Eternity Assisted Living LLC

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner or nurse. Findings include: 1. Review of the facility's policies and procedures for medication administration revealed no indication that the policies and procedures were reviewed and approved by a medical practitioner or nurse. 2. During an interview, E1 acknowledged that the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner or nurse.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members. Findings include: 1. The surveyor observed that a current drug reference guide was not available in the facility. 2. In an interview, E1 reported that the facility did not have a current drug reference guide.

Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a health and safety risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of Department documentation revealed the facility's perpetual license was effective on October 30, 2023. 2. The Compliance Officers (CO) arrived at the facility on April 21, 2025, at 11:40 am to conduct a compliance and complaint inspection. The Compliance Officer knocked on the front door. E2 answered the door at 11:47 am and would not let CO inside. E2 returned to the door and reported refusing to let CO inside due to the policy. Volunteer closed and locked the door and reported needing to call E1 to let CO inside. 11:56 am E2 returned to the door and CO was allowed to enter the facility. 3. In an interview, E1 acknowledged E2 failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license.

Based on documentation review, record review and interview, the manager failed to implement tuberculosis (TB) infection control activities that included baseline screening; obtaining documentation of freedom from infectious TB; annually obtaining documentation of the individual's freedom from symptoms of infectious TB (for an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201 1201); 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; annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. A review of the facility’s documentation revealed there was no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 2. A review of E2’s, E3’s, and E4’s personnel files revealed there was no documentation of E2 and E3 being free from infectious TB, and no annual training and education related to recognizing the signs and symptoms of tuberculosis. 3. A review of R2’s medical record and E2’s, E3’s, and E4’s personnel records revealed there was no documentation of a baseline screening available for review. 4. In an interview, E1 reviewed the facility’s documentation, record review, and personnel records. E1 acknowledged that the above required documentation was not available for review at the time of the survey.

Based on documentation review and interview, the manager failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. In documentation review, the facility's Quality Management program showed no documentation of an annual review, as required. 2. During an interview, E1 reported being unaware if an annual review of the Quality Management program was to be completed, as required. E1 acknowledged the facility did not have documentation of a review or evaluation of the effectiveness of the quality management program.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who is present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present. The deficient practice posed a risk as no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. The Compliance Officer arrived at the facility and observed E2 to be the only staff member in the facility with six residents present. E1 arrived at the facility approximately 35 minutes later. 2. The Compliance Officer observed a document titled "Manager's designee" posted on the facility’s wall. The "Manager's designee" form did not indicate E2 was accountable for the facility when the manager was not present. 3. In an interview, E1 acknowledged the "Manager's designee" form did not include E2.

Based on documentation review and interview, the manager failed to ensure a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. A review of the facility’s documentation revealed there was no documentation of a documented report that included an identification of each concern about the delivery of services related to resident care and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. 2. In an interview, E1 reported being unaware that the above documented report was required, and reported that none was available for review.

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for three of three caregivers and assistant caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E1's, E2’s, and E4's personnel records revealed no documented verification of E1's, E2’s, and E4's skills and knowledge. 2. The compliance officer observed E2 to be the only personnel present with six other residents when the compliance officer arrived. 3. In an interview, E1 reported that E4 was employed as a caregiver, and E2 was employed as a volunteer. E1 acknowledged that the personnel records did not include documented verification of skills and knowledge.

Based on record review and interview, the manager failed to ensure that one of three sampled caregivers of the assisted living facility had the skills and knowledge necessary to provide assisted living services, ancillary services, meet the needs of the residents, and ensure the residents' health and safety. Findings include: 1. The compliance officer observed E2 to be the only personnel present with six other residents when the compliance officer arrived. 2. In a request to review E2’s personnel record revealed that E2 did not have a personnel record available for review. Therefore, E2 did not have documented and verified skills and knowledge, no documentation of a caregiver certification, and fingerprint clearance card, and was not checked on the Arizona Adult Protective Services (APS) Registry. There was no evidence that E2 had the skill and knowledge necessary to provide assisted living services, ancillary services, meet the needs of the residents, and ensure the residents' health and safety. 3. In an interview, E1 acknowledged there was no evidence E2 had the skill and knowledge necessary to provide assisted living services, ancillary services, meet the needs of the residents, and ensure the residents' health and safety.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. In a request to review the facility work schedule for the last 12 months, it was revealed there was no documentation available for review to reflect caregivers and assistant caregivers working each day, including the hours worked by each. 2. In an interview, E1 acknowledged there was no documentation available for review that reflected the caregivers and assistant caregivers working each day, including the hours worked by each for the last 12 months.

Based on the record review and interview, the manager failed to ensure before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that was specific to the duties to be performed by the caregiver or assistant caregiver for four of four sampled personnel. Findings include: 1. A review of E1's, E2’s, E3's, and E4's personnel records revealed there was no documentation of orientation completed by E1, E2, E3, and E4. 2. In an interview, E1 acknowledged E1's, E2’s, E3's, and E4's personnel records did not have documentation of orientation.

Based on record review and interview, the manager failed to ensure the amount, type, and frequency of assisted living services being provided to the resident was included in the service plan, for three of three sampled residents. Findings include: 1. A review of R1’s service plan dated October 9, 2024, which did not reflect the amount and frequency of dressing, grooming, toileting, and transfer assistance. 2. A review of R2’s service plan dated February 10, 2025, reflected R2 required assistance with grooming and toileting. However, the frequency of grooming and toileting was not reflected. 3. A review of R3’s service plan dated January 13, 2025, reflected that R3 required assistance with grooming, oral care, and nail care. However, the amount and frequency of grooming, oral care, and nail care were not reflected. 4. In an interview, E1 reported R1 required assistance with dressing, grooming, toileting, and transfers. 5. In an interview, E1 reviewed R1's, R2’s, and R3’s service plans and acknowledged that their service plans did not include the required information.

Based on documentation review, the manager failed to ensure as a part of the policies and procedures, a plan was established, documented, and implemented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work is not available or not able to provide the required assisted living services. Findings include: 1. A review of the facility’s documentation revealed there was no established and documented back-up plan to ensure a manager or caregiver was available to provide assisted living services to six residents. 2. The compliance officer observed E2 to be the only personnel present with six other residents when the compliance officer arrived. 3. A request to review E2’s personnel record revealed that E2 did not have documentation of completion of a caregiver’s program. 4. In an interview, E1 acknowledged the residents were in the facility alone without a manager or caregiver present to provide assisted living services, and there was no back-up plan established, documented, or implemented.

Based on observation review, personnel record review, and interview, the manager failed to ensure a manager or caregiver was present at an assisted living home when a resident was present at the assisted living home. Findings include: 1. The compliance officer observed E2 to be the only personnel present with six other residents when the compliance officer arrived. 2. In a request to review E2’s personnel record, E2 did not have a personnel record available for review. Therefore, E2 did not have documentation of Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 3, In an interview, E1 acknowledged E2 did not have a caregiver certification, and acknowledged the residents were present, but a caregiver and manager were not.

Based on record review and interview, the manager failed to two of four sampled personnel records, including the individual's name, date of birth, and contact telephone number; the individual's starting date of employment or volunteer service; and Documentation of: i. the individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individuals’ education and experience were to their job duties; iii. the individuals’ completed orientation; iv. the individuals’ license or certification vi. evidence of freedom from infectious tuberculosis; vii. Cardiopulmonary resuscitation training; viii first aid training ix; documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C). Findings include: 1. When the compliance officer arrived, the compliance officer observed E2 was the only personnel present with six other residents. 2. The compliance officer observed E3’s manager’s license to be posted inside the facility. 3. In a request to review E2's and E3's personnel records revealed that E2 and E3 did not have personnel records available for review. 4. In an interview, E1 acknowledged there was no personnel record available for review for E2 and E3.

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 assisted living facility accepted the individual, and if the individual requested or expected to receive supervisory care services, personal care services, directed care services or if the individual required: continuous medical services; continuous or intermittent nursing services; or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant; for two out of three sampled residents. 1. A review of R1’s and R3’s medical record revealed R1 and R3 did not have documentation determining if R1 or R3 requested or expected to receive supervisory care services, personal care services, directed care services or if the individual required: continuous medical services; continuous or intermittent nursing services; or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 acknowledged that there was no documentation available to reflect that the above requirements were met.

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident was expected to receive for one of three sampled residents. Findings include: 1. A review of R1’s service plan dated October 9, 2024, did not reflect the level of care R1 was expected to receive. 2. In an interview, E1 acknowledged R1’s service plan did not reflect the level of care R1 was expected to receive.

Based on record review and interview, the manager failed to ensure a one of three sampled residents written service plans when initially developed and when updated, was signed and dated by the resident or the resident’s representative and the manager. Findings include: 1. A review of R1’s medical record revealed the service plan dated April 23, 2024, did not reflect that R1’s service plan was signed and dated by R1 or R1’s representative, or by the manager. 2. In an interview, E1 reviewed and acknowledged that R1’s service plan did not reflect that R1’s service plan was signed and dated by R1 or R1’s representative, or by the manager.

Based on record review and interview, the manager failed to ensure that a caregiver or assistant caregiver documented the services provided to three of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated April 23, 2024. R1's service plan reflected that R1 required assistance with bathing twice weekly, dressing, grooming daily, oral care, nail care, and toileting daily. There was no documentation to reflect that these services were provided to R1 since R1’s admission. 2. A review of R2's medical record revealed a service plan dated February 10, 2025. R2's service plan reflected that R2 required assistance with bathing twice weekly, grooming daily, oral care, and incontinence care daily. There was no documentation to reflect that these services were provided to R2 since R2’s admission. 3. A review of R3's medical record revealed a service plan dated February 10, 2025. R3's service plan reflected that R3 required assistance with bathing twice weekly, grooming daily, and oral care. There was no documentation to reflect that these services were provided to R3 since R3’s admission.

Based on record review and interview, the manager failed to ensure that a resident or resident's representative received a complete written copy of the requirements in subsection (B) and the resident rights in subsection (C) at the time of admission, for one of three sampled residents. Findings include: 1. A review of R1's medical record revealed no documentation to indicate R1 or R1's representative received a complete written copy of the requirements in subsection (B) and the resident rights in subsection (C). 2. In an interview, E1 acknowledged R1's medical record did not contain documentation to reflect R1 or R1's representative received a copy of the requirements in subsection (B) and the resident rights in subsection (C) at the time of admission.

Based on record review and interview, the manager failed ensure one of three sampled residents or resident representatives were informed of the policy on the health care directives. Findings include: 1. A review of R1's medical record revealed no documentation that R1 was informed of the facility's policy on health care directives. 2. In an interview, E1 acknowledged there was no documentation to reflect that the residents were informed of the policy on health care directives.

Based on observation, record review, documentation review and interview, the manager failed to ensure that the facility's established and documented medication policy and procedure for the review of a resident's medication regimen and method of administration to be reviewed by a medical practitioner met a resident's needs was implemented, which pose a health and safety risk to three of three sampled residents. Findings include: 1. The compliance officer observed R1’s, R2’s, and R3’s medications were stored by the facility. 2. A review of R1’s, R2’s, and R3’s service plans revealed that the residents were receiving medication administration services. There was no documentation that the resident's medical practitioner had reviewed the residents' medications on a regular basis to determine if the resident's medication regimen and method of administration met the resident's needs. 3. A review of the facility’s medication policies and procedures stated, “To ensure that the medication regimen meets the resident’s needs, the resident’s medication regimen and method of administration were reviewed by the medical practitioner at least every six months or more often if needed.” 4. In an interview, E1 acknowledged there was no documentation to reflect that R1’s, R2’s, and R3’s medication regimens were reviewed.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. Review of the facility's policies and procedures for medication administration revealed no indication that the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. During an interview, E1 acknowledged that the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on the record review and interview, the manager failed to ensure that medication was documented as administered to a resident in compliance with a medication order for three of three residents sampled. Findings include: 1. A review of R1’s medical record revealed R1 received medication administration services. R1’s record revealed the following medication orders dated April 2, 2024: Aspirin 81mg oral tablet, one tablet by mouth once a day, and Levetiracetam 5 ml by mouth two times a day. There was no documentation to reflect the medications administered to R1 since R1’s admission to the facility. 2. A review of R2’s medical record revealed R2 received medication administration services. R2’s record revealed the following medication orders dated September 5, 2023: Aspirin 81mg one tablet daily, Atorvastatin 40 mg one tablet at bedtime, Calcium vitamin D3 tablet 315-8.25mg-mcg two tablets once daily, Calcitonin nasal solution one spray nostril once daily, Lansoprazole 30mg one tablet daily, Levothyroxine sodium 100 mcg one tablet in the morning, Lidocaine patch 4% apply to lower back, Lisinopril 20 mg one tablet once daily, Metoprolol tartrate 25 mg one tablet by mouth twice daily, Paroxetine HCI 20 mg one tablet one time daily. There was no documentation to reflect the medications administered to R2 since R2’s admission to the facility. 3. A review of R3’s medical record revealed R3 received medication administration services. R3’s record revealed the following medication orders dated January 3, 2024: Aspirin 81 mg one tablet daily, Pantoprazole 20 mg one tablet daily, Meclizine 12.5 mg one tablet twice daily as needed. There was no documentation to reflect the medications administered to R3 since R3’s admission to the facility. 4. In an interview, E1 acknowledged there was no documentation to reflect that the medication was administered in compliance with the medication orders of R1, R2, and R3 since the residents were administered to the facility.

Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a locked area, which posed a health and safety risk for medications to be stored inappropriately. Findings Include: 1. During a facility tour, the surveyor observed the following medications were unsecured inside the facility's refrigerator: Lorazepam, Morphine, and Fluticasone Nasal Spray. 2. In an interview, E1 acknowledged the unsecured medications inside the refrigerator.

Based on observation and interview, the manger failed to ensure food was stored free from spoilage, filth, or other contamination and was safe for human consumption. The deficient practice posed a risk of food-borne illness. Findings included: 1. During the environmental inspection of the facility, the Compliance Officer observed the following inside the facility’s refrigerator: a plastic bag of withered green leaves and brown liquid substance, exposed lettuce, sour cream, and cottage cheese that expired November 13, 2024. 2. In an interview, E1 acknowledged that food was not stored free from spoilage, filth, or other contamination and may not have been safe for human consumption.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's disaster plan revealed there was no documentation indicating a disaster plan review was conducted at least once every 12 months. 2. In an interview, E1 was unable to provide documentation indicating a disaster plan review was conducted at least once every 12 months.

Based on record review and interview, the manager failed to ensure orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, within 24 hours after acceptance by the assisted living facility was documented for two of three sampled residents. Findings include: 1. A review of R1's and R3's medical records revealed no documentation of R1's and R3's orientation to the exits of the facility. 2. In an interview, E1 acknowledged R1's and R3's medical records did not contain documentation of the residents' orientation to exits from the facility.

Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies. Findings include: 1. The surveyor observed O1 to be the only pet in the facility. 2. A review of facility documentation revealed there was no documentation of a rabies vaccination for O1. 3. In an interview, E1 acknowledged that there was no documentation to reflect that O1 was vaccinated against rabies.