Grovers Assisted Living LLC

Based on interview and documentation review, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. In an interview, E3 stated there were two shifts at the facility, 6am-6pm and 6pm-6am. 2. A review of facility documentation revealed a disaster drill conducted on the morning shift of March 1, 2025 and on the evening shift of June 1, 2025. The disaster drill conducted on December 2, 2025 did not include any documentation that specified the shift it occurred on. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; and A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. 2. A review of R2's medical record revealed there was a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the health care institution failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of the facility's documentation records revealed no facility risk assessment for infectious TB was documented and available during the inspection. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. Owners 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..." 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of November 4, 2024. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility’s documentation revealed that there was no documentation that policies were reviewed at least once every three years and updated as needed. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility’s documentation revealed no documentation of a quality management plan. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of two caregivers sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of the facility’s documentation revealed a policy titled, "Caregiver's Qualifications, Job Description, and Duties and Responsibilities," with the following verbiage, "...4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services, and b. According to policies and procedures..." 2. A review of E2's personnel record revealed a hire date of February 1, 2024. The personnel record revealed no documentation of verification of skills and knowledge. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a documented residency agreement included a list of the services available from the assisted living facility at an additional fee or charge, the policy for refunding fees, charges, or deposits, and whether the manager or a caregiver was awake during nighttime hours, for two of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's and R2's medical records revealed residency agreements; however, the following items were missing: A list of the services available from the assisted living facility at an additional fee or charge; The policy for refunding fees, charges, or deposits; and Whether the manager or a caregiver was awake during nighttime hours. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver documented the services provided in a resident’s medical record, for two out of two residents sampled. 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 service plan dated November 4, 2025, that included the following: peri care daily; and incontinent, change every two hours. 2. A review of R1’s December 2025 activities of daily living sheet revealed the following: No documentation of peri care on December 1-31, 2025; and No documentation of incontinent related changes every 2 hours on December 1-31, 2025. 3. A review of R2’s medical record revealed a service plan dated October 3, 2025 that included the following: partial bath 5 days a week; and Incontinence care every 2-3 hours with every urination and bowel movement. 4. A review of R2’s December 2025 activities of daily living sheet revealed the following: No documentation of partial baths on December 1-31, 2025; and No documentation of incontinence care every 2-3 hours care on December 1-31, 2025. 5. In an exit interview, the findings were reviewed with E,3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident’s medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed the flu and pneumonia vaccines were offered on July 1, 2022. Current documentation of notification of the availability of a vaccination for influenza and pneumonia was not available. Based on R1's date of residency, this document was required. 3. A review of R2's medical record revealed the flu and pneumonia vaccines were offered on August 28, 2024. Current documentation of notification of the availability of a vaccination for influenza and pneumonia was not available. Based on R2's date of residency, this document was required. 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents included the time of the evacuation drill and any problems encountered in conducting the evacuation drill. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. A review of facility documentation revealed an evacuation drill conducted on June 1, 2025 and December 2, 2025. Documentation was not available showing the time of the evacuation drill and any problems encountered in conducting the evacuation drill. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance, for two of two residents sampled. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. Review of R1's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance. Based on R1’s date of acceptance, this documentation was required. 2. Review of R2's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance. Based on R2’s date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation, interview, and documentation review, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection (J)(2), including the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse; and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if the facility did not take any action to stop suspected abuse of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1 to have a bandage on top of R1's head and a black eye. 2. In an interview, R1 reported E2 dragged R1 out of bed, and as a result R1's head hit the floor. R1 stated the incident was reported to the other caregivers E3 and E4. 3. A review of facility documentation revealed there was no documentation that included the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse. 4. In an interview, E3 reported R1 reported the aforementioned incident. E3 acknowledged there was no report submitted to Adult Protective Services (APS) regarding R1's allegations nor documentation of an investigation. 5. In an interview, E2 denied the allegations reported by R1. E2 acknowledged R1 reported the allegations to E3 and E4. E2 acknowledged there was no report submitted to APS regarding R1's allegations nor documentation of an investigation

Based on record review and interview, the manager failed to ensure a resident's medical record included the correct dosage for a medication administered, for one of two sampled residents. The deficient practice posed a risk if a resident was administered an incorrect dosage of medication. Findings include: 1. A review of R1's medical record revealed a service plan dated June 27, 2023 which reflected R1 received medication administration services. 2. A review of R1's medical record revealed a medication order dated January 20, 2023 for "Omeprazole 20 mg (milligrams) one tablet daily." 3. A review of R1's medical record revealed a medication administration record (MAR) dated November 2023. R1's November 2023 MAR reflected R1 was administered "Omeprazole 50 mg" tablets once daily. 4. The Compliance Officer observed R1's medication container for "Omeprazole", which contained 20 mg tablets. 5. In interview, E2 reported R1's "Omeprazole" medication dosage was documented incorrectly on the MAR.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two 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 R2's service plan dated November 8, 2023 reflected R2 recieved medication administration services. 2. A review of R2's medical record revealed a medication order dated June 1, 2021 for "Lisinopril 40 mg (milligrams) take one tablet by mouth once daily, hold if systolic blood pressure less than 110." 3. A review of R2's medical record revealed a medication administration record (MAR) dated November 2023. R2's November 2023 MAR did not indicate whether R2's "Lisinopril" was administered or withheld, and R2's blood pressure was not documented. 4. In an interview, E2 acknowledged there was no documentation of R2's blood pressure available for review. E2 acknowledged there was no documentation to indicate whether R2's "Lisinopril" was administered or withheld.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration services. 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 service plan dated June 27, 2023. R1's service plan reflected R1 received medication administration services. 2. A review of R1's medical record revealed a medication order November 14, 2023 for "Microbid 100 mg (milligrams) take one tablet by mouth twice daily for seven days." 3. A review of R1's medical record revealed a medication administration record (MAR) dated November 2023. R1's November 2023 MAR did not list "Microbid" as a medication administered to R1. 4. In an interview, E2 reported R1 was administered "Microbid" for seven days as ordered, however the administration was not documented.