Flamingo Alh LLC

Based on documentation review and interview, after a reported allegation of abuse, according to A.R.S. \'a7 46-454, the manager failed to document the information required in R9-10-803.J.5.a-d, within five working days. Findings include: 1. During an interview, E1 reported R1, while in the hospital, alleged abuse happened when R1 resided at the facility. E1 reported an investigation was conducted; however, was not documented in accordance with R9-10-803.J.5. E1 reported no evidence of abuse was found. 2. In documentation review, the facility had a copy of documentation that showed the alleged abuse was reported to Adult Protective Services, as required. 3. During an interview, E1 acknowledged the facility did not complete the required documentation, following the facility's investigation.

Based on observation, interview, and documentation review, for one volunteer observed, the manager failed to have a personnel record for a volunteer, as required by this Article. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing a volunteer met the requirements to provide services for the residents. Findings include: 1. In observation, E2 and E3 were observed working on site during the inspection, with six residents present. 3. In an interview, E3 reported working on and off at the facility since 2021, when the new owners obtained the facility. E3 reported assisting with cleaning, and cooking. E1 reported E3 was a volunteer. 4. In record review, the compliance officer requested to review the personnel record for E3. No documentation of a record was provided. 5. In an interview, E1 reported having no personnel record for E3, and acknowledged the facility was required to have a personnel record for a volunteer.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. In record review, R1's medical record (received personal care services) included documentation R1 had a fall in June 2022, and a recent fall with an injury, on March 26, 2023. R1's service plan dated March 1, 2023, did not include documentation R1 had a history of falls, or was at risk for falls, and documented R1 was independent with mobility with the use of walker. 2. In an interview, E1 reported R1 had a fall in June 2022, and E1 and E2 reported R1 had a recent fall in March 2023. E1 acknowledged R1's service plan was not updated with R1's change of condition. 3. In record review, R2's medical record (received personal care services) included documentation of a determination, dated March 1, 2023, which indicated R2 was confined to a bed or chair because of an inability to ambulate even with assistance. A signed note from the MD, dated January 5, 2022, documented R2 was non-ambulatory and confined to a wheelchair. 4. In record review, R2's service plan, dated November 2, 2022, documented R2 was independent with ambulation with a walker. 5. In an interview, E1 and E2 reported R2 was unable to walk even with assistance, and acknowledged R2's service plan was not updated with R2's change of condition.