Fawn Assisted Living

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two personnel sampled. The deficient practice posed a risk if E1 and E2 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C.3 states: "3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of E1 and E2’s personnel records did not include documentation that E1 or E2 were not on the adult protective services registry pursuant to section 46-459. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program which included the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled, "Establishing a Quality Management Plan” The policy stated, “1. Staff will be familiar with the report of unusual occurrence form or incident report and be able to utilize whenever an incident occurs. 2. The manager will review all incident reports, document, evaluate, and identify the problem as to how such an incident happened and how to minimize or prevent the incident from happening again.” 2. A review of the facility’s quality management documentation revealed no quality management documentation. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on February 3, 2025.

Based on record review, documentation 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, and according to policies and procedures for one of the two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E1's personnel record revealed no documentation of skills and knowledge verification present in the record. Based on E1's hire date, this information was required. 2. A review of the facility's staff schedule revealed E1 worked multiple shifts during the month of January 2026. 3. A review of the facility's policies and procedures revealed a section titled, "Verifying Caregiver's Skills and Knowledge." The policy states, "Before the caregiver provided physical health services or behavioral health services, his or her skills and knowledge are verified and documented. 3. The manager will put the assessment sheet and information from previous employers in the employee's files." 4. 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 within five working days after a resident's acceptance by the assisted living facility, the documented agreement required in subsection (D), was signed by the resident, the resident's representative, the resident's legal guardian, or another individual who has been designated by the individual under A.R.S. § 36-3221 to make health care decisions on the individual's behalf, for one of two residents sampled. The deficient practice posed a risk if the required individuals were not informed of the terms of residency. Findings include: 1. R9-10-807.D states, "Before or at the time of an individual’s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed." 2. A review of R1's medical record revealed a residency agreement with all required elements. However, the agreement was not signed by the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under A.R.S. § 36-3221. Based on R1's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident. Findings include: 1. A review of R1’s medical record revealed a service plan, dated January 8, 2026. R1’s service plan did not include documentation of a home health agency or a need for any other ancillary services. 2. While on-site for the compliance inspection, the Compliance Officers observed R1 to have a port and covered wounds on R1's arms. 3. In an interview, E1 reported that R1 received intermittent nursing services through home health and was transported twice a week to dialysis. However, documentation of these services was not available on R1's service plan. 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 resident had a service plan that was established, documented, and implemented that included for a resident who required behavioral care: the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of two residents sampled. Findings include: 1. A review of R2’s medical record revealed a service plan, dated January 5, 2026, that indicated R2 required behavioral care. However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. 2. In an interview, E1 reported that E1 was unaware of the requirements for residents receiving behavioral care. E1 also reported R2 required behavioral care. 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 the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 8, 2026, that indicated R1 would receive the following services: Encouragement to eat meals and snacks; Cut up meat and vegetables; Encouragement of sufficient fluids to maintain hydration; Partial bed bath, as needed (prn); Full bed bath, three times a week; Shave, prn; Full assistance with dressing; Full assistance with grooming; Make bed; Change linen, one time a week and prn; Lotion, prn; Brief checks, every two to three hours; Brief changes, prn; Supervision throughout the day; Resident checks, every three to four hours at night; Turning, prn to prevent skin breakdown; Medication administration; and Assisted transfer. 2. A review of R1's activities of daily living (ADL) documentation for January 2026 revealed missing documentation of the following services provided on January 28, 2026: Partial bath; Linen change; Bowel movements; and Meals provided. However, documentation of all other aforementioned services provided to R1 was not available for review. 3. A review of R2's medical record revealed a service plan, dated January 5, 2026, that indicated R2 would receive the following services: Encouragement to eat meals and snacks; Encouragement of sufficient fluids to maintain hydration; Shower, three times a week; Shave, prn; Make bed; Change linen, one time a week and prn; Lotion, prn; Brief checks, every two to three hours; Brief changes, prn; Supervision throughout the day; Resident checks, every three to four hours at night; and Medication administration. 4. A review of R2's ADL documentation for January 2026 revealed missing documentation of the following services provided on January 28, 2026: Partial bath; Linen change; Bowel movements; and Meals provided. However, documentation of all other aforementioned services provided to R2 was not available for review. 5. In an interview, E1 reported that all aforementioned services were provided to R1 and R2, according to their service plans. 6. 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 resident was not subjected to restraint. The deficient practice posed a risk of injury and violated a resident's rights. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed R1 sitting on the edge of R1's bed facing the wall and window. On the opposite side of R1's bed, closest to the doorway, were two bed rails covering the full length of R1's bed. Behind R1's back was a wedge pillow. 2. In an interview, R1 reported that the bed rails were used to prevent R1 from falling out of bed. R1 confirmed that R1 was unable to get out of bed with the bedrails up. 3. In an interview, E1 reported that the bed rails were used to keep R1 in bed when unsupervised. 4. In an exit interview, findings were discussed with E1, and no additional information was provided.

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 that monitored 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 licensed at the directed care level. 2. During an environmental inspection of the facility with E1, the Compliance Officers observed that the back door was unlocked, not alerted, and not monitored. 3. In an interview, E1 acknowledged the back door was not monitored or alerted. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1’s medical record revealed a signed medication list, dated January 2, 2026, for the following medications: Insulin Lispro 100 milliliters (mL), inject per sliding scale three times a day (tid); Lantus 100 units (U)/mL, inject 10 U subcutaneously every day; Eliquis 5 milligram (mg), 1 tablet by mouth (po) twice a day (bid); Bumetanide 2 mg, 1 tablet po bid; Midodrine 5 mg, 2 tablets po tid. 2. A review of R1's medication administration record (MAR) for January 2026 revealed missing documentation of the administration of Insulin Lispro 100 mL on the following dates and times: January 27, 2026, at 5:00 PM; and January 28, 2026, at 8:00 AM, 12:00 PM, and 5:00 PM. 3. A review of R1's MAR for January 2026 revealed missing documentation of the administration of Lantus 100 U/mL on January 28, 2026, at 8:00 AM. 4. A review of R1's MAR for January 2026 revealed missing documentation of the administration of Eliquis 5 mg and Bumetanide 2 mg on the following dates and times: January 27, 2026, at 8:00 PM; and January 28, 2026, at 8:00 AM and 8:00 PM. 5. A review of R1's MAR for January 2026 revealed missing documentation of the administration of Midodrine 5 mg on the following dates and times: January 20, 2026 - January 28, 2026, at 8:00 AM; and January 19, 2026 - January 28, 2026, at 8:00 PM. 6. A review of R2’s medical record revealed a signed medication list, dated August 8, 2025, for the following medications: Aspirin 81 mg, 1 tablet po daily (qd); Risperidone 0.5 mg, 1 tablet po qd; Memantine 20 mg, 1 tablet po bid; and Risperidone 2 mg, 1 tablet po at bedtime (qhs). 7. A review of R2's MAR for January 2026 revealed missing documentation of the administration of Aspirin 81 mg and Risperidone 0.5 mg on January 28, 2026, at 8:00 AM. 8. A review of R2's MAR for January 2026 revealed missing documentation of the administration of Memantine 20 mg on the following dates and times: January 27, 2026, at 8:00 PM; and January 28, 2026, at 8:00 AM and 8:00 PM. 9. A review of R2's MAR for January 2026 revealed missing documentation of the administration of Risperidone 2 mg on January 26, 2026 - January 28, 2026, at 8:00 PM. 10. In an interview, E1 reported all medications were administered to R1 and R2 as ordered. 11. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster plan included how a resident’s medical record would be available to individuals providing services to the resident during a disaster, a plan to ensure each resident’s medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility’s documentation/policies and procedures revealed a disaster plan for the facility; however, the plan did not include the following. how a resident's medical record will be available to individuals providing services to the resident during the disaster a plan to ensure each residents medication will be available to administer to the resident during a disaster a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster. 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the 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 documentation/policies and procedures revealed the facility's disaster plan with no review date. 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Establishing a Quality Management Plan." This policy stated "The manager shall ensure that a plan is established, documented, and implemented for an ongoing quality management plan that includes a method to identify, document and evaluate incidents..." 2. Review of facility documentation revealed no documentation of a quality management report. 3. During an interview, E1 acknowledged a quality management report was not available for review.

Violation cited

Violation cited