Golden Care Ach

Based on record review and interview, the manager did not ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's and R2's medical records revealed no standardized emergency responder patient information form was prescribed with R1's and R2's information and available for review. 2. In an interview, E1 reported the forms were included in the policy and procedure, however, were not completed for each resident. E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated August 6, 2025, for personal care services. The service plan documented R1 was expected to receive assistance of one person to get in an out of the shower two times per week. 2. A review of R1's medical record revealed activities of daily living records from December 2025 and January 2026. The records documented R1 received daily assistance with bathing. 3. In an interview, E2 reported R1 had declined and bathing was required daily. E2 acknowledged a resident's written service plan was not reviewed and updated no later than 14 calendar days after a significant change in the resident's functional condition.

Based on record review and interview, the manager did not ensure the caregiver documented the services provided in the resident's medical record, for two of three 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 personal care service plan from August 2025, that indicated R1 would receive the following services: Dressing/Grooming - Assist in selecting clothes. Assist of one to complete daily dressing/grooming tasks - "Facility staff in non-CNA visit days." 2. A review of R1's medical record revealed an "Activities of Daily Living" checklist. However, no documentation of Dressing/Grooming tasks completed was available for review. 3. A review of R2's medical record revealed a personal care service plan from October 2025, that indicated R2 would receive the following services: Bathing/Hygiene - Shower - Resident prefers daily. Oral care daily. "Respect resident desire for privacy and autonomy during care but monitor routine". 4. A review of R2's medical record revealed an "Activities of Daily Living" checklist. However, R2 was documented as independent with Shower/Bath with no monitoring documented and no documentation of oral care completed was available for review. 5. In an interview, E2 reported R1 and R2 received all assisted living services included in R1's and R2's service plan. E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical record.

Based on observation and interview, the manager did not ensure that oxygen containers were secured in an upright position. Findings include: 1 . During an environmental inspection, the Compliance Officer observed an oxygen container stored unsecured next to a dresser in a resident bedroom. 2 . During an exit interview, findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager did not ensure the hot water temperature was maintained between 95º F and 120º F in areas of the assisted living facility used by residents. Findings include: 1 . During an environmental inspection, the Compliance Officer observed the hot water temperature in the kitchen of the facility to measure 124.2º F using a department approved temperature reader. 2 . In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During an environmental inspection, the Compliance Officer observed a open shelving space in the hallway which contained medical records for prior residents of the facility. The Compliance Officer observed a contact sheet posted on the wall of a shared space which contained a resident name and contact information for the resident's medical providers. 3. In an interview, E2 reported the documents on the shelves remained from previous owners of the facility. In the exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that medication was administered in compliance with a medication order and documented in the resident’s medical record, for one of three 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 order dated July 15, 2025 for the following medication: Pioglitazone HCL 30 milligram (mg) - 1 tab by mouth (po) per day. However, no medication order for Lorazepam 0.5mg - 1 tab po every 6 hours as needed (PRN) was available for review. 2. A review of R1's medical record revealed a document titled "Medication Administration Record" (MAR) for the month of January 2026. The MAR revealed the following medications were administered to R1: Pioglitazone HCL 30 mg was administered January 1, 2026 through January 8, 2026; and Lorazepam 0.5mg - administered January 1, 2026 and January 4, 2026 through January 8, 2026. 3 . A review of R1's medications revealed R1 was receiving Pioglitazone HCL 15 mg - 1 tab po QD. 4. In an exit interview, E2 reported hospice had provided the incorrect medication and R1 was receiving the medication on hand. E1 acknowledged medication was not administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked area. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed an unlocked cabinet in R3's bathroom containing R3's medications labeled: Lactulose 10 gram (gm)/15 milliliter (ml) Solution; and Budesonide 0.25 milligram (mg)/ 2ml Vials. In an unlocked cabinet in R2's bathroom, the compliance officer observed the following medication prescribed to R2: Chllorhexidine Gluconate Oral Rinse USP, 0.12%. 2. In an exit interview with E2, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager did not ensure the premises and equipment used at the assisted living were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During an environmental inspection, the Compliance Officer observed the toilet seat lid in a resident bathroom to be broken with exposed cracks and a toilet tank which appeared to be missing the lid exposing the internals of the toilet. 2 . During an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored by the assisted living facility were maintained in a locked area inaccessible to residents. Findings include: 1 . During a tour of the facility, the Compliance Officer observed a cabinet under the kitchen sink with latches installed. However, no locks were installed on the cabinet which contained the following poisonous or toxic materials: Windex window cleaner; Comet with Bleach; Cutter Backyard Bug Control; Comet Classic Kitchen Cleaner; and Raid Defend - Ant and Roach. 2 . In an exit interview, E2 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.

Based on documentation review, record review and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed documents titled "Activities of Daily Living (ADL sheet)" dated September 2023 for each resident. R1's and R2's ADL sheets contained dashes to reflect the services were provided to each resident. However, the entries on the ADL sheets were not authenticated by the individual(s) who provided the services to the residents. 2. In an interview, E1 reported being unaware the documentation of the services provided to the residents required authentication.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility's disaster plan revealed the most recent documented review date was January 1, 2022. 2. In an interview, E1 reviewed and acknowledged the disaster plan was not reviewed annually.