Dementia Campus Assisted Living Center

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled, “Opioid Administration," which stated, “B. For residents receiving an opioid medication on an as needed basis (PRN): I. Prior to administration, personnel will assess the resident’s pain level using the PAINAD scale and document the pain level on the resident's progress note. II. After 30 minutes the caregiver will assess the effectiveness of the opioid and document the pain score on the resident’s progress note.” 2. Review of R1’s medical record revealed a signed medication order dated October 14, 2025 which stated, “Hydrocodone 5 mg- acetaminophen 325 mg tablet give ½ tab by mouth twice daily as needed for pain." 3. Review of R1’s medical record revealed a medication administration record (MAR) for October 2025. This MAR showed “Hydrocodone/ APAP 5-325 mg ½ tab” was administered on October 11th, 13th, 15th, 20th, 21st, 23rd, 24th, 28th, and 27th. This MAR did not include the pain level or effectiveness per the policy. 4. Review of R1’s medical record revealed a document titled, “Communication Notes” which stated: October 11, 2025, “PRN hydrocodone/ acetaminophen administered at 1200. PT did not eat breakfast & refused lunch. Resident started to feel better @ 1400…” October 13, 2025 stated “...was given ½ tablet of hydrocodone/ Acetaminophen at 1200 PO at ADC + was effective p 1 hr…” October 15, 2025 stated, “PRN hydro/ Apap administered @ 1200 for HA. Resident returned form ALF from ADC… Headache resolved @ 1400. “ October 24, 2025 stated, "Scheduled Rx administered, but resident continued to ℅ severe back pain hours after. PRN Norco administered @ 930…” October 28, 2025 stated, “Resident watching T.V took meds no issue went to bed after movie hot up x5 to use BR got PRN ointment and Hydro @ 0215 and 0230 slept until 0545 still in pain gave scheduled tylenol then back to sleep no other changes…” 5. Review of R1’s medical record revealed R1’s current service plan dated August 2025, revealed R1 was receiving directed level of care services and medication administration. 6. In an exit interview, the findings were reviewed with E1, E3, and E4 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C)(2), for two of two personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: ... 2. Verify the current status of a person's fingerprint clearance card." 2. Review of E1’s and E2’s personnel records revealed valid fingerprint clearance cards; however, no documentation verifying the current status of each individual’s fingerprint clearance card was available for review. When the Compliance Officer requested documentation of fingerprint clearance card verification, documentation was submitted of verification of the cards the same day as the inspection. 3. A review of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed valid fingerprint clearance cards for E1 and E2. 4. In an exit interview, the findings were reviewed with E1, E3, and E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services to be provided to the resident, for two of two sampled residents. The deficient practice posed a risk if a resident's service plan did not include accurate amounts of services to be provided. Findings include: 1. Upon request to review R1's service plan, the following documentation was provided: -A document titled "Visit Note Report" dated January 6, 2023, which reflected R1 required partial assistance with dressing and reminders for shoes, assistance with showers and shampoo as needed, partial assistance with hair care needs, and reminders for shaving and oral care. However, the amount, type, and frequency required for the aforementioned services were not indicated; -A document titled "Visit Note Report" dated March 17, 2023, which reflected R1 required partial assistance with dressing and reminders for shoes, assistance with showers and shampoos as needed, partial assistance with hair care needs, and reminders for oral care. However, the amount, type, and frequency required for the aforementioned services were not indicated; -A document titled "Visit Note Report" dated August 7, 2023, which reflected R1 required reminders for oral care. However, the amount, type, and frequency required for this service were not indicated; -A document titled "Visit Note Report" dated October 16, 2023, which reflected R1 was independent with toileting but required incontinence care reminders. However, the amount and frequency required for this service were not indicated; and -A document titled "Visit Note Report" dated December 27, 2023, which reflected R1 was independent but required partial assistance with dressing, reminders for oral care, and assistance with showers and shampoos, as needed. 2. Upon request to review R2's service plan, the following documentation was provided: -Documents titled "Episode Detail Report", "Patient Information Report", "Client Allergies Report", "Client Medication Report", "Medical Record Coordination Note Report", "Client Vaccination History Report", "Vital signs Report", "Client Calendar Report", "Oasis Home Health Patient Tracking Sheet", "Wound Assessment Tool Report", and "Wound Record Report." None of these documents included the amount, type, or frequency of assisted living services required by R2; -A document titled "Visit Note Report" dated July 5, 2023, which reflected R2 required partial assistance with dressing and personal care related to shoes, assistance with shampoo as needed, and partial assistance with oral care. However, the amount, type, and frequency required for the aforementioned services were not indicated; -A document titled "Visit Note Report" dated September 13, 2023, which reflected R2 required full assistance with dressing, partial assistance with shoes, full assistance with hair care, and partial assistance with oral care. However, th

Based on documentation review, oberservation, and interview, the manager failed to ensure documentation of the disaster plan review included the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. The deficient practice posed a risk if employees were unable to implement the facility's disaster plan in an emergency. Findings include: 1. Upon request to review the facility's annual disaster plan review, the following documentation was provided: -A document titled "Record of Review and Distribution" dated April 2023. The document included the names and signatures of employees participating in the review. However, the documentation did not include the time of the review, critique of the review, and if applicable, recommendations for improvement; and -A document titled "Quality Management Program Minutes" dated April 26, 2023. The document stated "EPP (emergency preparedness plan) review was conducted." The document included a critique of the review, date of the review, and the employees participating in the review. However, the documentation did not include the time of thereview. 2. The Compliance Officer observed a calendar on E8's cell phone, which reflected "EPP review and QAPI 10:30-1PM" on April 26, 2023. 3. In an interview, E1 and E8 acknowledged the findings. However, E1 and E8 did not agree that the documentation provided for review was not in compliance with the requirements for a disaster plan review as stated in Arizona Administrative Code (A.A.C.) R9-10-818(A)(3)(a)-(d).

Based on observation, documentation review, and interview, the manager failed to ensure pets were licensed consistent with local ordinances. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a dog on the facility's premises. 2. A review of the facility's pet records revealed no documentation to indicate O3 was licensed consistent with local ordinances. 3. In an interview, E1 acknowledged there was no other documentation available for review to reflect O3 was licensed consistent with local ordinances.