Elite Assisted Living 3

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for two of two sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. 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 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. Review of R1’s medical record revealed a form titled, “Physician’s Orders.” However, the form did not contain the following information: The name, address and telephone number of the resident's current pharmacy. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. Basic information about the resident's physical and mental conditions and basic medical history, such as

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB), for one of two employees who had or was expected to have more than eight hours of direct interaction with residents. The deficient practice posed a high potential health and safety risk to residents and staff of TB exposure. 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)..." 2. Review of E2's personnel record revealed two negative TB skin tests and a signs or symptom screening. However, documentation of assessing risk of prior exposure to infectious TB was not available. Based on E2's hire date, this documentation was required. 3. During an interview, E3 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the inspection conducted on April 4, 2024.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a document titled, "Physician Determination Form" dated January 22, 2024. However, it did not include a signature or an electronic signature from a physician, registered nurse practitioner, registered nurse, or physician assistant. A typed name of a nurse practitioner was on the form. 2. In an interview, E3 and E4 acknowledged the “Physician Determination Form" was not signed as required. 3. This is a repeat deficiency from the inspection conducted on June 25, 2024.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1’s medical record revealed a current written service plan dated March 3, 2025. The service plan indicated R1 received medication administration. 2. Review of R1’s medical record revealed a signed medication order dated April 21, 2025 with the original date listed as February 11, 2025. The medication order stated: “Belsomra 10 MG Tablet take 1 tablet by mouth nightly” 3. Review of R1’s medical record revealed a signed medication order dated April 21, 2025 with the original date listed as July 26, 2024. The medication order stated: “Mirtazapine 30 MG tablet take 1 tablet by mouth every night” 4. Review of R1’s medical record revealed an April 2025 medication administration record (MAR). This MAR revealed the following: Belsomra 10 MG was “Med not received” from April 1st- 30th. Mirtazapine 30 MG was “Med not received” from April 7th- 30th. 5. The Compliance Officer observed no available medication for Belsomra 10 MG and an empty blister pack for Mirtazapine 30 MG. 6. In an interview, E3 and E5 reported, “Med not received” means the pharmacy did not deliver the medication to the facility. 7. In an interview, E3 and E4 acknowledged R1’s medications were not administered in compliance with a medication order.

Based on observation, documentation review, and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed an unlocked kitchen cabinet that contained the following: Two spray bottles of Great Value All Purpose Cleaner with Bleach; Two spray bottles of Great Value Multi- Purpose Cleaner; One bottle of Ajax Ultra super degreaser; One spray bottle of Easy Off cleaner Degreaser; and One bottle of Great Value Dishwasher Gel 2. Review of the facility’s policy and procedures revealed a policy titled, “Environmental Standards” which stated, “11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents.” 3. In an interview, E3 and E4 acknowledged the toxic materials were stored in an unlocked area.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 and E2 acknowledged R1's medical record did not include documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed no documentation of R1's residency agreement. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 reported there was no residency agreement with R1 upon R1's admission. E1 acknowledged R1's medical record did not contain R1's residency agreement.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a written notice of termination of residency or date the resident terminated residency, for one of three discharged residents sampled. Findings include: 1. A review of R1's medical records revealed no notice of termination, or the date the resident terminated residency. 2. In an interview, E1 acknowledged there was no documentation of termination in R1's medical records.

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 two of two residents sampled. The deficient practice posed a risk as the Department was unable to verify services were provided by a qualified individual, and the Department was provided false and misleading information. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(26) states "Authenticate 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. At the time of the inspection, the Compliance Officer observed E2, E3, and E4 were the only personnel in the facility. 3. A review of R1's medical record revealed a document titled "ADL's" (activities of daily living) dated April 2024. The document included E3's and E9's initials to indicate E3 and E9 provided assistance to R1 from April 1, 2024 through April 5, 2024. However, the initials were not assigned to a written signature as required per A.A.C. R9-10-101(26)(b). 4. A review of R2's medical record revealed a document titled "ADL's" dated October 2023. The document included E6's and E8's initials to indicate E6 and E8 provided assistance to R2 from October 1, 2024 through October 24, 2024. However, the initials were not assigned to a written signature as required per A.A.C. R9-10-101(26)(b). 5. A review of R1's medical record revealed a medication administration record (MAR) dated April 2024. The MAR reflected E7 administered all of R1's prescribed medication from April 1, 2024 through April 5, 2024. 6. A review of facility documentation revealed a personnel schedule dated April 2024. The schedule reflected E7 was not scheduled to work during the month of April. 7. In an interview, E4 reported E7 was no longer employed at the facility, and the credentials used to sign for R1's medications were not the same as the individual administering the medications.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away 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. A review of facility documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed the back door of the facility allowed a resident to be at least 30 feet away from the facility. However, the door did not control or alert employees of the egress of a resident from the facility. 3. The Compliance Officer observed a door in the master bedroom leading to the back porch allowed a resident to be at least 30 ft away from the facility. However, the door did not control or alert employees of the egress of a resident from the facility. 4. In an interview, E1 acknowledged E1 failed to ensure the means of exiting the facility controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility.