Imperial Palace Assisted Living LLC

Based on documentation review, interview, and record review, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently and required information could not be verified. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) covering training regarding fall prevention and fall recovery, including the time frame for continued competency training. 2. In an interview, E1 reported staff received training regarding fall prevention and fall recovery annually. 3. A review of E2’s personnel record revealed E2 was hired as the manager on September 12, 2023. The review revealed documentation of training regarding fall prevention and fall recovery dated January 2, 2023, and May 20, 2024. However, the review revealed E2 did not receive training regarding fall prevention and fall recovery upon hire or annually after May 20, 2024. 4. In an interview, E1 stated, “There’s a lapse.” When the Compliance Officer asked if E1 had provided the Compliance Officer with E2’s entire personnel record, E1 stated, “Yes.” 5. A review of E3’s personnel record revealed E3 was hired as a caregiver on January 22, 2025. The review revealed documentation of training regarding fall prevention and fall recovery dated December 19, 2024, and February 22, 2025. However, the review revealed E3 did not receive training regarding fall prevention and fall recovery upon hire. 6. In the exit interview, the findings were reviewed with E1 and E1 provided no additional information.

Based on observation, interview, documentation review, and record review, the governing authority failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings: 1. The Compliance Officer observed E4 working at the facility. 2. In an interview, E1 reported E4 was hired as a caregiver. 3. A review of facility documentation revealed a series of personnel schedules which indicated E4 worked as a caregiver every day between January 1, 2025, and the date of the inspection, with the exception of October 3-5, 2025. 4. A review of R1’s and R2’s medical records revealed documentation of assisted living services (ADLs) provided to R1 and R2 and medication administration records (MARs) dated January 2026. The ADLs and MARs revealed E4 provided assisted living services to R1 and R2 on January 1-14, 2026. 5. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed a photocopy of a caregiver certificate reportedly given by Best of All Institute of Training on December 20, 2010. 6. In an interview, E4 reported E4 came to the United States of America for the first time in November 2018. E4 reported E4 took the caregiver training course and received E4’s caregiver training certificate in 2019. 7. In the exit interview, the findings were reviewed with E1 and E1 reported E4 must have been wrong about when E4 first came to the United States of America and when E4 received E4’s caregiver certificate. When the Compliance Officer asked if E1 or E4 had any type of documentation demonstrating E4 was in Arizona in 2010 when the caregiver certificate was supposedly issued, E1 and E4 reported not having any.

Based on documentation review, interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING POLICY.” The P&P stated: “Employees are required to accurately record all time worked, including the time they begin and end each shift. Staff should also record the beginning and ending time of any split shift or departure from work for personal reasons. Employees are responsible for completing their own name records on a daily basis. Altering, falsifying, tampering with time records, and/or recording time on another employee's time record will result in disciplinary action, up to and including termination.” 1. A review of facility documentation revealed a personnel schedule dated January 2026. The schedule indicated the following: - E3 and E4 worked from 7:00 AM to 7:00 PM on January 1-15, 2026; - E3 worked from 7:00 PM to 7:00 AM on January 2, 4, 10-14, 2026; and - E4 worked from 7:00 PM to 7:00 AM on January 1, 3, and 5-9, 2026. 2. In an interview, E3 reported E4 administered all morning and mid afternoon medications and E3 administered all evening and nighttime medications. 3. A review of R2’s medical record revealed a medication administration record (MAR) and a “CONTROLLED SUBSTANCE ADMINISTRATION RECORD AND INVENTORY” (CASRI) dated January 2026. The MAR and CSARI revealed E3 administered medication to R2 at 11:00 PM on January 1, 3, and 5-9, 2026, even though E3 did work on those dates at those times according to the personnel schedule. 4. A review of R1’s and R2’s medical records revealed documentation of assisted living services (ADLs) provided to R1 and R2 dated January 2026. The ADLs revealed E4 provided assisted living services at 3:00 AM and 5:00 AM on January 2, 4, 10-14, 2026, even though E4 did work on those dates at those times according to the personnel schedule. 5. In an interview, E1 reported E3 and E4 were live-in caregivers and worked each shift together. E1 acknowledged the personnel schedule did not indicate E3 and E4 worked each shift together. E1 further acknowledged the personnel schedule did not include an accurate accounting of the hours worked by E3 and E4. 6. In the exit interview, the findings were reviewed with E1 and E1 provided no additional information.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “RECORDING AND DOCUMENTATION.” The P&P stated, “Documentation will be completed by the caregiver or personnel completing the task, providing the service or assisting the resident. No person is to document care or services provided by another individual.” 2. In an interview, E1 reported E3 and E4 were live-in caregivers and worked each shift together and would often help each other provide services to the residents. 3. A review of R1’s medical record revealed documentation of assisted living services (ADLs) provided to R1 dated January 2026. The ADLs revealed the following: - E4 provided R1 with oral care two times daily on January 1-14, 2026; - E4 combed R1’s hair on January 1-14, 2026; and - E4 gave R1 sponge baths on January 1-14, 2026. 4. In an interview, when the Compliance Officer asked who provided R1’s oral care, E3 stated, “[R1’s] the one brush [R1’s] teeth. When the Compliance Officer asked who combed R1’s hair, E3 stated, “[R1’s] the one brush [R1’s] hair” and “We give only the comb.” WHen the Compliance Officer asked if caregivers gave R1 sponge baths, E4 stated, “No.” 5. A review of R2’s medical record revealed ADLs provided to R2 dated January 2026. The ADLs revealed the following: - E4 gave R2 sponge baths on January 1-14, 2026; - E4 provided R2 with oral care two times daily on January 1-14, 2026; - E4 combed R2’s hair on January 1-14, 2026; - E4 dressed R2 on January 1-14, 2026 - E4 provided skin care to R2 on January 1-14, 2026; and - E4 elevated R2’s feet when R2 was sitting on January 1-14, 2026. 6. In an interview, when the Compliance Officer asked if caregivers gave R2 sponge baths, E4 stated, “No” and “Not often.” E1 reported R2 brushed R2’s own teeth. When the Compliance Officer asked who combed R2’s hair, E4 stated, “[R2].” When the Compliance Officer asked who dressed R2, E4 stated, “[R2’s] the one.” E3 reported E3 changed R2’s shirt on January 14, 2026, without E4 present, even though E4 was the caregiver who documented the service on the ADLs. When the Compliance Officer asked who provided skin care, E4 stated, “[R2].” E1 reported R2 elevated R2’s own feet when sitting. When the Compliance Officer asked what services caregivers provided to R2, E1 reported caregivers administered R2’s medications and provided R2 with showers, peri care, and nail care. 7. In a separate interview, E1 reported E4 was the caregiver who documented services on the ADLs even though E4 was not always the caregiver who provided those services, stating, “[E4] did sign

Based on observation, documentation review, interview, and record review, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance, and the name and signature of the individual administering or providing assistance in the self-administration of medication, for one of three sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. At 2:15 PM, the Compliance Officer observed a medication tablet on the dining room table with the number “019” imprinted on the tablet. 2. A review of drugs.com revealed the tablet as Tramadol Hydrochloride 100 mg. 3. In an interview, E1 reported the tablet belonged to R3. 4. A review of R3’s medical record revealed a medication administration record (MAR) and a “CONTROLLED SUBSTANCE ADMINISTRATION RECORD AND INVENTORY” (CSARI) both dated January 2026. The MAR indicated E4 administered R3’s tramadol at 7:00 AM on the date of the inspection while the CSARI indicated E4 administered R3’s tramadol at 6:00 AM on the date of the inspection. 5. In an interview, E4 reported the tramadol sitting on the dining room table was the tramadol E4 was to have administered to R3 on the morning of the inspection. E4 reported E4 did not administer the tramadol but documented the administration anyway in error. 6. In the exit interview, the findings were reviewed with E1 and E1 provided no additional information.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed the front door was unlocked and had an alert installed. However, the alert was missing the necessary magnet portion and did not sound when the Compliance Officer opened the door The Compliance Officer further observed no monitoring system in place. 3. In an interview regarding the missing magnet portion of the alert, E3 stated, “It got removed.” 4. The Compliance Officer observed a sliding glass door leading from a bedroom to the backyard. However, the Compliance Officer observed no alert installed and heard no alert upon opening the door. The Compliance Officer further observed no monitoring system in place. 5. In an interview, when the Compliance Officer asked if the sliding glass door ever had an alert installed since the facility opened, E1 stated, “This one, no.” 6. In the exit interview, the findings were reviewed with E1 and E1 provided no additional information.