Lakeside Assisted Living LLC

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled "Fall Prevention and Recovery," that stated: "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter." 2. A review of E1's personnel record revealed E1 had no Fall Prevention and Fall Recovery training. 3. A review of E2's personnel record revealed E2 had Fall Prevention and Fall Recovery training; however, it was dated February 2024. 4 In an exit interview, the findings were reviewed with E4, and no additional information was required.

Based on record review and interview, the assisted living home failed to maintain written documentation of emergency responder (EMS) information that included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9) for two of three residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1's and R2’s medical records revealed the standardized emergency responder patient information form. However, the form was missing the name, address, and telephone number of the resident's current pharmacy. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure a personnel record included the individual’s starting date of employment. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officers observed E1 working at the time of the inspection alone in the house with no supervision. 2. A review of E1’s personnel record did not have the date of hire of the employee documented. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

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. A review of the facility’s documentation revealed no documentation showing the governing authority reviewed and evaluated the effectiveness of a quality management program at least once every 12 months. 2. A review of the facility’s policies and procedures, revealed a policy titled "Quality Management Program Including Incident Reports," that stated: "The facility governing authority reviews and evaluates the effectiveness of the quality management program at least once every 12 months." 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for one of two personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled "Employees and Volunteers Qualifications," that stated: "Each employee meets the qualifications, required skills, education knowledge, and experience." 2. A review of E1’s personnel record did not include documentation of the verification of E1’s skills and knowledge. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of the two 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 E1's personnel record revealed documentation of a TB signs and screening; however, it was not checked and marked as negative or positive. 3. A review of E2's personnel record revealed E2’s hire date of August 26, 2024. In addition, documentation of a TB signs and screening was available; however, it was not checked and marked as negative or positive. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. The Compliance Officers arrived at the facility and observed that E1 was alone in the facility without supervision. 2. A review of E1's personnel record revealed no documentation showing E1 had received orientation specific to the duties to be performed. 3. A review of the employee work schedule revealed documentation indicating that E1 worked both the day and night shift on November 24, 2025. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. The facility was licensed at the Directed Care Level. 2. The Compliance Officers arrived at the facility and observed that E1 was alone in the facility without supervision. 3. A review of E1’s personnel record did not have the date of hire or the role of the employee documented. A further review of E1’s personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 4. A review of the azcg.tmutest.com website revealed no documentation of a caregiver training certificate for E1. 5. A review of the facility’s policies and procedures, revealed a policy titled "Employees and Volunteers Qualifications," that stated: "C. Assistant Caregivers. 1. Will perform duties as established by the facility manager or manager designee. 2. Services will be provided to the resident only after receiving the specific training and documentation and under the supervision and direction of another caregiver or manager." 6. In an exit interview, the findings were reviewed with E4, and no additional information was provided

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three residents 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 R1's medical record revealed no documentation of the individual’s freedom from infectious tuberculosis. Based on R1’s date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E4 no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record, for three of three sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R1’s current service plan, dated November 2025, revealed R1 received the following services: -Nail care, “Nails checked daily and trimmed as needed”; and -Hair care, “Daily and as needed” 2. A review of R1’s activities of daily living (ADL) for the month of November 2025 revealed no documentation of hair or nail care services. No other documents were provided at the time of the inspection. 3. A review of R2’s current service plan dated November 2025, revealed R2 received the following service: -Nail care, “Nails checked daily and trimmed as needed” 4. A review of R2’s (ADL) for the month of November 2025 revealed no documentation of nail care services. No other documents were provided at the time of the inspection. 5. A review of R3’s current service plan dated November 2025, revealed R3 received the following services: -Nail care, “Nails checked daily and trimmed as needed”; and -Hair care, “Daily and as needed” 6. A review of R2’s (ADL) for the month of November 2025 revealed no documentation of hair or nail care services. No other documents were provided at the time of the inspection. 7. In an interview, E4 reported the services were provided however they were not documented. 8. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of three residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of R2's medical record revealed a current written service plan that included directed care services and medication administration. 2. A review of R2’s November 2025 medication administration record (MAR) revealed “furosemide 20 mg take one tablet by mouth every other day” was administered for the month of November to present day. 3. A review of R2’s signed medication orders that were provided did not have furosemide 20 mg listed with the other medications. No other documentation was provided at the time of the inspection. 4. The Compliance Officers observed approximately four furosemide tablets in the pill bottle. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs and the department was provided false or misleading information. Findings include: 1. A review of R2's medical record revealed a current service plan dated November 2025, which stated, “Bed Ridden”. 2. A review of R2's medical record revealed a signed and dated determination dated February 4, 2025. However, additional documentation signed by a medical practitioner every six months was not available for review. 3. In an interview, the Compliance Officers asked for the missing determination for R2. E3 was observed with E3’s back towards the Compliance Officers, writing on a paper. Shortly after E3 brought over R2’s updated determination. However, the Compliance Officers smudged the date on the documentation E3 provided, indicating wet ink. 4. In an interview, E4 acknowledged the document that E3 provided to the Compliance Officers was falsified and written moments before it was presented to the Compliance Officers. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was 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 provided access to an outside area, and 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. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E4, the Compliance Officers observed that the front door leading out to the front of the house had an alarm; however, the alarm was inactive and the front yard area was not secured. 3. The Compliance Officers observed that in R1's room, the door leading to the backyard was unlocked and the door alarm was inactive. R1 received directed care services. 4. The Compliance Officers observed that the sliding back doors to the backyard were unlocked and the alarms were inactive. 5. In an exit interview. The findings were reviewed with E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of ten residents sampled. 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 R2's medical record revealed a current service plan for directed care services dated November 2025. This service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order. This order stated "Metoprolol Tartrate Tablet 50 MG take one tab(s) orally 2 times a day [Comments: Hold for systolic less than 110].” 3. A review of R2's November 2025 medication administration record (MAR) revealed "Metoprolol Tartrate Tablet 50 MG take one tab(s) orally 2 times a day [Comments: Hold for systolic less than 110].” was administered from November 1st to present. However, documentation was not available showing R2's systolic blood pressure (SBP) reading before each administration of the medication. 4. In an interview, E4 reported the SBP was taken before administration, but was not documented to be reviewed. 5. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members. This posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking. Findings include: 1. A review of R1's, R2's, and R3’s medical records revealed that they required medication administration. 2. During an environmental inspection of the facility, the Compliance Officers observed that no drug reference guide was available on site. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure there was a current toxicology reference guide that was available for use by personnel members. Findings include: 1. The Compliance Officers requested the current toxicology reference guide. However, the toxicology reference guide was not provided to the department for review. 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that medication was stored in a separate locked, 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 the environmental inspection, the Compliance Officers observed medication stored in an unlocked mini fridge in the kitchen. Medications included: Morphine Sulfate 20 MG/ 5 ML SOLN Morphine 20 MG/ML syringe, Lorazepam Oral Syringe 6ml. 2. During the environmental inspection, the Compliance Officers observed an unlocked cabinet in the kitchen with the following medications stored in it: Skintegrity ECO Paraben Free Hydrogel Antibiotic & Pain Relief Skintegrity Wound Cleaner Tetracyte First Aid & Antibiotic 3. A review of the facility’s policies and procedures revealed a policy titled "Medications Including Opioids, Narcotics, and Schedule 2," that stated: "Part II - Receiving, Storing Medication. 3. Medication stored by the facility must be secured in a locked storage area, closet, cabinet, or self-contained unit used for medication storage only. " 4. In an exit interview, findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The deficient practice posed a risk to physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed Lysol Disinfectant Wipes stored on the bathroom shelf next to the sink, as well as a bottle of Clorox Clinging Bleach Gel placed next to the toilet in R1’s bathroom, both stored by the facility. 2. The Compliance Officers observed the following bottles of toxic materials in the unlocked laundry room: Fabuloso Multi-Purpose Cleaner Great Value Glass Cleaner Great Value Toilet Bowl Cleaner Kirkland Laundry Detergent Lysol Disinfectant Spray 3. The Compliance Officers observed that the unlocked laundry room led to an unlocked garage containing the following bottles of toxic materials: Ajax Bleach Powder Cleanser Kaboom Shower, Tub & Tile Cleaner Value Refill Tilex Isopropyl Alcohol Quality Care Oven and Grill Cleaner 4. The Compliance Officers observed the following tubes of toxic materials in an unlocked cabinet in the kitchen: Cerama Bryte Stainless Steel Polish Rust-Oleum Painters Touch Ultra Cover Premium Latex Paint Sealant Fix 5. The Compliance Officers observed the following bottles of toxic materials stored under the kitchen sink in an unlocked cabinet: Liquid Plumr Urgent Clear Gel Dish Detergent Pods Liquid Ajax Ultra Liquid Ajax Ultra Triple Action 6. A review of the facility’s policies and procedures, revealed a policy titled "Environmental and Physical Plant Safety, includes Pest Control Program," that stated: "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents." 7. In an exit interview, the findings were reviewed with E4, and no additional information was provided.