Deanne Assisted Living

The manager failed to ensure a resident's written service plan was signed and dated by the manager for one of four residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s medical record contained a service plan dated November 19, 2025, which was not signed by the manager. 2. A review of R4’s medical record contained a service plan dated December 3, 2025, which was not signed by the manager.  3. In an interview, E1 reviewed and acknowledged R1’s and R4’s service plans did not have a signature from E2.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of four sampled residents. Findings include: 1. A review of R4’s medical record revealed a service plan dated November 28, 2025, for personal level of care. R4's service plan revealed R4 would be provided the following assistance: pressure sore monitoring/care, staff will report any skin issues to nurse, staff will apply lotion to skin after shower, assess skin daily, medication administration services, eating assistance of meal set up and meats cut, requires total care in bathing assistance two to three times weekly, required total care assistance with dressing daily and as needed, total assistance with grooming (hair care, oral care, and nail care), resident was bed bound and required total caregiver assistance with transfers, total care in toileting assistance every two hours. There was no documentation of services provided to R4. 2. In an interview, R4 reported not being fed for an entire day on multiple days, not being repositioned as reported to R4’s representative, occasionally the catheter bag was full and not changed, and the caregivers are sometimes rough when providing care, and the caregivers do not provide R4 nighttime care unless R4’s family is present. 3. In an interview, E1 acknowledged that there was no documentation available for review to reflect that the above services were provided to R4.

Based on record review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. During an interview, R4 reported that on multiple occasions they were not fed for an entire day, were not repositioned as staff had reported to their representative, and that their catheter bag was sometimes left full. R4 also stated that caregivers were occasionally rough when providing care and did not provide nighttime care unless R4’s family was present. 2. A review of R4’s medical record revealed there was no documentation of any services provided to R4 since R4’s admission. 3. In an interview, E1 denied that services were not provided; however was not able to provide documentation that the above services were provided. This is a repeat deficiency from the complaint investigation conducted on April 5, 2024.

Based on documentation review, record review, observation, and interview, the manager failed to ensure that documentation of medication administration showed the name and signature of the individual administering or providing assistance in the self-administration of medication for three of four residents reviewed. The Department was provided with false and misleading information. Findings include: 1. A review of documentation contained a policy and procedure titled “recording of medication assistance provided to residents and maintenance of medication record,” which stated “6. The trained caregiver will sign off the medication for the date and time the medication was given to the resident and the medications taken by initialing the medication administration record or completing the PRN flow sheet." 2. A review of R1, R2, and R3’s medical records revealed E4 documented the above resident’s medications were administered their 8 am medication dosage by E4. 3. Upon arrival, the compliance officer observed E2 and E3 to be the only staff at the facility. E5 arrived approximately 35 minutes later. During the survey, E2, E3, and E5 were the only staff present for the duration of the survey. 4. In an interview, E5 reported it was E4’s day off, and it would be E2 and E3 scheduled to work for the remainder of the day. 5. In an interview, E3 reported not being logged into the medication documentation system under E3’s credentials, and was logged into E4’s credentials, and it did not record E3’s signature.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, and was documented in the resident’s medical record, for two of four sampled residents. Findings include: 1. A review of R2’s medical records revealed the following medication orders dated November 25, 2025: THEO-24 CAP 100MG take one capsule by mouth every 8 PM and hold if heart rate is more than 85 bpm, Midodrine 10MG tablet three times daily, hold if systolic blood pressure is less than 120. 2 A Review of R2’s medical record contained a document titled “medication administration record” dated November 2025, which stated R2 was administered Theo 24 cap 100 mg and Midodrine 10 mg from November 1, 2025, through November 31, 2025. However, R2’s heart rate or diastolic blood pressure was not taken before administration of the above medications as required by the medication order. 3. A review of R1’s medical record contained the following medication orders dated November 25, 2025: SENNA tablet 8.6-50 MG one tablet by mouth two times a day; Hydrochlorot 25MG one tablet by mouth daily; Citalopram 40MG one tablet daily, Levothyroxine 112 MCG one tablet by mouth daily, Simvastatin 40 mg one tablet by mouth every night; and Trazodone 100 MG one tablet every night. 4. A review of R1’s medical record contained a document titled “medication administration record" dated November 2025, which reflected that R1 was not administered any medications on November 8, 2025. There was no order to withhold R1’s medications. There was no documentation in the record to reflect that R1 was away from the facility. 5. In an interview, E5 reviewed the medical records of R1 and R2, and acknowledged there was no documentation to reflect that the residents were administered medication in compliance with a medication order, and it was documented in the residents’ medical records. This is a repeat deficiency from the complaint investigation conducted on April 5, 2024.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for three of three sampled employees. Findings include: 1. A review of E1's, E2's and E3's personnel records revealed documentation of negative TB tests. However, documentation of TB screening conducted by the facility was not available for review. 2. In an interview, E1 acknowledged E1's, E2's, and E3's personnel records did not contain documentation of freedom from TB as specified in A.A.C. R9-10-113.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB) as required in Arizona Administrative Code (A.A.C.) R9-10-807(A), for three of three residents sampled. Findings include: 1. A review of R1's, R2's and R3's medical records revealed documentation of negative TB tests. However, documentation of TB screening conducted by the facility was not available for review. 2. In an interview, E1 acknowledged R1's, R2's, and R3's medical records did not contain documentation of freedom from TB as required in A.A.C. R9-10-807(A).

Based on observation and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. Findings include: 1. During the environmental inspection of the facility, at approximately 12:30 PM, the Compliance Officer observed E2 and E3 preparing hot dogs and chips for lunch. The Compliance Officer also observed a posted menu dated April 2024. For lunch on April 9, 2024 (the date of the inspection), the menu stated "TACO TUESDAY, refried beans, salad, fruit, milk/tea, PBJ sandwich and soup." 2. In an interview, E2 reported tacos were not served for lunch on April 9, 2024 because the meat did not thaw in time. 3. In an interview, E1 acknowledged the food menu did not include any food substitutions no later than the morning of the day of meal service with a food substitution.

Based on documentation review and interview, when the manager had a reasonable basis to believe abuse, neglect, or exploitation occurred on the premises, the manager failed to initiate and document an investigation of the abuse, neglect, or exploitation within five working days. The deficient practice posed a risk if a resident was not adequately protected from abuse, neglect, or exploitation. Findings include: 1. A review of Department documentation revealed a report of an incident received on April 3, 2024. The complaint alleged a resident (later identified as R1) arrived to a medical center on February 9, 2024 with multiple pressure injuries, injuries from incontinence, and bruising. 2. A review of facility documentation revealed no documentation of an initiated investigation of the reported neglect of R1. 3. In an interview, E1 reported Adult Protective Services visited the facility regarding allegations R1 was neglected.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk of physical and/or psychosocial harm. Findings include: 1. In an interview, R4 reported E3 yelled profanity at R4 because R4 dropped a pill on the floor. R4 also reported witnessing other residents being yelled at. 2. In an interview, R3 reported the caregivers were "tough." R3 did not provide any further context. 3. A review of Department documentation revealed a report stating the following: "[E4] insisted on exposing R2 and began to pull roughly on R2's newly placed Foley bag and tube...[E4] was profoundly rough with R2 and spoke to R2 unkindly and rudely." 4. In an interview, E1 acknowledged the interview statements were accurate, and reported being unaware of the above concerns of any violations of the resident rights to be treated dignity, respect, and consideration.

Based on documentation review, observation, record review, and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for three of four residents sampled. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance, and the Department was provided false and misleading information. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(26) states "[a]uthenticate" means "to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record; c. A rubber-stamp signature; or d. An electronic signature code." 2. The Compliance Officer arrived at the facility at approximately 2:00 PM on April 5, 2024. At the time of arrival, the Compliance Officer observed E3 present at the facility. E2 and E4 accompanied the Compliance Officer from a survey at a different licensed facility under the same ownership conducted between approximately 11:00 AM and 1:30 PM on April 5, 2024. 3. A review of R1's, R2's, and R3's medical records revealed documents titled "ADLs" (activities of daily living) dated March 2024 and April 2024. The ADL documentation included E3's initials to indicate E3 provided assistance with activities of daily living to R1, R2, and R3 from April 1, 2024 through April 5, 2024. However, the initials were not assigned to a written signature or name. 4. A review of R1's, R2's, and R3's medical records revealed medication administration records (MARs) dated April 2024. The MARs reflected E2 administered all of R1's, R2's, and R3's prescribed medications from April 1, 2024 through noon on April 5, 2024. However, E2 was not present at the facility at noon on April 5, 2024. 5. In an interview, E4 reported the credentials used to sign for R1's, R2's, and R3's medications were not the same as the individual administering the medications.

Based on record review and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of four sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R3's medical record revealed a service plan dated December 27, 2023. The service plan reflected R3 received medication administration services. R3's medical record also contained a medication administration record (MAR) dated April 2024. The April 2024 MAR reflected R3 was not administered any medications from April 1, 2024 through April 4, 2024. 2. A review of R3's medical record revealed the following medication orders: -"Pantoprazole 40 mg (milligrams) tablet once daily" dated September 22, 2023; -"Lantus inject 40 units every night" dated October 21, 2023; -"Potassium 20 meq (milli-equivalent units) once daily in the morning" dated November 8, 2023; -"Quetiapine 50 mg one tablet at night" dated January 19, 2024; and -"Nifedipine 30 mg one tablet at bedtime" dated March 16, 2024. 3. In an interview, E4 acknowledged there was no documentation available for review to reflect R3's medication was administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for three of three residents sampled. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed an updated service plan, dated in January of 2023, for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 2. A review of R2's (admitted in 2021) medical record revealed an updated service plan, dated in January of 2023, for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 3. A review of R3's (admitted in 2023) medical record revealed an updated service plan, dated in February of 2023, for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 4. In an interview, E1 acknowledged the service plans were not signed and dated by the residents or residents' representatives.

Based on documentation review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of the facility's policies and procedures revealed an undated document titled "Caregiving Series Volume 5 - Fall Prevention." However, the document did not include the initial training and continued competency training requirement nor did it address fall recovery. 2. A review of E2's personnel record revealed a Continuing Education Unit, dated September 18, 2022. However, the certificate was issued from a caregiver training school. 3. A review of E3's personnel record revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 4. A review of E4's personnel record revealed a Continuing Education Unit, dated September 18, 2022. However, the certificate was issued from a caregiver training school. 5. In an interview, E1 acknowledged the facility's document did not discuss the facility's training program or the frequency required for personnel to be trained. E1 also aknowledged E3 did not have any documentation of fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one resident sampled who was admitted in 2023. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. A review of R3's medical record revealed a written service plan. However, based on R3's acceptance date, the service plan was completed after the 14 calendar day requirement. 2. In an interview, E1 acknowledged R3's service plan was not completed within 14 calendar days after R3's date of acceptance.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. The Compliance Officer observed a refrigerator, in the kitchen, storing food. The refrigerator thermometer read 50\'b0F. A second thermometer read 48\'b0F. The Compliance Officer used a Department-issued thermometer and the temperature read 45.9\'b0F. 2. In an interview, E1 acknowledged the kitchen refrigerator temperature was not maintained at 41\'b0F or below.