Fellowship Square Historic Mesa Oasis

Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation, initiate an ivestigation of the suspected abuse, neglect, or exploitation, and maintain documentation including all requirements of this rule for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if a resident was not protected from abuse, neglect, or exploitation. Findings include: 1. A review of facility documentation revealed no incident report for R1. 2. In an interview, E1 acknowledged hospital staff where R1 was receiving medical attention had informed E1 that R1 was alleging a sexual assault. E1 was informed on September 24, 2024. E1 acknowledged the incident had not been reported by the facility in compliance with A.R.S. \'a7 46-454.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of two sampled employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E2's personnel record revealed a fingerprint clearance card with an expiration date of February 12, 2024. No other documentation to reflect E2's compliance with A.R.S. \'a7 36-411(A) was provided at the time of the inspection. 3. A review of the Arizona Department of Public Safety (DPS) website revealed E2's fingerprint clearance card expired on February 12, 2024. The website also revealed E2 had no application for renewal. 4. In an interview, E1 acknowledged E2's fingerprint clearance card was expired. E1 acknowledged E2 had not yet submitted an application for renewal to DPS.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed "Micro-kill foaming Disinfectant Cleaner" stored in an unlocked kitchen cabinet which was accessible to residents. 2. In an interview, E2 acknowledged the aforementioned toxic material was not stored in a locked location and inaccessible to residents.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1. A review of the facility documentation revealed a policy and procedure dated March 29, 2022 titled "Fall Reduction Policy." However, the policy and procedure did not include the initial training and continued competency training requirement. 2. In a joint interview, E1 and O2 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.

Based on record review, documentation 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 individual was accepted by the assisted living facility; to include whether the resident required continuous medical services, continuous nursing services, intermittent nursing services or restraints, for five of five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs if the resident needed a higher level of care. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R1's date of admission, to include whether R1 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. A review of R2's (admitted in 2022) medical record revealed documentation dated within 90 calendar days before R2's date of admission, to include whether R2 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 3. A review of R3's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R3's date of admission, to include whether R3 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 4. A review of R4's (admitted in 2022) medical record revealed documentation dated within 90 calendar days before R4's date of admission, to include whether R4 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 5. A review of R5's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R5's date of admission, to include whether R5 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 6. In an interview, E1 reported to be unaware of this requirement. E1 reported the facility utilized a document titled "Physician Plan of Care." 7. A review of facility documentation revealed a document titled "Physician Plan of Care." However, the document did not include whether a resident required continuous medical services, continuous nursing

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for three of five residents sampled. The deficient practice posed a risk as services provided could not be verified against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated in March 2023 for personal care services. The service plan stated R1 was to receive assistance in activities of daily living for the following service: -Bathing Morning 2x per week by facility staff and self ..."[R1] requires assistance in and out of shower for safety ...Staff assists with washing hard to reach areas, lower legs and back." 2. A review of R1's activities of daily living (ADL) log dated June 1, 2023-June 30, 2023 revealed documentation to indicate R1 received assistance with bathing 2x per week was not available for review. 3. In an interview, E1 reported R1 was on hospice and received assistance with bathing by staff from the hospice agency. E1 reported R1's service plan would be updated. 4. A review of R2's medical record revealed a service plan dated in April 2023 for directed care services. The service plan stated R2 was to receive assistance in activities of daily living for the following services: -Hygiene: Nails-provide total care, Teeth/Dentures-provide set up, and Hair/Shaving-provide set up ..."[R2] is able to brush teeth once staff has loaded brush with toothpaste and constant verbal cueing. Nail care provided by staff, [R2] is able to comb hair with verbal cueing ..." -Dressing: Provide Supervision morning and evening ...[R2] has difficulty following direction, does not always comprehend what is asked ...is able to dress self with constant verbal cueing until task is done." -Housekeeping: Caregivers provide weekly and PRN laundering of Memory Care Residents sheets, towels and personal clothing. 5. A review of R2's ADL log dated June 1, 2023-June 30, 2023 revealed documentation to indicate R2 received assistance with the above mentioned services was not available for review. 6. In an interview, E1 reported R2 received assistance with the above mentioned services, however, the services were not being documented. 7. A review of R4's medical record revealed a service plan dated in June 2023 for directed care services. The service plan stated R4 was to receive assistance in activities of daily living for the following services: -Hygiene: Nails-Provide total care, Teeth/Dentures-provide total care, and Hair/Shaving-provide total care ..."[R4] is unable to follow directions due to cognitive decline/dementia ..." -Housekeeping: Caregivers provide weekly and PRN laundering of Memory Care Residents sheets, towels and personal clothing. 8. A review of R4's ADL log dated June 1, 2023-June 30, 2023 revealed documentation to indicate R4 received assistance with the above mentioned services was not available for review. 9. In an interview, E1 rep