Gems Assisted Living 3

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of Department documentation revealed this statute went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Fall Recovery” dated April 10, 2023. The P&P stated: "This facility shall develop an initial training, conduct, and administer continued competency Training in Fall Prevention and Fall Recovery Program every 6 months.” 3. A review of E2's personnel record revealed E2 was hired as the manager. The review revealed E2 received training regarding fall prevention and fall recovery on May 20, 2024, and February 20, 2025. However, the review revealed no such training within six months after May 20, 2024. 4. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed E3 received training regarding fall prevention and fall recovery on February 20, 2024, and February 20, 2025. However, the review revealed no such training within six months after February 20, 2024. 5. A review of E6’s personnel record revealed E6 was hired as a caregiver. The review revealed E6 did not receive training regarding fall prevention and fall recovery until February 20, 2025, more than eight months after E6 was hired. 6. A review of E4's, E7’s, and E12’s personnel records revealed E4, E7, and E12 were hired as caregivers. However, the review revealed no documentation demonstrating E4, E7, and E12 received initial training regarding fall prevention and fall recovery. 7. A review of E8's and E11’s personnel records revealed E8 and E11 were hired as caregivers. However, the review revealed no documentation demonstrating E8 and E11 received initial training regarding fall prevention and fall recovery or continued competency training every six months thereafter. 8. A review of E9's personnel record revealed E9 was hired as a housekeeper. However, the review revealed no documentation demonstrating E9 received initial training regarding fall prevention and fall recovery. 9. A review of E10's personnel record revealed E10 was hired as a housekeeper. The review revealed E10 received training regarding fall prevention and fall recovery on February 20, 2024. However, the review revealed no continued competency training every six months thereafter. 10. In an interview, E1 acknowledged facility personnel failed to administer a training program for all staff regarding fall prevention and fall recovery initially and every six months as required by P&P.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for seven of twelve sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 3. A review of facility documentation revealed a policy and procedure titled “TUBERCULOSIS (“TB”) TESTING” dated April 10, 2023. The P&P stated, “This facility provides in-service training and education related to recognizing and symptoms of tuberculosis yearly.” 4. A review of E3's personnel record revealed E3 was hired before this rule went into effect. However, the review revealed E3 did not receive training and education related to recognizing the signs and symptoms of TB until August 20, 2024. 5. A review of E4's, E7’s, and E9’s personnel records revealed E4, E7, and E9 were hired after this rule went into effect. However, the review revealed no documentation demonstrating E4, E7, and E9 received training and education related to recognizing the signs and symptoms of TB upon hire. 6. A review of E8's and E10’s personnel records revealed E8 and E10 were hired after this rule went into effect. However, the review revealed E8 and E10 did not receive training and education related to recognizing the signs and symptoms of TB until August 20, 2024. 7. A review of E11's personnel record revealed E11 was hired before this rule went into effect. However, the review revealed no documentation demonstrating E11 received training and education related to recognizing the signs and symptoms of TB upon hire or annually thereafter. 8. In an interview, E1 acknowledged not all employees received annual training and education related to recognizing t

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A) and (C), for six of twelve sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population and the Department was provided false or misleading information. Findings include: 1. A.R.S. § 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work." 2. A.R.S. § 36-411(C)(1-2) and (4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card…4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 3. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on April 10, 2024. The POC indicated this deficiency was corrected by E1, E2, O1, and others on April 10, 2024. The POC stated: “Following the survey, all staff fingerprint cards were reviewed. Employees without fingerprint clearance submitted their prints, which the manager cross checked against the public safety website. Moving forward, the manager will ensure that all staff members either have a fingerprint card, or an active application number before starting employment with Gems, or within 20 days of being hired. Employees who did not have a fingerprint card during the survey were either terminated, or sent immediately to get fingerprinted, or given opportunity to submit a good [ca

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of nine sampled caregivers. The deficient practice posed a risk if a manager or a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "CPR AND FIRST AID” dated April 10, 2023. The P&P stated: "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and that their certification is maintained and [is] current as long as they are employed by this facility.” The review further revealed a series of personnel schedules which indicated E3 worked on a regular basis between May 2024 and September 2024. 2. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed a first aid and CPR certification dated as expired on May 10, 2024. The review further revealed a current first aid and CPR certification dated as issued on September 5, 2024, nearly four months after E3’s previous certification expired. 3. In an interview, E1 confirmed E3 worked without first aid and CPR certification for nearly four months.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of nine sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING and RECORD KEEPING” dated April 10, 2023. The P&P stated: “Each employee hired by this facility must have the following on Employee’s file…5. Verification of skills and Knowledge.” The review revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT” dated April 10, 2023. The P&P stated: “Upon being hired by the facility the applicant must [have]...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for.” The review further revealed a series of personnel schedules which indicated E8 worked on a regular basis between July 2024 and November 2024. 2. A review of E8's personnel record revealed E8 was hired as a caregiver. However, the review revealed no documentation demonstrating the manager ensured E8's skills and knowledge were verified and documented before E8 provided physical health services. 3. In an interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment.

Based on documentation review, record review, and interview, the manager failed to ensure a manager and a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of ten sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of…iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) and (c)(i-ii) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution.” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (“TB”) TESTING” dated April 10, 2023. The P&P stated: “1. All individuals including residents of this facility will be screened fo

Based on documentation review, record 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 facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of a resident and the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on April 10, 2024. The POC indicated this deficiency was corrected on September 20, 2024. The POC stated: “All resident records were reviewed and the updated form was sent to PCP to complete and return.” 2. A review of R2's medical record revealed R2 was admitted to the facility before September 20, 2024 (the correction date on the POC). However, the review revealed no documentation in compliance with this rule, contrary to the POC. 3. In an interview, E1 reported R2 moved from one facility owned by O1 (the owner of this facility), to a second facility owned by O1, to this facility owned by O1. E1 reported not knowing R2 needed documentation in compliance with this rule for each facility, including for this one. This is a repeat citation from the complaint and compliance inspection conducted on April 10, 2024.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, the residency agreement did not include R1's date of occupancy or expected date of occupancy. 2. In an interview, when the Compliance Officer asked if the residency agreement the Compliance Officer reviewed was R1’s full residency agreement, E1 stated, “Yeah.” When the Compliance Officer informed E1 R1’s residency agreement did not include R1's date of occupancy or expected date of occupancy, E1 stated, “Okay.” Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's and R2’s medical records revealed current service plans which indicated R1 and R2 were to receive assistance with dressing. However, the service plans did not include the frequency of assistance with dressing. 2. In an interview, when the Compliance Officer asked if caregivers assisted R1 and R2 with dressing, E1 stated, “Yes.” E1 acknowledged R1’s and R2’s service plans did not include the frequency of assistance with dressing. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. 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 and R2’s medical records revealed current service plans which indicated R1 and R2 were to receive assistance with dressing. The review further revealed documentation of assisted living services provided to R1 and R2 (ADLs) dated April 2025. However, the ADLs revealed no documentation of assistance with dressing for R1 or R2. 2. In an interview, when the Compliance Officer asked if caregivers assisted R1 and R2 with dressing, E1 stated, “Yes.” E1 reported caregivers assisted R1 and R2 with dressing but did not document it. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 10, 2024.

Based on documentation review and interview, the manager failed to ensure policies and procedures (P&Ps) were implemented for inventorying controlled substances. The deficient practice posed a risk as the standards expected of employees to ensure resident safety were not followed. Findings include: 1. A review of facility documentation revealed a P&P titled "STORING, INVENTORYING AND DISPENSING OF CONTROLLED MEDICATIONS," dated April 10, 2023. The P&P stated: “2. For every medication marked with a ‘C’, a Narcotic Inventory Sheet should be maintained… 5. When assisting a resident in taking a controlled medication, a staff member should: Count the number of tablets/capsules available (e.g., in a bubble-packed card) and enter that number in the ‘Amount on Hand’ column on the form. Draw a line through the ‘Amount Received’ column. Write the number of tablets/capsules to be given at the designated time in the ‘Amount Given’ column. Subtract the number of tablets/ capsules written in the ‘Amount Given’ column from the number in the ‘Amount on Hand’ column. Write the resulting number in the ‘Amount Remaining’ column (this should be the number of tablets/capsules left after the current dose is taken).” 2. A review of facility documentation revealed a narcotics count binder. The review revealed a "Controlled Medication Record" document for each of the observed controlled medications for R1, R2, R4, R5, and R6. However, the documents did not contain columns for the “Amount on Hand” as required per P&P. 3. In an interview, E1 acknowledged facility personnel did not implement the P&P.

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(A), (C), and (E), for four of five sampled personnel members. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution. 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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.R.S. \'a7 36-411(C)(2) states: "C. Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 3. A.R.S. \'a7 36-411(E) states: "E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1 or has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked." 4. A review of facility documentation revealed a policy and procedure titled "FINGERPRINT" dated April 12, 2023. The policy and procedure stated: " The hiring individual will check and document fingerprinting requirements for each employee or volunteer to ensure they have a valid fingerprint card...Owner or Manager of this assisted living facility must require prospective employee to obtain fingerprint clearance, and must make efforts to verify with the Department of Public Safety (DPS) the status of prospective employee's fingerprint clearance card." 5. A review of E3's personnel reco

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures covering assistance in the self-administration of medication and medication administration (P&Ps) were implemented to protect the health and safety of a resident. The deficient practice posed a risk to residents who were not prescribed accessible medications. Findings include: 1. A review of facility documentation revealed a P&P titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: g. Storing medications properly and securely." 2. During the environmental inspection of the facility, the Compliance Officer observed a plastic lock box in the refrigerator. The Compliance Officer observed the lockbox was locked. However, with minimal force, the lid of the box opened approximately four inches in height on one side making the medications inside accessible and not secure as required by P&Ps. Inside the box, the Compliance Officer observed "Lorazepam," "Megestrol Acetate," and "Morphine Sulfate." 3. In an interview, E1 reported the medication box was locked. However, E1 acknowledged the medications were accessible and not entirely secured. 4. A review of facility documentation revealed a P&P titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: f. Taking, reading, and implementing physician medication and treatment orders." 5. A review of R1's and R3's medical records revealed current service plans which indicated R1 and R3 required medication administration services. The review further revealed medication administration records (MARs) dated April 2024 which indicated R1 and R3 received medication administration services for multiple medications in April, some being administered daily. However, the review revealed no signed medication orders for R1 or R3. 6. A review of facility documentation revealed an incident report involving R2 dated October 28, 2023. The incident stated: "[Employee 1] pre-popped medication for all residents. [Employee 2] handed the wrong meds to wrong resident [R2]." 7. In an interview, E1 acknowledged R1's, R2's, and R3's medications were not administered in compliance with a medication order.

Based on record 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 facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three sampled residents. The deficient practice posed a risk if the facility was unable to meet the needs of a resident. Findings include: 1. A review of R1's medical record revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 stated, "We're still out of compliance." Technical assistance was provided on this rule during the complaint inspection conducted on June 16, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for three of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION MANAGEMENT," dated April 12, 2023. The P&P stated: "All residents' medications will be handled according to the procedures outlined [below]: f. Taking, reading, and implementing physician medication and treatment orders." 2. A review of R1's and R3's medical records revealed current service plans which indicated R1 and R3 required medication administration services. The review further revealed medication administration records (MARs) dated April 2024 which indicated R1 and R3 received medication administration services for multiple medications in April, some being administered daily. However, the review revealed no signed medication orders for R1 or R3. 3. A review of facility documentation revealed an incident report involving R2 dated October 28, 2023. The incident stated: "[Employee 1] pre-popped medication for all residents. [Employee 2] handed the wrong meds to wrong resident [R2]." 4. In an interview, E1 acknowledged R1's, R2's, and R3's medications were not administered in compliance with a medication order.