Hacienda at the River

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's policies and procedures in writing at 9:33 AM. The Compliance Officer periodically reminded E1 of the still unprovided documents throughout the inspection. However, the facility's policies and procedures were not provided for review. 2. A review of E4's personnel record revealed E4 had been hired on July 13, 2023 as a caregiver. However E4's personnel record did not include initial training in Fall Prevention and Fall Recovery. E4's personnel record included documentation of training in "Fall Safety, Fall Prevention, First Aid for Falls and Fall Recovery for Residents..." dated August 3, 2023. 3. A review of E5's personnel record revealed E5 had been hired on December 3, 2024 as a caregiver. However E5's personnel record did not include initial training in Fall Prevention and Fall Recovery. E5's personnel record included documentation of training in "Fall Safety, Fall Prevention, First Aid for Falls and Fall Recovery for Residents..." dated January 9, 2025. 4. A review of E7's personnel record revealed E7 had been hired on October 31, 2023 as a housekeeper. However E7's personnel record did not include initial training in Fall Prevention and Fall Recovery. E7's personnel record included documentation of training in "Fall Safety, Fall Prevention, First Aid for Falls and Fall Recovery for Residents..." dated February 9, 2024. 5. In an interview, E1 and E2 acknowledged E4's, E5's and E7's personnel records did not include documentation of initial training in fall prevention and fall recovery.

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. During the on-site inspection, at 9:33 AM, the Compliance Officer requested to review the facility's policy and procedure manual. The Compliance Officer reminded E1 of this requirement during the on-site inspection, however, the facility's policies and procedures were not provided for review. 2. During the on-site inspection, at 9:33 AM, the Compliance Officer requested to review the facility's quality management reports. The Compliance Officer reminded E1 of this requirement during the on-site inspection, however, the facility's quality management reports were not provided for review to include documentation the governing authority had reviewed and evaluated the quality management program. 3. In an interview, E1 and E2 acknowledged quality management reports, including the governing authority's review, had not been provided for review.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of six personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. \'a7 36-411 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. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. 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. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to se

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation within two hours after a Department request as required by this Article. Findings include: 1. On February 3, 2025 at 9:33 AM, the Compliance Officer requested the following documentation during the on-site inspection: - complete resident medical records; - the facility's policies and procedures; - quality management reports; and - work schedules for the previous 12 months. However, this documentation was not provided for review during the on-site inspection. 2. On February 3, 2025 at 11:30 AM, the Compliance Officer was provided, for each requested resident, one service plan, TB clearance, and a portion of the physicians's admission orders, not including the physicians's signature page. The Compliance Officer provided a copy of R9-10-811.C to E1 to assist with the request. 3. On February 3, 2025 at 11:55 AM, the Compliance Officer was provided, for each requested resident, a face sheet, an unsigned medication list, and one month of medication administration records. No further medical records were provided for review during the on-site inspection. 4. In an interview, E1 and E2 acknowledged the requested documentation had not been provided for review within two hours after a Department request. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023 and the on-site compliance inspection conducted on October 27, 2022.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of six employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A 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 employed by the health care institution, provides volunteer services for the health care institution, or 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: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of the CDC publication, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" revealed a section titled: "Baseline Testing for M. tuberculosis Infection After TST Within the Previous 12 Months," which states, "...If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting (Box 1). This additional TST represents the second stage of two-step testing. The second test decreases the possibility that boosting on later testing will lead to incorrect suspicion of transmission of M. tuberculosis in the setting." 4. A review of E4's personnel record revealed E4 had been hired as a caregiver in July of 2023. 46's personnel record included a skin test for TB (TST) dated a week before hire. However, E4's personnel record did not include documentation of a baseline screening questionnaire or a second step TST at the time of hire. E4's personnel record included a baseline screening questionnaire dated February 20, 2024, and a second TST dated September 2

Based on documentation review, observation, interview, and record review, the manager accepted an individual who needed services which were not within the assisted living facility's scope of services and a home health agency of hospice service agency were not involved in the care of the individual, for three of five residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "Determination for Admission AZ Only" dated August 20, 2024. The document indicated R1 required intermittent nursing services and included the note, "HH POT/OT." 2. A review of R1's medical record revealed a service plan dated January 15, 2025 for directed care services. However, the service plan did not include documentation of home health services. 3. A review of R1's medical record revealed no prior service plans were provided for review. 4. A review of R1's medical record revealed the name, address, and contact individual , including contact information, of the home health agency were not available for review per R9-10-803.L.1.a. 5. A review of R1's medical record revealed any information provided by the home health agency was not available for review per R9-10-803.L.1.b. 6. In an interview, E1 reported R1 had not received home health services as required. 7. A review of R4's medical record revealed a document titled "Determination for Admission AZ Only" dated November 13, 2024. The document indicated R4 required intermittent nursing services and included the note, "Home Health." 8. A review of R4's medical record revealed a service plan dated December 24, 2024 for directed care services. However, the service plan did not include documentation of home health services. 9. A review of R4's medical record revealed no prior service plans were provided for review. 10. A review of R4's medical record revealed the name, address, and contact individual , including contact information, of the home health agency were not available for review per R9-10-803.L.1.a. 11. A review of R4's medical record revealed any information provided by the home health agency was not available for review per R9-10-803.L.1.b. 12. A review of R5's medical record revealed a document titled "Determination for Admission AZ Only" dated December 12, 2024. The document indicated R5 required intermittent nursing services and included the note, "Home Health for PT/OT" 13. A review of R5's medical record revealed a service plan dated January 20, 2025 for directed care services. However, the service plan did not include documentation of home health services. 14. A review of R5's medical record revealed no prior service plans were provided for review. 15. A review of R5's medical record revealed the name, address, and contact individual , including contact information, of the home health agency were not available for review per R9-10-803.L.1.a. 16. A review of R5's medical record revealed any information provided by the home health agency was not available for review per R9-1

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10), for five of five residents sampled. Findings include: 1. During the on-site inspection, the Compliance Officer, at 9:33 AM, requested in writing, complete medical records for five sampled residents. 2. A review of the provided documentation for the five sampled residents revealed residency agreements had not been provided for review, along with multiple other items. 3. During the on-site inspection, the Compliance Officer, at 11:40 AM, provided E1 with a copy of R9-10-811.C to assist E1 with knowing what documents are required to be included in a resident's medical record. However, residency agreements for the five residents were not provided for review. 4. In an interview, E1 and E2 acknowledged there was no documented residency agreement dated before or at the time of each resident's acceptance into the facility provided for review.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of five residents sampled. Findings include: 1. A review of R3's medical record revealed a service plan dated January 11, 2025. The service plan documented R3 required the following assisted living service: "Eating/Meals/Hydration...[R3] will maintain independence with eating/meals...Care associate will weight resident monthly or as per orders. Weight changes of +/- 3 lbs in a month must be reported to the Nurse, the family and MD and assessment completed." 2. A review of R3's service plan revealed the following weights, "Jan'25: 149.5 lb, Dec'24: 153.7 lb....," a loss of more than three pounds in one month. However, documentation of notification of the nurse, the family, and "MD," and any type of assessment were not provided for review. 3. In an interview, E1 and E2 acknowledged R3's service plan indicated R3 had lost more than three pounds in one month and R3's service plan required actions to be taken in response, however, documentation of any actions taken according to the service plan had not been provided for review.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. During the on-site inspection, at 9:33 AM, the Compliance Officer requested, in writing, complete medical records for five sampled residents. 2. A review of the provided documentation for the five sampled residents revealed documentation of services provided to each resident had not been provided for review, along with multiple other items. 3. During the on-site inspection, the Compliance Officer, at 11:40 AM, provided E1 with a copy of R9-10-811.C to assist E1 with knowing what documents are required to be included in a resident's medical record. However, documentation of services provided to each of the five sampled residents were not provided for review. 4. In an interview, E1 and E2 acknowledged documentation of services provided to each resident had not been provided for review. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for five of five residents sampled. Findings include: 1. During the on-site inspection, at 9:33 AM, the Compliance Officer requested, in writing, complete medical records for five sampled residents. 2. A review of the provided documentation for the five sampled residents revealed documentation of each resident's orientation to exits from the assisted living facility had not been provided for review. 3. During the on-site inspection, the Compliance Officer, at 11:40 AM, provided E1 with a copy of R9-10-811.C to assist E1 with knowing what documents are required to be included in a resident's medical record. However, documentation of each resident's orientation to exits from the assisted living facility was not provided for review. 4. In an interview, E1 and E2 acknowledged documentation of each resident's orientation to exits from the assisted living facility had not been provided for review.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for four of four residents sampled who received medication administration. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's and R3's medical record revealed initial orders, signed at the time of each resident's acceptance, however, current orders were not provided for review. For both residents, their current Medication Administration Record documented the administration of medications for which no signed order had been provided. 2. A review of R4's medical record revealed a Medication Administration Record (MAR) dated January 2025, which documented the following: - For the medication, "Metoprolol Succ ER 50 MG, take 1 tablet by mouth twice daily, hold for SBP < 100," on January 1, 2025 at 8 PM, R4's systolic blood pressure was 89, however, the medication had not been held as ordered; and - For the medication, "Triamterene-HCTZ 37.5-25 MG, Take 1 tablet by mouth twice daily, hold for SBP < 100," on January 1, 2025 at 8 PM, R4's systolic blood pressure was 89, however, the medication had not been held as ordered 3. A review of R5's medical record revealed a list of medication orders dated November 20, 2024, including: - "metoprolol tartrate tablet: 50 mg...hold for sbp < 100 hr <60, twice a day: 09:00, 20:00." 4. a review of R5's medical record revealed a Medication Administration Record (MAR) dated January 2025. The MAR documented the administration of "Metoprolol Tartrate 50 MG, Take 1 tablet by mouth twice daily for hypertension. Hold for SBP<100 HR<60 (Additional Directions: INV NO QTY/RF/DATE)," as follows: - R5's heart rate was not recorded on any day in January 2025; - R5's medication was administered at 8 AM on each day instead of the ordered time; - R5's systolic blood pressure was not documented at 8 AM on January 6, or January 8 through January 31st; - R5's systolic blood pressure was not documented at 8 PM on January 3, 4, or January 7 through January 31st; - On January 3 at 8 AM, the medication was not administered with the reason, "5 = Hold / See Nurse Notes," however, no vitals or nurse notes were available; - On January 3 at 8 PM, the MAR had been left blank; - On January 4 at 8 PM, the medication was not administered with the reason: "9 = Other / See Nurse Notes," however, no vitals or nurse notes were available; - On January 6 at 8 AM, the medication was not administered with the reason: "MU = Medication Unavailable/ See PN," however, no vitals or nurse notes were available; - On January 6 at 8 PM, the medication was available and was administered; and - On January 7 at 8 AM, the medication was again not administered with the reason: "MU = Medication Unavailable/ See PN," however, no vitals or nurse notes were available. 5. In an interview, E1 and E2

Based on documentation review, observation, and interview, the manager failed to ensure 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. A documentation review of the facility work schedule revealed the facility worked three shifts per day. 2. A documentation review of facility disaster drills revealed the most recent disaster drill on the overnight shift had been conducted on December 31, 2024 at 5 AM. 3. A documentation review of facility disaster drills revealed the second most recent disaster drill on the overnight shift had been conducted on July 23, 2024 at 5:15 AM, more than three months prior to the December 2024 drill. 4. In an interview, E1 and E2 acknowledged documentation of disaster drills conducted on each shift at least once every three months had not been provided for review. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023 and the on-site compliance inspection conducted on October 27, 2022.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drills included, if applicable, an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated. Findings include: 1. A review of facility documentation revealed an evacuation drill, dated May 24, 2024. However, the drill documentation did not include an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated. 2. In an interview, E1 and E2, acknowledged the provided documentation of the evacuation drill did not include an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature measured at 125.8\'b0 F in R5's assisted living unit. 2. In an interview, E1 and E2 acknowledged the hot water temperatures had not been maintained between 95 \'b0F and 120 \'b0F in an area of the assisted living facility used by residents. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on observation, documentation review and interview the manager failed to ensure animals residing at the facility were licensed consistent with local ordinances. The deficient posed a risk if a pet allowed into the facility did not meet the Pima County licensing requirements. Finding include: 1. During an environmental inspection of the facility, the Compliance Officer observed two dogs in the assisted living section of the facility. 2. During the on-site inspection, at 9:33 AM, the Compliance Officer requested to review pet records. The Compliance Officer reminded E1 of this requirement after more than two hours had elapsed without any pet records having been provided. However, no pet records were provided for review. 3. In an interview, E1 and E2 acknowledged current licenses for each dog at the facility had not been provided for review. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on observation, documentation review and interview the manager failed to ensure animals residing at the facility were vaccinated against rabies. Finding include: 1. During an environmental inspection of the facility, the Compliance Officer observed two dogs in the assisted living section of the facility. 2. During the on-site inspection, at 9:33 AM, the Compliance Officer requested to review pet records. The Compliance Officer reminded E1 of this requirement after more than two hours had elapsed without any pet records having been provided. However, no pet records were provided for review. 3. In an interview, E1 and E2 acknowledged documentation of current rabies vaccination for each dog at the facility had not been provided for review.

Based on record review, documentation review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for one of three residents sampled who received directed care services. The deficient practice posed a risk if employees were unaware of a significant change in a resident's condition. Findings include: 1. A review of R5's medical record revealed a service plan, updated June 24, 2024, for directed care services. However, the service plan did not include documentation of R5's weight or documentation from a medical practitioner stating weighing R5 was contraindicated. The provided service plan was overdue for an update, however, a current service plan for R5 was not available for review. 2. A review of department records revealed a plan of correction submitted to the Department on August 29, 2024 for inspection #BYJZ11, conducted on June 7, 2024. The plan of correction stated, for rule R9-10-815.C.6.a-b, the correction had been completed on July 17, 2024. The plan of correction stated, "The Resident Care Director completed a full audit of service plans for resident's receiving Directed Care Services and 100% of service plans were updated to include a current weight...The Resident Care Director or designee will monitor compliance with the updated process by auditing the Electronic Medical Record for completion of weight entries on a monthly basis." 3. In an interview, E1 and E2 acknowledged R5's service plans did not include R5's weight or documentation from a medical practitioner stating weighing the resident was contraindicated. This is a repeat deficiency from the on-site complaint inspection conducted on June 7, 2024, the on-site compliance and complaint inspection conducted on October 17, 2023, and the on-site compliance inspection conducted on October 27, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for four of five residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, the Department was unable to determine substantial compliance, and false or misleading information was provided to the Department. Findings include: 1. On September 26, 2024 at 9:45 AM, the Compliance Officer requested full charts for R1, R2, R3, R4, and R5 from E2. 2. On September 26, 2024, at 10:15 AM, the Compliance Officer was provided partial charts for each resident. The provided records included initial orders for each resident, however, they did not include current, signed medication orders for any of the five sampled residents. The Compliance Officer notified E1 of the omission and E1 agreed to provide current, signed medication orders for each resident. However, as of the exit interview, conducted on September 26, 2024 at 12:00 PM, current signed orders, and full charts for each resident, had not been provided for review. 3. A review of R1's medical record revealed a service plan, updated August 14, 2024, for personal care services. The service plan included medication administration and stated, "Provide medication assistance to [R1] to include administering, reordering and storage of medications per provider order. Observe for swallowing difficulties. Report Observations." 4. A review of R1's medical record revealed current, signed medication orders were not available for review. 5. A review of R1's medical record revealed a signed list of medication orders dated October 26, 2023, which included: - "Metoprolol XL 100mg 1 daily"; - "Furosemide 20mg 1 daily"; - "Amlodipine 10mg 1 daily"; - "Ezetimibe 10mg 1 daily"; - "Losartan 50mg 1 twice daily"; - "Eliquis 5mg Twice daily"; - "Digoxin 0.125mg Daily on Mon, Wed"; and - "Insulin Glargine 30 units, Every evening after dinner." 6. During an environmental inspection of the facility, at 11:15 AM, the Compliance Officer observed R1 was by themselves in their bedroom. The Compliance officer observed R1 had a clear medication cup on a cabinet next to R1's bed, containing two pills and a small piece of a tissue. The Compliance Officer observed an unlocked drawer in R1's bedside cabinet contained various medications, including, "Orajel," and "Premarin." 7. In an interview, R1 showed the Compliance Officer the medication cup on R1's cabinet. R1 reported R1 does not take the "water pill" before lunch because it makes R1 go to the restroom constantly, R1 stated the staff handed R1 the cup of medications but R1 saves some of them for after lunch. R1 reported not knowing what the other two pills were, but said one looked like R1's blood pressure medication. R1 showed the Compliance Officer the tube of, "Premarin," cream and stated R1 rubs it on R1's wrists for arth

Based on observation, record review, and interview, the manager failed to ensure that medication 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 the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed R1 was in R1's bedroom alone. The Compliance officer observed R1 had a clear medication cup on a cabinet next to R1's bed, containing two pills and a small piece of a tissue. The Compliance Officer observed an unlocked drawer in the bedside cabinet contained various medications, including, "Orajel," and "Premarin." 2. In an interview, R1 showed the Compliance Officer the medication cup on R1's cabinet. R1 reported R1 does not take the "water pill" before lunch because it makes R1 go to the restroom constantly, R1 stated the staff handed R1 the cup of medications but R1 saves some of them for after lunch. R1 reported not knowing what the other two pills were, but said one looked like R1's blood pressure medication. R1 showed the Compliance Officer the tube of, "Premarin," cream and stated R1 rubs it on R1's wrists for arthritis. R1 reported R1 had not taken insulin the previous day at all because R1 was sweaty and shaky when R1 woke up and knew R1 should not take insulin when R1 felt like that and the staff had argued with R1 about it. R1 showed the Compliance Officer some bottles of apple juice stored in the same drawer with the medications and stated R1 knows to keep apple juice around for when R1's blood sugar is low like that. 3. A review of R1's medical record revealed a service plan, updated August 14, 2024, for personal care services. The service plan included medication administration and stated, "Provide medication assistance to [R1] to include administering, reordering and storage of medications per provider order. Observe for swallowing difficulties. Report Observations." 4. In an interview, E1 and E2 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on October 17, 2023, from the onsite compliance inspection conducted on October 27, 2022, and from the on-site compliance inspection conducted on November 8, 2021.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, when initially developed and when updated, for one of one residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated April 25, 2024. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 2. A review of 12's medical record revealed a service plan updated June 5, 2024. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 3. In an interview, E1 and E2 acknowledged the service plans provided for R1 did not include all required signatures. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022 and the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for one of one residents sampled who received directed care services. The deficient practice posed a risk if employees were unaware of a significant change in a resident's condition. Findings include: 1. A review of R1's medical record revealed a service plan, dated April 25, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R1's medical record revealed a service plan, dated June 5, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 3. In an interview, E1 and E2 acknowledged R1's service plans did not include R1's weight or documentation from a medical practitioner stating weighing the resident was contraindicated. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022, and the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the hot water temperature measured at 125.1\'b0 F in a resident's private bathroom in the personal care services building. 2. In an interview, E1 and E2 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of seven personnel members sampled. The deficient practice posed a risk if E6 and E8 were a danger to a vulnerable population. Findings include: 1. A review of E6's personnel record revealed E6 was hired as a caregiver in September of 2023. The record included a copy of E6's fingerprint clearance card, which was issued on September 20, 2019, with an expiration date of September 20, 2025. In addition, the record included an employment application which outlined E6's work history between May 2017 and October 2018, and between May 2022 and September 2023. However the application indicated E6 was "Unemployed" between November 2018 and April 2022. Further, the record included a resume for E6 which included a section titled, "Work Experience," which identified E6's work history between May 2017 thorough October 2018, and May 2022 through "present." However, evidence of employment between November 2018 and April 2022 was unavailable for review. 2. A review of E8's personnel record revealed E8 was hired as a caregiver in March of 2022. The record included a copy of E8's fingerprint clearance card, which was issued on August 14, 2020, with an expiration date of August 14, 2026. In addition, the record included an employment application which outlined E8's work history between June 2019 and February 2021. However the application indicated E8 was "Unemployed" between March 2019 and January 2021, and between February 2021 and March 2022. 3. In an interview E1 acknowledged E6's and E8's employment history contained more than a six month gap in employment prior to being hired as caregivers. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On October 17, 2023, the Compliance Officers requested the following document during the on-site inspection: - a Therapeutic Diet Manual; - the Policies and Procedures; - Current medication orders for R2, R3, and R5; and - Work schedules for the previous 12 months. However, this documentation was not provided for review within the two hour window. 2. In an interview, E1 and E2 acknowledged the requested documentation had not been provided for review within two hours after a Department request. Technical assistance for this rule was provided during the on-site compliance inspection conducted on October 27, 2022.

Based on interview and documentation review, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe exploitation had occurred on the premises, the manager complied with all the requirements in R9-10-803(J), which posed a health and safety risk. Findings include: 1. In an interview, E1 reported R5 was missing a ring and the facility investigated the allegation of exploitation. E1 reported adult protective services and the police were contacted. E1 reported R5's family confirmed they had not taken the ring and it was missing. E1 reported no witnesses reported seeing anyone taking the ring. E1 reported after investigating this incident as well as other allegations of missing items, an employee and their lead were both terminated due to credible concerns of missing food taken from the facility, however, the facility was not able to determine if the resident's missing items were stolen. E1 provided an incident investigation report to the Compliance Officers. 2. A review of facility documentation revealed an incident investigation report which concluded with the termination of E8 due to "theft". However, the investigation report was not dated within five days following the alleged incident and did not include the following: - documentation of the reports made to Adult Protective Services and to the police; - the dates, times and a description of the suspected exploitation of R5, only of other residents; - A description of any change to R5's emotional condition; and - the names of witnesses to the suspected exploitation. 3. In an interview, E1 and E2 acknowledged the provided investigation report did not include all of the required items and did not include any documentation of the specific incident regarding R5's missing property.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, and included medication administration or assistance in the self-administration of medications, for six of six sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated July 20, 2023, for Personal Care Services. However, R1's service plan did not include the following required information: - Whether R1 would receive medication administration or assistance in the self-administration of medications; - The type, amount and frequency of, "breathing treatments"; - The amount and frequency of, "laundry" services; and - The type, amount, and frequency of "skin maintenance." 2. A review of R2's medical record revealed a service plan, dated August 11, 2022 , for Directed Care Services. However, R2's service plan did not include the following required information: - The type, amount and frequency of, "Joint Limitations." 3. A review of R3's medical record revealed a service plan, dated April 27, 2023, for Directed Care Services. However, R3's service plan did not include the following required information: - Whether R3 would receive medication administration or assistance in the self-administration of medications; and - The frequency of, "bathing" services. 4. A review of R4's medical record revealed a service plan, dated August 21, 2023, for Personal Care Services. However, R4's service plan did not include the following required information: - Whether R4 would receive medication administration or assistance in the self-administration of medications; - The frequency of, "skin maintenance"; - The frequency of, "grooming" services; and - The type, amount, and frequency of, "toileting" services. 5. A review of R5's medical record revealed a service plan, dated December 02, 2022, for Directed Care Services. However, R5's service plan did not include the following required information: - The frequency of, "Showers"; - The frequency of, "Brushing Hair/Teeth, Shave & Wash Face, Applying Lotion"; - The frequency of, "Housekeeping/Trash Liners/Soiled Clothing/Incontinence Supplies;" and - Whether R3 would receive medication administration or assistance in the self-administration of medications 6. A review of R6's medical record revealed a service plan, dated October 17, 2023, for Personal Care Services. However, R6's service plan did not include the following required information: - The frequency of "Grooming/Oral Hygiene" services. 7. In an interview, E1 and E2 acknowledged the service plans provided for each resident did not accurately include the amount, type and frequency of assisted living services being provided to each resident, and did not include whether each resident would receive medication administration or assistance in the self-administration of medications,

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for three of six residents sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 11, 2022, for directed care services. A current service plan was requested, however, the second service plan provided for review was dated October 17, 2023, the date of the inspection. 2. A review of R3's medical record revealed a service plan, dated April 27, 2023, for directed care services. A current service plan was requested, however, a current service plan was not provided for review. 3. A review of R5's medical record revealed a service plan, dated December 02, 2022, for directed care services. A current service plan was requested, however, a current service plan was not provided for review. 4. In an interview, E1 and E2 acknowledged the service plans provided for R2, R3 and R5 indicated service plans for directed care residents had not been reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, when initially developed and when updated, for three of six residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated August 11, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 2. A review of R2's medical record revealed a service plan dated October 17, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 3. A review of R5's medical record revealed a service plan dated December 02, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 4. A review of R6's medical record revealed a service plan dated October 17, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan. 5. In an interview, E1 and E2 acknowledged the provided service plans for R2, R5 and R6 had not been signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plans, when initiated or when updated. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for five of five sampled residents reviewed. Findings include: 1. A review of the facility work schedule revealed the facility worked on three shifts per day, a first shift from 6 a.m. to 2:30 p.m., a second shift from 2 p.m. to 10:30 p.m., and a third shift from 10 p.m. to 6:30 a.m. 2. A review of five sampled resident medical records revealed all five resident's records included a service plan detailing the services to be provided to each resident. 3. A review of five sampled resident' electronic medical records revealed electronic documentation of services provide to each resident. For each required service, the electronic record documented the initials of the caregiver and the time the service was provided. However, for all five residents, the electronic service records included gaps during which a caregiver had not documented services provided during their shift. 4. In an interview, E1 and E2 acknowledged the provided medical records did not include documentation of all of the services provided to each resident on each shift by each caregiver.

Based on documentation review and interview the manager failed to ensure a dog residing at the facility was licensed consistent with local ordinances. Finding include: 1. A review of facility documentation revealed a current rabies vaccination for a resident's dog. However, documentation of current licensure in Pima County for the dog was not provided for review. 2. In an interview, E1 and E2 acknowledged a current license for the resident's dog had not been provided for review.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for three of three residents sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 11, 2022, for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. A review of R3's medical record revealed a service plan, dated April 27, 2023, for directed care services. However, the service plan did not include documentation of R3's weight or documentation from a medical practitioner stating weighing R3 was contraindicated. 3. A review of R5's medical record revealed a service plan, dated December 2, 2022, for directed care services. The service plan included documentation of R5's weight in July and August 2023, however documentation of R5's weight in September and October, or documentation from a medical practitioner stating weighing R5 was contraindicated was unavailable for review. 4. In an interview, E2 reported vital sheets are used to collect this information on a monthly basis. E1 and E2 acknowledged R2's, R3's and R5's service plans did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a cabinet in R6's bathroom which did not have a lock and was accessible to R6 at all times. Inside the cabinet, the Compliance Officers observed tubes of, triamcinolone acetonide, "Preparation H," and Hydrocortisone cream. 2. A review of R6's medical record revealed a service plan, updated October 17, 2023, for personal care services which included the service, "[R6's] medications will be stored in the locked medication cabinet in [R6's] room and administered as prescribed by the physician." 3. In an interview, E1 and E2 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022, and from the on-site compliance inspection conducted on November 8, 2021.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During a facility tour, the Compliance Officers observed a refrigerator located in the directed care building, "Cottonwood", contained a thermometer which registered at 45\'b0F. The Compliance Officers observed the refrigerator contained foods requiring refrigeration. 2. In an interview, E1 and E2 acknowledged potentially hazardous foods requiring refrigeration were not maintained at 41\'b0F or below.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator. Findings include: 1. During the facility tour, the Compliance Officers observed a refrigerator in the personal care building. The refrigerator contained foods requiring refrigeration. However, the refrigerator did not contain a thermometer 2. In an interview, E2 reported the refrigerator is provided by the facility for resident use, and it is used by residents to store their own food or snack items. 3. In an interview, E1 and E2 acknowledged the refrigerator did not contain a thermometer.

Based on documentation review and interview, the manager failed to ensure a disaster plan review was documented according to R9-10-818(A)(3)(a-d). Findings include: 1. A review of the facility's policies and procedures revealed a disaster plan. The disaster plan had been signed and dated annually by the manager to indicate a review. However, the time of the review, the name of each employee who participated, and a critique of the review were not available. 2. In an interview, E1 and E2 acknowledged the annual disaster plan review was not documented as required by the rule.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked on three shifts per day, a first shift from 6 a.m. to 2:30 p.m., a second shift from 2 p.m. to 10:30 p.m., and a third shift from 10 p.m. to 6:30 a.m. 2. A review of facility disaster drills conducted during the previous twelve months revealed documentation of the following drills conducted during the previous twelve months: - No drills conducted between October 2022 and December 2022; - First shift drills were conducted on January 27, 2023, April 11, 2023, May 16, 2023 and August 10, 2023; - Second shift drills were conducted on April 11, 2023, June 26, 2023, July 18, 2023 and September 14, 2023; and - Third shift drills were conducted on February 9, 2023, April 11, 2023, July 5, 2023, and October 13, 2023. 3. In an interview, E1 and E2 acknowledged documentation of disaster drills conducted on each shift at least once every three months for the previous twelve months had not been provided to the Compliance Officers upon request. This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed documented evacuation drills during the previous twelve months were conducted on November 17, 2022. However, documentation of an evacuation drill due on or before May 17, 2023 was not provided for review. 2. In an interview, E1 and E2 acknowledged documentation of evacuation drills conducted at least once every six months had not been provided to the Compliance Officers upon request.