. Findings include: 1. The record for E1 (hired November 1, 2023) failed to reveal documentation of first aid certification. 2. The record for E4 (hired November 21, 2018), revealed documentation of first aid certification that expired on June 15, 2021. 3. During an interview, E2 acknowledged that the manager and caregiver provided services to residents without documentation of first aid training certification.

Based on observation and interview, the manager failed to ensure that a calendar of planned activities is conspicuously posted for residents to see. Findings include: 1. The posted activity calendar was dated May, 2024. 2. During an interview, E2 acknowledged that a current activity calendar was not conspicuously posted.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months. Findings include: 1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided failed to reveal that resident evacuation drills had been conducted. No other evacuation drill documentation was available for review. 2. During an interview, E2 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a calendar of planned activities was maintained for 12 months after the last scheduled activity. Findings include: 1. The following activity calendars were not available for review: July 1, 2023 - December 31, 2023. 2. During an interview, E2 stated, "We've been running activities I just don't have the documentation." 3. During an interview, E2 acknowledged the required documentation was not available for review.

Based in observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu is served. Findings include: 1. No menu was observed posted in the facility. 2. During an interview, E2 acknowledged that no menu was posted in the facility.

Based on observation and interview, the manager failed to ensure that the premises were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. Observation of the carpeting located in the main hallway between the dining room and kitchen doorway was observed to be heavily soiled. The soiled area was approximately 5' by 3' in diameter and had a dark gray to black appearance. 2. Review of the facility policies and procedures indicated the premises will be maintained in a clean condition. 3. During an interview, E2 acknowledged that the premises was not maintained in a clean condition according to policies and procedures.

Based on documentation review and interview, the manager failed to ensure that the dog that was allowed in the facility, was licensed consistent with local ordinances. Findings include: 1. Review of the file for a dog allowed in the facility (O3), failed to reflect documentation indicating that the dog was licensed. 2. During a telephone interview with the local authority it was determined that the dog required a license. 3. During an interview, E2 acknowledged that facility documentation failed to indicate the dog had a current license. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Based on documentation review and interview, the manager failed to ensure that three of three pets that resided at the facility, were vaccinated against rabies. Findings include: 1. The record for a dog allowed in the facility (O3) contained no documentation indicating that the dog had been vaccinated against rabies. 2. The record for a cat allowed in the facility (O2) contained no documentation indicating that the cat had been vaccinated against rabies. 3. The record for a cat allowed in the facility (O1) contained no documentation indicating that the cat had been vaccinated against rabies. 4. During an interview, E2 acknowledged the documentation available for review failed to reflect the pets were currently vaccinated against rabies. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Based on record review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. Review of the record for E4 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 5. Review of the record for E5 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 6. During an interview, E2 acknowledged that the required documentation was not available.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented 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, E2 acknowledged that the required documentation was not available for review.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff 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 training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. 2. Review of the record for E1 (hired November 1, 2023), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E2 (hired November 8, 2023), failed to reveal documentation of fall prevention and fall recovery training. 4. Review of the record for E3 (hired September 16, 2021), failed to reveal documentation of fall prevention and fall recovery training. 5. During an interview, E2 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on record review and interview the manager failed to ensure that a record for one of three employees included all the information required in sub-sections a. through c. of this rule. Findings include: 1. During an interview, E2 indicated that E1 was employed as the manager of the facility. 2. No personnel record for E1 was available for review. 3. During an interview, E2 stated "(E1) started at the facility as the manager on November 1, 2023." 4. During an interview, E2 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that one of two sample resident records contained a service plan that included the level of service the resident is expected to receive. Findings include: 1. The record for R1 contained a current service plan that did not include the level of service the resident was receiving. 2. During an interview, E2 stated, "The resident is personal care." 3. During an interview, E2 acknowledged the resident record did not contain the required information. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Based on record review and interview the manager failed to ensure for two of two sample service plans, a resident had a written service plan that when initially developed and when updated, is signed and dated by: The resident or resident's representative; The manager; The nurse or medical practitioner who reviewed the service plan. Findings include: 1. Review of the record for R1 (receiving medication administration, personal care services), revealed that the following service plans were not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan: August 22, 2023, September 21, 2023, and February 23, 2024. 2. Review of the record for R2 (receiving medication administration, personal care services), revealed that the following service plans were not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan: August 22, 2023, September 26, 2023, October 8, 2023 and March 5, 2024. 3. During an interview E2 acknowledged the required documentation was not available for review. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 15, 2023.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection can be found, was conspicuously posted. Findings include: 1. Inspection of the facility failed to reveal the posting indicating the location at which a copy of the most recent Department inspection report can be found. 2. During an interview, E1 acknowledged the required documentation was not conspicuously posted.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "monthly" basis. 2. No quality management reports were available for review. 3. During an interview, E2 stated, "I don't have that."

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy. Findings include: 1. The record for R3 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required. 2. During an interview, E1 acknowledged that the record did not contain evidence of freedom from TB before or within seven calendar days after the resident's date of occupancy.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained a service plan that included the level of service the resident is expected to receive. Findings include: 1. The record for R3 contained a service plan dated December 29, 2022 that did not include the level of service the resident was receiving. 2. During an interview, E2 stated, "The resident is Supervisory care." 3. During an interview, E1 acknowledged the resident record did not contain the required information.

Based on record review and interview the manager failed to ensure for three of three sample service plans, a resident had a written service plan that when initially developed and when updated, is signed and dated by: The resident or resident's representative; The manager; If required, the nurse or medical practitioner who reviewed the service plan. Findings include: 1. Review of the record for R1 (receiving medication administration, nursing services, personal care services), revealed that the service plan dated April 23, 2023 was not signed and dated by the resident or their representative. 2. Review of the record for R2 (receiving medication administration, personal care services), revealed that the service plan dated April 23, 2023 was not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan. 3. Review of the record for R3 (receiving supervisory care services), revealed that the service plan dated December 29, 2022 was not signed and dated by the resident or their representative or the manager. 4. During an interview E1 acknowledged the required documentation was not available for review.

Based on record review and interview for one of two sample personal care resident records, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident reside in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs can be met by the facility as per their scope of services. Findings include: 1. During an interview, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs can be met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Based on observation and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members. Findings include: 1. The drug reference guide available for review was the Nursing Drug Handbook, copyright date 2022. 2. The Internet web site for the drug reference guide revealed that a more current edition was available for distribution. 3. During an interview, E2 stated, "That's the most current one I have."

Based on documentation review and interview, the manager failed to ensure that one of two pets that were allowed in the facility, were licensed consistent with local ordinances. Findings include 1. Review of documentation for O3, a dog allowed in the facility, failed to reflect that the dog was licensed. 2. During a telephone interview with the local authority it was determined that the dog required a license. 3. During an interview, E1 acknowledged that facility documentation failed to indicate the dog had a current license.

Based on documentation review and interview, the manager failed to ensure that four of five pets that reside at the facility, were vaccinated against rabies. Findings include: 1. Review of documentation for O2, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies. 2. Review of documentation for O3, a dog that resides in the facility, failed to indicate that the dog was vaccinated against rabies. 3. Review of documentation for O4, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies. 4. Review of documentation for O5, a cat that resides in the facility, failed to indicate that the cat was vaccinated against rabies. 5. During an interview, E1 acknowledged the documentation available for review failed to reflect the pets were currently vaccinated against rabies.