Dina's Assisted Living Home

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 a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental tour, the Compliance Officers observed a bag of medication on a book shelf. The Compliance Officers observed the following unlocked medications: - Atenolo 25mg 1 TAB PO QD - Buspirone HCL 5mg 1 TAB PO BID - Senna Plus 8.6mg - 50mg 2 TAB PO HS - Tramadol HCL 50mg 1 TAB PO QD 2. In an interview, E1 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review, record review, and interview, for two of two residents reviewed, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04. The deficient practice posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A.R.S. 36-420.04.A states, "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 (HIPAA) 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 the medical records for R1 and R2 did not include a standardized form for each resident that included the information as required in A.R.S. 36-420.04. 3. In an interview, E1 acknowledged the documentation provided to the Compliance Officers did not include the required information prescribed in A.R.S. 36-420.04.A.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if employees were unable to implement the disaster plan in an emergency. Findings include: 1. A review of facility documentation revealed that a review of the facility's disaster plan was last conducted on October 1, 2022. 2. In an interview, E1 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113, for two of two personnel reviewed. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)... c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;" 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's personnel record revealed that E1 was hired on May 01, 2022. A review of E1's personal records revealed no documentation of annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed. 4. A review of E2's personnel record revealed E2 was hired on December 01, 2024. A review of E2's personnel record revealed a negative TB skin test that was less than 12 months old, however, no additional documentation of freedom from infectious TB was available for review. Based on E2's hire date, this documentation was required. 5. In an interview, E1 acknowledged that E1's and E2's personal records revealed no documentation as specified in R9-10-113. 6. Technical assistance was provided on this Rule during the compliance inspection conducted on June 20, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed documentation indicating the policies and procedures were reviewed by the previous manager on March 6, 2021. 2. During an interview, E1 acknowledged there was no documentation indicating the facility's policies and procedures were reviewed by the manager once every three years and updated as needed.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officers observed that medical records for R1, R2, and R3 were stored on a bookshelf located in the dining area. The Compliance Officers also observed visitors coming and going throughout the morning. 3. In an interview, E1 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on record review, observation, and interview, the manager failed to ensure medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed an April 2025 (MAR). The MAR revealed R1 received medication administration for the following medication from April 1, 2025, to the morning of April 25, 2025. - Trazodone 150mg 1 TAB PO QHS 2. A review of R1's medical record revealed R1 received medication administration. A review of R1's medical record revealed documentation for an order for "Trazodone 150mg 1 Tab PO QHS. " However, the document was not signed by a medical practitioner. 3. In an observation of R1's medication, Trazodone 150mg was available. 4. A review of R2's medical record revealed an April 2025 MAR. The MAR revealed R2 received medication administration for the following medication from April 1, 2025, to the morning of April 25, 2025. - Trazodone 50mg 1 TAB PO QHS 5. A review of R2's medical record revealed R2 received medication administration. A review of R2's medical record revealed no documentation for an order for "Trazodone 50mg 1 Tab PO QHS. " 6. In an observation of R1's medication, Trazodone 150mg was available. 7. In an interview, E1 reported the above-mentioned medication was administered. E1 acknowledged that R1 and R2 received medication administration without a signed medication order.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed an April 2025 medication administration record (MAR). The MAR revealed R1 received medication administration for the following medications from April 1, 2025, to the morning of April 25, 2025. - Omeprazole 20mg 1 TAB PO BID - Furosemide 40mg 1 TAB PO QD - Citalopram 40mg 1 TAB PO QD - Diltiazem HCI ER 180 mg 1TAB PO QD - Trazodone 150mg 1 TAB PO QHS However, the MAR did not have documentation indicating the medications were administered from the evening of April 25, 2025, to the present. 2. A review of R2's medical record revealed an April 2025 MAR. The MAR revealed R2 received medication administration for the following medications from April 1, 2025, to the morning of April 25, 2025. - Senna Lax 8.6mg 1 TAB PO QD - Trazodone 50mg 1 TAB PO QHS However, the MAR did not have documentation indicating the medications were administered from the evening of April 25, 2025, to the present. 3. In an interview, E1 reported the above-mentioned medications were administered evening of April 25, 2025, to the present. E1 acknowledged R1's and R2's medical records did not include documentation the medications were administered.

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. Findings include: 1. A review of E3's personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 reviewed E3's personnel record and acknowledged E3's record revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E3 reviewed E3's personnel record and acknowledged E3's record revealed no documentation of fall prevention and fall recovery training. E3 reported E3 believed E3 did receive the training, however, the documentation could not be located.

Based on documentation review, record review, observation, and interview, the manager accepted and retained a resident who were confined to a bed or chair because of an inability to ambulate even with assistance, without documentation from the resident or resident's representative requesting the resident be accepted by or remain in the assisted living facility, and without a determination from a medical practitioner which stated that the residents' needs could be met by the facility. Findings include: 1. A review of the facility records revealed the facility is licensed for Directed level of care. 2. A review of R1's medical record revealed a directed care service plan completed on the date of R1's admission to the facility. The service plan identified R1 as "bed bound." The medical record did not contain documentation from the resident or resident's representative requesting the resident be accepted by or remain in the assisted living facility until February 20, 2023 and did not contain a determination from a medical practitioner which stated that the resident's needs could be met by the facility until August 23, 2022. 3. In an interview, E1 reviewed R1's medical record. E1 acknowledged R1 was admitted to the facility and identified as "bedbound." E1 acknowledged R1's medical record did not contain documentation at the time of admission to demonstrate the resident or resident's representative requesting the resident be accepted by or remain in the assisted living facility, and without a determination from a medical practitioner which stated that the residents' needs could be met by the facility.

Based on observation, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. Findings include: 1. During a facility tour with E1, the Compliance Officer observed that R1 did not have a bell, intercom, or other means to alert employees to needs or emergencies. The surveyor observed no other means to alert a caregiver to R1's needs. 2. In an interview with E1, E1 acknowledged that R1 did not have a bell, intercom, or other means to alert employees. E1 reported R1 "can't use one." E1 reported R1 makes "noises" to alert staff. 3. In an interview, the compliance officer provided R1 with a bell from an empty resident room. The compliance officer asked R1 if R1 could use the bell to alert staff of R1's need for assistance. R1 shook his head and proceeded to demonstrate R1 could ring the bell. 4. In an interview, E1 acknowledged R1 was able to use the bell to alert staff of R1's needs. E1 acknowledged the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies

Based on observation, documentation review and interview, the manager failed to insure a pest control program in compliance with R3-8-201.C.4, which states in part "[a]n individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator..." was implemented. Findings include: 1. During a tour of the facility, the Compliance Officer observed two bottles of Ortho Home Defense Insect Killer. 2. A review of the facilities policies and procedures revealed a policy titled "Environmental and Physical Plant Standards." The policy stated " Manager or maintenance individual will check, spray preventively document monthly for pest control. If pest activity is found, a professional pest control company will be employed to provide pest control services." 3. In an interview O1 reported O1 uses the identified spray to spray the rocks around the facility pool. O1 reported O1 is not a licensed applicator. 4. In an interview, E1 acknowledged the facilities policies and procedures are not in compliance with R3-8-201.C.4. E1 acknowledged the facility was not utilizing a certified applicator to address the facilities pest control policy. E1 acknowledged the manager failed to insure a pest control program in compliance with R3-8-201.C.4 was implemented.