Everlasting Services at Ahwatukee

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident 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. The facility was authorized to provide directed care services. 2. During the facility tour, the Compliance Officers observed ambulatory residents. 3. During the facility tour with E2, the Compliance Officers observed a sliding glass door from the dining room to a small patio that was not controlled or alerted. 4. In an interview, E4 reported there was a resident who wandered and had episodes of elopement from the facility. 5. In an interview, E2 and E4 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

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 R2’s medical record revealed a current service plan dated December 6, 2024. This service plan indicated R2 received medication administration. 2. Review of R2’s medical record revealed a signed medication order dated May 15, 2024 which stated, “Aripprazole 5 mg take one tablet by mouth every day.” 3. Review of R2’s medical record revealed a March 2025 medication administration record (MAR). This MAR did not include documentation showing Aripprazole 5 mg was administered. 4. The Compliance Officers observed Aripprazole 5 mg was not available. 5. In an interview, E2 reported Aripprazole 5 mg was discontinued. However, a signed discontinue order was not provided at the time of the inspection. 6. In an interview, E2 and E4 acknowledged Aripprazole was not administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the facility tour, the Compliance Officers observed residents ambulating and one wheelchair user. The resident using a wheelchair was able to move about independently. 2. During the facility tour the Compliance Officers observed the following: Shepard hooks lying on the ground A plant cage protector lying on the ground Drip irrigation lines exposed and running across the ground Pathway in the backyard with an uneven surface to the planter boxes used by the residents. 3. Review of documents revealed a Safety Policy, from the Policy and Procedure Manual dated January 2017, “Free from Hazards - The manager will ensure the Everlasting Services is as safe as possible and that the grounds are maintained and safe for all residents. Routine checks and evaluations of equipment, grounds, life safety equipment, any attached garages, rooms, kitchens and hallways. All will be monitored for any risks and kept free as possible from hazard to all residents of all levels of cognition and physical function”. 4. In an interview, E2 acknowledged the premises at the assisted living facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury

Based on observation 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 if toxic materials were accessible. Findings include: 1. The Compliance Officers observed ambulatory residents in the facility. 2. The facility was licensed for the directed level of care. 3. During the facility tour with E1, the Compliance Officers observed the following: An unlocked laundry room door, which contained several toxic materials; including but not limited to, Laundry Detergent, Lysol spray, and Dish soap A bottle of Isopropyl Alcohol 91% on the medication cart. An open tube of Neosporin in the first aid kit, in a side pouch of the Medication cart. 4. Review of the facility’s Policy and Procedure manual, dated January 2017- revealed a Policy titled “Cleaning Supplies: Poisonous or Toxic Materials”. The policy stated, “Cleaning supplies, poisons, and insecticides will be safely stored in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and not accessible to residents.” 5. During an interview, E2 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.