Freedom Care at Bella Vista LLC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2) for one of two personnel reviewed. The deficient practice posed a risk as required information could not be verified for personnel to determine a person's fitness to work in the assisted living home. Findings include: 1. A.R.S. § 36-411(C)(2) states, "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website revealed E2 currently had a valid fingerprint clearance card. However, there was no verification of E2’s fingerprint verification within E2's record. 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 and complaint inspection conducted on February 28, 2025.

Based on record review, observation, documentation review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R2’s current service plan, dated January 15, 2026, revealed R2 received medication administration. 2. A review of R2’s medical record revealed a medication list dated July 1, 2025. However, the list was not signed by a medical practitioner as required. The list contained the following medications: • “Quetiapine (Seroquel 25 mg oral tablet) daily at bedtime.”; • “Aspirin (Aspirin EC 81 mg oral delayed release tablet) once every day.”; • “Carbidopa-levodopa (25 mg-100 mg oral tablet) twice a day.”; • “Levetiracetam (Keppra 500 mg oral tablet) twice a day.”; • “Levothyroxine (Synthroid 75 mcg (0.075 mg) oral tablet) daily in the morning.”; • “Midodrine (midodrine 2.5 mg oral tablet) three times a day.”; and • “Pravastatin (pravastatin 40 mg oral tablet) once every day.” 3. A review of R2's medical record did not include a medication order for Trazodone 50 mg, 1 tablet PO QHS. 4. A review of R2’s medical record revealed a medication administration record (MAR) dated January 2026 and February 2026. The MAR revealed R2 received the following medications on the following dates: • Pravastatin 40 mg 1 tab PO QD at 8 AM: January 1, 2026, to February 3, 2026; • Trazodone 50 mg 1 tab PO QHS at 8 PM: January 1, 2026, to February 3, 2026; • Quetiapine 50 mg 1 tab PO TID at 8 AM, 12 PM, and 8 PM: January 1, 2026, to February 3, 2026; • Aspirin 81 mg 1 tab PO QD at 8 AM: January 1, 2026, to February 3, 2026; • Carbidopa-Levodopa 25 mg-100 mg 2 tab PO BID at 8 AM and 8 PM: January 1, 2026, to February 3, 2026; • Levetiracetam/Keppra 500 mg 1 tab PO BID at 8 AM and 8 PM: January 1, 2026, to February 3, 2026; and • Levothyroxine (Synthroid 75 mcg /0.075) 1 tab QD in the morning at 8 AM: January 1, 2026, to February 3, 2026. 5. The Compliance Officers observed Midodrine 2.5 mg 1 tablet prefilled in R2's medication organizer for administration three times a day. 6. A review of the facility’s policies and procedures revealed a policy titled, “Part I – Doctor Orders, Provisions of Medication, Handling Medication, Assisting Resident in Procuring (obtaining) Medication”, which stated, “4. Every time the Resident’s Service Plan is updated, all Doctor’s Orders for each Resident will be consolidated on a single Doctor’s Order form and faxed or mailed to the doctor's office for review and signature to ensure that the Resident’s medication regimen and method of administration meets the resident’s needs, unless the current medication is listed in the Service Plan and reviewed by a Registered Nurse.” 7. A review of R2’s current service plan, dated January 15,

Based on record review, documentation review, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one 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. Review of R1’s current service plan, dated August 14, 2025, revealed R1 received medication administration. 2. A review of R1’s medical record revealed a signed medication order dated January 19, 2025, which included the following: “Hydralazine HCI 25 mg 1 tablet oral 2 times a day as needed for Hypertension. Give 1 tablet by mouth twice daily as needed for SBP>160.” 3. A review of R1’s medical record revealed a Resident Vital Signs Chart dated January 2026 and February 2026. The Chart revealed R2’s systolic blood pressure exceeded 160 on the following dates and times: • January 13, 2026: AM B/P 195/92; • January 14, 2026: AM B/P 193/92; • January 15, 2026: PM B/P 167/84; • January 16, 2026: AM B/P 178/90; PM B/P 170/86; • January 17, 2026: AM B/P 184/96; PM B/P 163/93; • January 19, 2026: AM B/P 166/99; PM B/P 183/116; • January 21, 2026: AM B/P 171/92; • January 22, 2026: AM B/P 183/95; • January 23, 2026: AM B/P 194/134; PM B/P 161/107; • January 24, 2026: AM B/P 193/99; • January 25, 2026: AM B/P 185/100; • January 26, 2026: AM B/P 165/94; • January 27, 2026: AM B/P 170/100; • January 28, 2026: AM B/P 163/103; PM B/P 169/89; • January 29, 2026: AM B/P 181/94; • January 30, 2026: AM B/P 166/97; PM B/P 168/90; • January 31, 2026: AM B/P 173/92; PM B/P 169/90; • February 1, 2026: AM B/P 182/115; PM B/P 163/73; • February 2, 2026: AM B/P 181/97; PM B/P 162/93; • February 3, 2026: AM B/P 168/91; PM B/P 179/103; and • February 4, 2026: AM B/P 174/94; PM B/P 180/97. 4. A review of R1’s medical record revealed a medication administration record (MAR) dated January 2026 and February 2026. The MAR stated “Hydralazine 25mg 1 tab PO BID, hold if Systolic BP higher than 160.” Noticeably, the MAR did not match the medication order to administer when R1's systolic blood pressure was greater than 160. The MAR revealed the medication was not documented as administered on the following dates and times, in accordance with R1’s Vital Signs Chart above: • January 13, 2026: AM; • January 14, 2026: AM; • January 15, 2026: PM; • January 16, 2026: AM & PM; • January 17, 2026: AM & PM; • January 19, 2026: AM & PM; • January 21, 2026: AM; • January 22, 2026: AM; • January 23, 2026: AM & PM; • January 24, 2026: AM; • January 25, 2026: AM; • January 26, 2026: AM; • January 27, 2026: AM; • January 28, 2026: AM & PM; • January 29, 2026: AM; • January 30, 2026: AM & PM; • January 31, 2026: AM & PM; • February 1, 2026: AM & PM; • February 2, 2026: AM & PM; • February 3, 2026: AM & PM; and • February 4, 2026: AM & PM. 5. A review of the facility’s policies and procedures revealed a policy titled, “Part III – Medication

Based on observation, record review, document review, and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents’ health and safety. Findings include: 1. During an environmental tour, the Compliance Officers observed one unsecured bottle of Guaifenesin LIQ 100/5 ML located on R1’s bedside table in R1’s personal room. 2. During the environmental tour, the Compliance officers observed the following items located inside an unlocked drawer in the kitchen where non-medication items were being stored: one bag of Vapo Cool cough drops; one bag of Halls cough drops; one combination box of DayQuil and Nyquil; one 2-pack of Tylenol Cold & Flu Severe Night caplets; and one blister pack of Chloroacetic lozenges. 3. During the environmental tour, the Compliance Officers observed one box of Polyethylene Glycol 3350 powder located in an unlocked cabinet in the kitchen where non-medications were stored. 4. During the environmental tour, the Compliance Officers observed that the medication storage cabinet located in the kitchen was unsecured. The cabinet contained medications for all the residents in the facility. Further inspection of the cabinet revealed the lock was not functioning at the time of inspection. 5. A review of R1’s current service plan, dated August 14, 2025, revealed R1 received medication administration. 6. A review of the facility’s policies and procedures revealed a policy titled, “Part II – Receiving, Storing Medication” which stated, “3. Medication stored by the facility must be secured in a locked storage area, closet, cabinet, or self-contained unit used for medication storage only.” 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance and complaint inspection conducted on February 28, 2025.