Hidden Valley Assisted Living

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for one of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E2’s personnel record revealed no documentation for fall prevention and recovery training. 2. A review of the facility's staff schedule revealed E2 provided services to the residents. 3. In an exit interview, the findings were reviewed with E1 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.C 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 and R2's medical records revealed no standardized form to be used if an emergency responder was contacted. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures for one of the two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of the facility's records revealed documentation in their policies and procedures titled, "CAREGIVER, ASSISTANT CAREGIVER AND VOLUNTEER" that contained the following verbiage: "The hiring person or manager will ensure, check, and document that each caregiver or assistant caregiver providing physical health services or behavioral care services have the required skills and knowledge before providing any service. This will be completed by checking 2 Personal and 2 Professional references upon hire....The skills and knowledge are verified by the manager at the time of the orientation, before providing assisted living services to a resident." 2. A review of R2's personnel record revealed a document titled, "Character references" that listed two personal and two professional references, however, only the two professional references were contacted by the facility manager. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed no documentation that included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's date of acceptance, this documentation was required. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a resident’s medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Finings include: 1. During an environmental inspection of the facility, the Compliance Officers observed that there was a binder of files left out on a table belonging to one of the residents. The binder contained documents that revealed the protected health information of a resident and could be easily accessed by any person in the facility or subjected to loss or damage. 2. The name of the resident was listed on the front of the binder. 3. In an exit interview, the findings were reviewed with E1 who stated they did not know the files were out of place, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed there was no medication order on file for the following medications: Polythylene, mix 17 gm in 8 oz water and drink daily; and Trazodone, 50 mg,1 tab by mouth daily at 8pm. 2. A review of R1's medical record revealed a medication administration record (MAR) that showed documentation that R1 was administered the following medications: Polythylene, mix 17 gm in 8 oz water and drink daily; Trazodone, 50 mg,1 tab by mouth daily at 8pm; 3. 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 that there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the facility's documentation revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility, the Compliance Officers (COs) observed there was an alarm on a sliding door in the facility that led to the backyard, however, the alarm did not make a sound when the door was opened. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident’s medical record, for one of the two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. The Compliance Officers (COs) requested a printed copy of R2's September 2025 medication administration record (MAR) at the start of the inspection. 2. A review of R2’s September 2025 MAR revealed no documentation that the following medications were administered on September 1-9, 2025: Meclizine/Antivert, 25 mg, 1 tablet po twice a day; Methocarbamol/Robaxin, 500 mg, 2 tablets po three times a day; Omeprazole, 20 mg, 1 tablet po daily evenings; Prochlorperazi 10 mg, 1 tablet po every six hours; Sertraline/Zoloft, 100 mg, 2 tablets po every morning; and Trazodone, 50mg, 1 tab po daily at night. 3. The COs observed that each of the above medications had a pill from its pill bottle in the medication organizer in the proper sections assigned to the instructed administration times according to the directions of each medication. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation 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 residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed a refrigerator in the kitchen that contained a box with a code combination. The COs were able to open the box and easily access the medication that was inside. The medication included: Morphine Sulfate, 100 mg; Lorazepam, 2mg; Lantus Insulin Injection Pen, 100mL; Bisacodyl suppositories, 10 mg; and Timolol Maleate eyedrops, 0.5%. 2. During an environmental inspection of the facility, the COs observed a medicine cabinet behind a mirror in the bedroom of R2 and R3. The cabinet contained Refresh Plus lubricant eyedrops medication. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on April 24, 2024.

Based on observation and interview, the manager failed to ensure that a refrigerator used by the assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed there was no thermometer for a refrigerator used to store food for residents. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation and interview, the manager failed to ensure that a disaster plan included when, how, and where residents will be relocated, how a resident’s medical record will be available to individuals providing services to the resident during a disaster, a plan to ensure each resident’s medication will be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility’s documentation/policies and procedures revealed a disaster plan for the facility, however, the plan did not include the following: where and how residents will be relocated, along with the address of relocation; how a resident’s medical record will be available to individuals providing services to the resident during a disaster. a plan to ensure each resident’s medication will be available to administer to the resident during a disaster; a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster; 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a smoke detector was installed in each bedroom. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed there was no smoke detector in the bedroom of the live-in caregiver. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of five employees reviewed. The deficient practice posed a 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E1 and E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E1 and E3's hire date, this documentation was required. 4. In an interview, E4 acknowledged E1 and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the name and signature of the individual administering medication, for one of two residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of R2's (received medication administration) medical record revealed a signed medication order dated April 2024, for the following medications: -Clopidogrel 75 mg take one tablet daily -Buspirone 15 mg take one tab twice a day 2. A review of R2's medication administration record (MAR) for April 2024, listed Clopidogrel and Buspirone. However, the MAR did not contain the name and signature of the individual administering the medication for the 8:00 AM administration on April 10th and April 12, 2024. 3. In an interview, E2 reported the medication was administered to R2, however, E2 forgot to sign the MAR. E2 acknowledged the medical record for R2 did not include the name and signature of the individual administering the medication. .

Based on observation, documentation review, and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed the following medication in a ziplock bag sitting on a shelf inside the kitchen refrigerator: - Multiple syringes of "Humalog KwikPen 3ML 100 u/ML." 2. A review of facility documentation revealed a policy titled "Medication and Medication Services Policies and Procedures." The policy stated " Medication requiring refrigeration will be kept in a locked container in the refrigerator." 3. In an interview, E2 acknowledged the medication were stored unlocked.