Estancia Assisted Living at Dana Park, LLC

Based on record review and interview, the manager failed to ensure written notification of a resident's elopement was provided to the Department within 24 hours of the elopement being discovered. The deficient practice posed a risk as the facility did not know the whereabouts of a resident. Findings include: 1. A review of facility documentation revealed an incident report documenting an elopement by R1 on November 24, 2025. 2. A review of Department documentation revealed that no notification was made to the Department within 24 hours of the elopement being discovered. 3. In an exit interview, the findings were reviewed with E4 over the phone and no additional information was provided.

Based on record review and interview, for two of two employees reviewed, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. A review of E1's personnel record did not include documentation of the facility's good-faith effort to contact E1's previous employers. 3. A review of E2's personnel record did not include documentation of the facility's good-faith effort to contact E2's previous employers. 4 . In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four residents sampled. The deficient practice posed a TB exposure risk to residents. 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. A review of R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Based on R3's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. A review of R3's medical record did not include documentation the resident's service plan was signed and dated by the resident or resident's representative and manager for the service plan dated August 20, 2025. Based on R3's admission date, this documentation was required to be complete. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of four sampled resident records that were reviewed who had resided at the assisted living facility for more than 12 months. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R3's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccine. Based on R3's acceptance date, this documentation was required. 3. In an exit interview the findings were reviewed with E4 and no additional information was provided.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed there were two shifts. 2. A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times: -February 11, 2025 at 9:30 am -May 11, 2025 at 10:00 am 3. In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented. 4. In an exit interview the findings were reviewed with E4 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two personnel sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures (reviewed and approved April 20, 2023) revealed a policy titled, "Personnel." The policy stated, " ... A caregiver is required to meet all the requirements for an assistant caregiver as well as the following: ... C. Have their CPR and First Aid Card provided by a hand on service (can not be completed online)." 2. A review of E2's personnel record revealed current documentation of E2's CPR/First Aid training from the "National CPR Foundation" issued July 8, 2023 and valid for two years. However, the CPR training did not include a hands-on demonstration of techniques as required. 3. In an email exchange, a representative from the "National CPR Foundation," stated, "Our courses are online only." 4. In an interview, E1 and E2 acknowledged E2's personnel record did not include current CPR training with hands-on demonstration as required.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the activities of daily living according to the resident's service plan for two of two residents sampled. The deficient practice posed a risk to the health and safety of the resident as the resident was not provided with the services required. Findings include: 1. A review of R1's medical record revealed a service plan dated January 23, 2024. Under the title, "Mobility" the service plan stated, "Bed Ridden, Wheel Chair, Hoyer Lift, Fall Risk, Needs Supervision; Requires Positioning: Yes, 2 hour(s)." 2. A review of R1's "Tasks and ADL's Log" revealed positioning was not listed as a service provided to R1. 3. A review of R2's medical record revealed a service plan dated February 26, 2024. Under the title, "Mobility" the service plan stated, "Bed Ridden, Wheel Chair, Fall Risk; Requires Positioning: Yes, 2 hour(s)." 4. A review of R2's "Tasks and ADL's Log" revealed positioning was not listed as a service provided to R2. 5. In an interview, E1 reported R1 and R2 were repositioned at every brief change, which was documented as being provided at 6:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM. 6. In an interview, E1 and E2 acknowledged R1 and R2 did not receive assisted living services according to R1's and R2's service plan, as being repositioned at every brief change was not provided every two hours. E1 and E2 also acknowledged the repositioning services in R1's and R2's service plan were not documented as required.