Estancia Assisted Living at Discovery Park

Based on documentation review, record review, and interview, the manager of the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). 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.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document 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: (...).” 2. A review of R1 and R2's medical records revealed documentation of the standardized EMS form; however, it did not include the following: The reason or reasons the emergency responder was requested on behalf of the resident; 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; 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. 3. A review of R3's medical records revealed documentation of the standardized EMS form; however, it did not include the following: 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; 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. 4. A review of R4's medical records revealed no documentation of the standardized EMS form at the time of the inspection. 5. In an interview, E1 acknowledged that the standardized emergency responder form was not fully completed for R1, R2, and R3, and that the form for R4 was not provided to the Compliance Officers. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness 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 E3's personnel revealed documentation of E3's freedom from infectious TB that was less than 12 months old. However, based on E3's date of hire, this documentation was not completed before E3 began providing services at the facility. 3. In an interview, E3 reported that E3 provided physical health services at the facility prior to obtaining the freedom from infectious TB documentation. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided according to the resident's service plan for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's service plan lists the following services to be provided by the facility: bathing, twice daily and as needed; laundry, daily and as needed. 2. A review of R2's medical record revealed documentation of R2's activities of daily living (ADL) for the month of August 2025. This ADL documentation revealed only the following: bathing, however, it was only documented as completed on August 8 and August 15 instead of being completed twice daily and as needed. laundry, however, it was only documented as completed on August 8 and August 15 instead of being completed daily and as needed. 3. In an interview, R2 reported R2 received all required services in the month of August 2025. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that medication stored by the facility 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 an environmental inspection of the facility with E1, the Compliance Officers observed medicated ointment in the bedroom of R3 labeled "Diclofenac Sodium Topical Gel, 1% (NSAID)". 2. A review of R3's medical record revealed no documentation that R3 self-administered medication. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed a refrigerator in the dining room area that did not contain a thermometer. 2. During an environmental inspection of the facility, E1 confirmed the refrigerator was actively being used to store food for residents. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of R2's medical record revealed an incident report concerning a recent fall dated for August 17, 2025. This fall resulted in the resident needing medical services. 2. A review of R2's medical record revealed R2's incident report was missing documentation of the names of individuals who observed the accident, the actions taken by the caregiver or assistant caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. R2's incident report contained a section labeled "Based on investigational findings, describe prevention measures implemented", however, the answer was left blank. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers found a bottle of disinfectant spray in an unlocked laundry room. The Compliance Officers also found two cans of Febreze air freshener spray in a kitchen drawer. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.