Laurel Assisted Living Home LLC

Based on documentation review, interview, and record review, the governing authority failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of Department documentation revealed this statute went into effect on October 1, 2021. 2. A review of facility documentation revealed a policy and procedure (P&P) titled “FALL PREVENTION AND FALL RECOVERY TRAINING PROGRAM.” The P&P stated: “a. The assisted living facility shall develop and administer a comprehensive training program for all staff concerning fall prevention and fall recovery. b. The training program shall encompass initial training for newly hired staff and continued competency training for existing staff.” However, the P&P did not clearly include a time frame for continued competency training. 3. In an interview, E1 clarified facility personnel received the training upon hire and annually thereafter. 4. A review of E2’s personnel record revealed E2 was hired as the manager in 2025. The review revealed documentation demonstrating E2 received training regarding fall prevention and fall recovery through a third party company on January 7, 2025, before E2 was hired, and not by the facility upon hire as stated in the P&P. 5. A review of E3’s personnel record revealed E3 was hired as a caregiver before this statute went into effect. The review revealed E3 received training regarding fall prevention and fall recovery through a third party company on November 11, 2021, and February 15, 2024, and not by the facility as stated in the P&P. The review revealed E3 received training regarding fall prevention and fall recovery by the facility on July 7, 2025. The review further revealed more than one year between the trainings on November 11, 2021, and February 15, 2024, as well as between the trainings on February 15, 2024, and July 7, 2025. 6. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver in March 2025 then promoted to caregiver in April 2025. However, the review revealed E5 did not receive training regarding fall prevention and fall recovery until July 7, 2025, and not upon hire as stated in the P&P. 7. In an interview, when the Compliance Officer brought up the issue of E2’s, E3’s, and E5’s fall prevention and fall recovery training, E1 offered no comment.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for one of four sampled applicable personnel. The deficient practice posed a risk if a caregiver or assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “EMPLOYEE ORIENTATION” dated October 2018. The P&P stated, “New staff will be given an orientation form/skills/knowledge verification form and it will be completed by the manager or manager’s designee and the employee before providing services to residents.” The review further revealed a series of personnel schedules which indicated E5 worked several shifts each month between May 2025 and August 2025. 2. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, R8’s, R9’s, and R10’s medical records revealed documentation of assisted living services provided to the ten residents (ADLs) and medication administration records (MARs) dated August 2025. The ADLs and MARs revealed E5 provided assisted living services and medication administration to all ten residents in August 2025. 3. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver in March 2025 then promoted to caregiver in April 2025. The review revealed an orientation and skills and knowledge checklist. However, the “EMPLOYEE SKILLS CHECKED” portion was blank.” The review revealed no documentation of E5’s skills and knowledge as an assistant caregiver or as a caregiver. 4. In an interview, E1 reported the manager had not verified and documented E5’s skills and knowledge.

Based on documentation review, record review, 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 as 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. A review of facility documentation revealed a “QUALITY MANAGEMENT REPORT” dated March 2025. The report revealed R1 had eloped from the facility on March 15, 2025. 3. A review of R1’s medical record revealed a progress note dated March 15, 2025. The progress note stated: “at 10:35 in the Morning we Found Out that [R1] was Missing. Caregivers were Busy For Accomodating the need’s oF the Other’s Residence. And key For the Main Door is inside the Drawer Close to the kitchen. An we did not expert that [R1] took the key and open the Door and [R1] Switch oFF the ALam and that’s why nobody noticed [R1] skip. One oF the caregivers Found out the Door is SLightLy open and the keys left inserted in the Door Lock. and caregiver PromptLy search [R1]. in the Street. And in about 20 Minutes searching [R1] we decide to call police to inform and Report what happen. Then one oF the caregivers Cantinue to search [R1] and Finally Found [R1] walking along the Street closed to the post oFFice. We called police to inform them that [R1] Found.” 4. A review of E4’s personnel record revealed an “Employee Warning Letter” dated March 15, 2025. The letter stated: “10:35 the Caregiver noticed that the door is slightly open Caregivers immediately locate [R1] because [R1] is the only one ambulate and have a history of escaping.Caregivers immediately called the Manager to report the incident and then 3 Staffs starts searching [R1], after 20minutes of searching caregivers failed to find [R1] the Manager seek the help of the Police…Around 12:30 one of the Caregivers found [R1] infront of the USPS Shaw Bute location walking.” 5. A review of Google Maps revealed the Unites States Postal Service Phoenix Shaw Butte Station was 0.6 miles walking distance from the facility. 6. In an interview, E1 confirmed the details of the incident.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of five sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 3. A review of E3’s personnel record revealed E3 was hired as a caregiver before this rule went into effect. The review revealed E3 received training and education related to recognizing the signs and symptoms of TB on January 15, 2024, and March 17, 2025, and not initially or annually thereafter. 4. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver in March 2025 then promoted to caregiver in April 2025. However, the review revealed E5 did not receive training and education related to recognizing the signs and symptoms of TB until April 8, 2025, and not upon hire. 5. In an interview, when the Compliance Officer brought up the issue of E3’s and E5’s TB training, E1 offered no comment. Technical assistance was provided on this rule during the compliance inspection conducted on August 16, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of five sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(3) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E5's personnel record revealed E5 was hired after January 1, 2025. The review revealed a printout from the Adult Protective Services (A.P.S.) registry dated March 26, 2025, after E5 was hired. The printout revealed E5 was not on the A.P.S. registry. However, the review revealed facility personnel did not check the A.P.S. registry until after E5 was hired. 3. In an interview, E1 confirmed facility personnel did not check the A.P.S. registry for E5 until after E5 was hired.

Based on documentation review, observation, and interview, the manager failed to ensure a list of resident rights was conspicuously posted. The deficient practice posed a risk if residents were not properly informed of their rights. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54)(a-b) states: "'Conspicuously posted' means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. The Compliance Officer observed a document titled "RESIDENT'S RIGHTS" posted where the public entered the premises of the health care institution. 3. A review of the facility's "RESIDENT'S RIGHTS" posting revealed it stated: "B. A resident has the following rights: 7. To receive a referral to another health care institution if the assisted living in [sic] unable to provide physical health services or behavioral health services for the residents." However, this statement was contrary or inconsistent with the required resident rights listed in A.A.C. R9-10-810(C)(7) which states: "C. A resident has the following rights: 7. To receive a referral to another health care institution if the assisted living facility is not authorized or not able to provide physical health services or behavioral health services needed by the patient." 4. In an interview, E1 acknowledged the posted resident rights did not match those required by rule. This is a repeat citation from the compliance inspection conducted on August 16, 2023.

Based on documentation review, record review, and interview, the manager 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 two of four caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services and the Department was provided false or misleading information. Findings: 1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the compliance inspection conducted on August 16, 2023. The POC indicated this deficiency was corrected on November 15, 2023. The POC stated: “Starts August 20, 2023, the Manager put [E4] as an Assistant Caregiver and no longer works by [E4’s self], rather a Certified Caregiver works with [E4] and under the supervision of the Delegated Manager. Work Schedule has been changed and [E4], and 2 others [E1 and E3] were enrolled in November 15, 2023 at CAREE, a Certified Caregiving Training Program…[E1, E3, and E4 are] supposed to take the test on January 2024.” 2. A review of E3's personnel record revealed E3 was hired as a caregiver in 2021. However, the review revealed E3’s caregiver certificate was not issued until June 25, 2025. 3. A review of E4's personnel record revealed E4 was hired as a caregiver in 2022. However, the review revealed E4’s caregiver certificate was not issued until November 23, 2024. 4. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed the following: - E1 received a caregiver certificate on January 27, 2024, as reported in the POC; - E3 did not receive a caregiver certificate until June 25, 2025, in contradiction with the POC; and - E4 did not receive a caregiver certificate until November 23, 2024, in contradiction with the POC. 5. A review of facility documentation revealed a series of personnel schedules dated between June 2024 and November 2024. The schedule revealed the following: - On 25 occasions in June 2024, E3 and E4 worked the morning shift (7:00 AM to 7:00 PM) without a certified caregiver present; - On four occasions in June 2024, E4 worked the night shift (7:00 PM to 7:00 MM) without a certified caregiver present; - On 27 occasions in July 2024, E3 and E4 worked the morning shift without a certified caregiver present; - On 27 occasions in August 2024, E3 and E4 worked the morning shift without a certified caregiver present; - On 25 occasions in September 2024, E3 and E4 worked the morning shift (7:00 AM to 7:00 PM) without a certified caregiver present; - On 28 occasions in October 2024, E3 and E4 worked the morning shift without a certified caregiver present; and - On 20 occasions in November 2024, E3 and E4 worked the morning shift without a certified caregiver present. 6. In an interview, when the Compliance Officer brought up the issue of E3 and E4

Based on record review, documentation review, and interview, the manager failed to ensure an assisted living facility had caregivers and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to ensure the health and safety of a resident. Findings include: 1. A review of E3's personnel record revealed E3 was hired as a caregiver in 2021. However, the review revealed E3’s caregiver certificate was not issued until June 25, 2025. 2. A review of E4's personnel record revealed E4 was hired as a caregiver in 2022. However, the review revealed E4’s caregiver certificate was not issued until November 23, 2024. 3. A review of the caregiver certificate verification website (azcg.tmutest.com) confirmed E3 did not receive a caregiver certificate until June 25, 2025, and E4 did not receive a caregiver certificate until November 23, 2024. 4. A review of facility documentation revealed a series of personnel schedules dated between June 2024 and November 2024. The schedule revealed the following: - On 25 occasions in June 2024, E3 and E4 worked the morning shift (7:00 AM to 7:00 PM) without a certified caregiver present; - On four occasions in June 2024, E4 worked the night shift (7:00 PM to 7:00 MM) without a certified caregiver present; - On 27 occasions in July 2024, E3 and E4 worked the morning shift without a certified caregiver present; - On 27 occasions in August 2024, E3 and E4 worked the morning shift without a certified caregiver present; - On 25 occasions in September 2024, E3 and E4 worked the morning shift (7:00 AM to 7:00 PM) without a certified caregiver present; - On 28 occasions in October 2024, E3 and E4 worked the morning shift without a certified caregiver present; and - On 20 occasions in November 2024, E3 and E4 worked the morning shift without a certified caregiver present. 5. In an interview, when the Compliance Officer brought up the issue of E3 and E4 working alone without caregiver certificates, E1 offered no comment. 6. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver in March 2025 then promoted to caregiver in April 2025. The review revealed an orientation and skills and knowledge checklist. However, the “EMPLOYEE SKILLS CHECKED” portion was blank.” The review revealed no documentation of E5’s skills and knowledge as an assistant caregiver or as a caregiver. 7. A review of facility documentation revealed a series of personnel schedules which indicated E5 worked several shifts each month between May 2025 and August 2025. 8. In an interview, E1 reported the manager had not verified and documented E5’s skills and knowledge.

Based on observation, documentation review, record review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant 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. When the Compliance Officer arrived at the facility at approximately 9:45 AM, the Compliance Officer observed E3 and E4 working at the facility and no other personnel. Shortly thereafter, the Compliance Officer observed E1 arrive. 2. A review of facility documentation revealed a personnel schedule dated August 2025. The schedule indicated E3 and E5 were scheduled to work between 7:00 AM and 7:00 PM on the date of the inspection with E4 being scheduled to work between 7:00 PM and 7:00 AM, in contradiction with the Compliance Officer’s observation. 3. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, R8’s, R9’s, and R10’s medical records revealed documentation of assisted living services provided to all 10 residents (ADLs) dated August 2025. The ADLs revealed documentation demonstrating the following: - On August 1, 4-8, and 11, 2025, E5 provided all services, day and night; - On August 2-3, 9-10, 12-16, and 18, 2025, E4 provided all services, day and night; and - On August 17, 2025, E3 provided all services, day and night. 4. A review of facility documentation revealed a personnel schedule dated August 2025. The schedule revealed documentation demonstrating the following in contradiction with the ADLs: - E3 did not work on August 17, 2025; - E4 did not work on August 2-3, 9-10, and 16, 2025; - E4 did not work from 7:00 AM to 7:00 PM on August 12-15 and 18, 2025; and - E5 did not work from 7:00 PM to 7:00 AM on August 1 and 4-8, 2025. 5. In an interview, E1 acknowledged the personnel schedule was inaccurate. E1 reported E6 was out and E3 was with E1 at a training during the day on August 17, 2025. E1 reported E4 covered E5’s morning shifts on August 18-19, 2025. E1 reported caregivers from E1’s other home often came and helped at this facility and vice versa. E1 acknowledged E1 did not update the personnel schedule to reflect the changes. The Compliance Officer requested an accurate personnel schedule. 6. A review of facility documentation revealed a newly created personnel schedule dated August 2025. The schedule revealed documentation demonstrating the following in contradiction with the ADLs: - E3 did not work from 7:00 AM to 7:00 PM on August 17, 2025; - E4 did not work from 7:00 AM to 7:00 PM on August 2-3, 9-10, and 12-16, 2025; - E4 did not work from 7:00 PM to 7:00 AM on August 18, 2025; and - E5 did not work from 7:00 PM to 7:00 AM on August 1, 4-8, and 11, 2025. 7. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, R8’s, R9’s, and R10’s medical records revealed medication administration records (MARs) dated August 2025. The M

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan indicated R1 was incontinent and was to receive “Total [incontinence] care.” However, the service plan did not include the frequency of incontinence care. The review revealed documentation of assisted living services provided to R1 (ADLs) dated August 2025. The ADLs revealed R1 received frequent assistance with ambulation, checks on R1’s whereabouts throughout the day, night checks, partial baths, and turns while in bed. However, R1’s service plan did not include these five services. 2. A review of R2's medical record revealed a current service plan. The service plan indicated R2 was to receive assistance with feeding, mobility, and toileting. However, the service plan did not include the frequency of these three services. The review revealed ADLs dated August 2025. The ADLs revealed R2 received frequent checks on R2’s whereabouts throughout the day, night checks, partial baths, and turns while in bed. However, R2’s service plan did not include these four services. The service plan further indicated R2 was to receive assistance with dressing and hygiene on a daily basis. 3. In an interview, E1 reported R2 received assistance with dressing and hygiene twice per day. E1 acknowledged R1’s and R2’s service plans did not include the accurate amount, type, and frequency of assisted living services being provided to R1 and R2. This is a repeat citation from the compliance inspection conducted on August 16, 2023.

Based on interview and observation, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. In an interview, the Compliance Officer requested the resident medical records. E4 reported the medical records were kept in a closet in the office area. 2. The Compliance Officer observed E4 reach into a small basket on a shelf in the office area and retrieve a set of keys. The Compliance Officer observed E4 use one of the keys to unlock a closet in the office. Inside the closet, the Compliance Officer observed resident records. The Compliance Officer observed a binder containing resident records sitting on a shelf in the office area, separate from the closet. 3. In an interview, E4 reported the binder contained documentation of medications and assisted living services provided to the residents. 4. The Compliance Officer observed other binders containing resident records on the shelf below the first binder. 5. In an interview, E1 reported the other binders on the lower shelf were resident hospice binders. This is a repeat citation from the compliance inspections conducted on August 16, 2023, and March 10, 2022.

Based on record review, interview, and documentation review, the manager failed to ensure a resident’s medical record contained documentation of assisted living services provided to the resident, for ten of ten total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1’s medical record conducted at approximately 10:15 AM revealed documentation of assisted living services provided to R1 (ADLs) dated August 2025. However, the ADLs revealed R1 had already received oral care twice, assistance with dressing twice, incontinence brief changes three times, as well as fluid intake encouragement and incontinence care for the entire day on the date of the inspection. The review further revealed R1 had already watched a movie or participated in a memory care game on the date of the inspection. 2. In an interview, E1 reported R1 had not watched any movies or participated in any memory care games on the date of the inspection. E1 further reported the facility personnel had only provided oral care and assistance dressing one time on the date of the inspection, and not twice as documented on the ADLs. 3. A review of R3’s, R7’s, and R8’s medical records conducted at approximately 10:15 AM revealed ADLs dated August 2025. However, the ADLs revealed R3, R7, and R8 had already received oral care twice, assistance with dressing twice, incontinence brief changes three times, as well as fluid intake encouragement and incontinence care for the entire day on the date of the inspection. 4. A review of R2’s, R4’s, R5’s, R6’s, R9’s, and R10’s medical records conducted at approximately 10:15 AM revealed ADLs dated August 2025. However, the ADLs revealed R2, R4, R5, R6, R9, and R10 had already received oral care twice, assistance with dressing twice, incontinence brief changes three times, as well as fluid intake encouragement, incontinence care, and wheelchair transfers for the entire day on the date of the inspection. 5. In an interview, E1 acknowledged caregivers signed for services not yet provided. E1 reported the caregiver signing off on the ADLs was not always the caregiver providing the services. E1 reported E3 was usually assigned to R4, R5, R7, and R8; E4 was usually assigned to R2, R3, R6, R9, and R10; and the night shift caregiver was assigned to all residents. E1 reported the caregiver providing the services to the resident would tell the caregiver assigned to document services that day that the service had been provided and that caregiver would then document those services. 6. A review of all ten residents’ ADLs for August 2025 revealed documentation demonstrating the following: - On August 1, 4-8, and 11, 2025, E5 provided all services, day and night; - On August 2-3, 9-10, 12-16, and 18, 2025, E4 provided all services, day and night; and - On August 17, 2025, E3 provided all services, day and night. 7. A review of facility documentation revealed a personnel schedule d

Based on record review, documentation review, and interview, 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 the medication, for ten of ten total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1’s, R2’s, R3’s, R4’s, R5’s, R6’s, R7’s, R8’s, R9’s, and R10’s medical records revealed medication administration records (MARs) dated August 2025. The MARs revealed E3 administered all medications at all documented times to all ten residents on August 17, 2025. 2. A review of facility documentation revealed a personnel schedule dated August 2025 which indicated E3 did not work on August 17, 2025. Instead, the schedule revealed E6 and E7 worked from 7:00 AM to 7:00 PM and E8 worked from 7:00 PM to 7:00 AM. 3. In an interview, when the Compliance Officer asked if E3 had worked on Sunday, August 17, 2025, E3 stated, “No.” When the Compliance Officer showed E3 the MARs with E3’s initials under August 17, 2025, E3 paused and reported E3 administered the morning medications at approximately 7:30 AM then left the facility at approximately 9:00 AM for a training. E1 reported E3 returned at approximately 12:00 PM to administer the lunch medications, left again at approximately 1:00 PM to continue the training, then returned again shortly before 4:00 PM. 4. In an interview, E1 acknowledged the personnel schedule was inaccurate. E1 reported E6 was out and E3 was with E1 at a training during the day on August 17, 2025. E1 reported caregivers from E1’s other home often came and helped at this facility and vice versa. The Compliance Officer requested an accurate personnel schedule. 5. A review of facility documentation revealed a newly created personnel schedule dated August 2025 which indicated E3 did not work from 7:00 AM to 7:00 PM on August 17, 2025. Instead, the schedule revealed E6 and E8 worked from 7:00 AM to 7:00 PM and E3 and E4 worked from 7:00 PM to 7:00 AM. 6. In an interview, E1 reported the newly created schedule was accurate. When the Compliance Officer pointed out the discrepancies between the schedule, what E1 and E3 had already reported, and the MARs, E1 reported the caregivers lived at the facility and helped out whenever needed, even when the caregiver was not on the schedule. When the Compliance Officer informed E1 that doing so meant the schedule was inaccurate, E1 again argued the schedule was accurate, despite the discrepancies between the newly created schedule, what E1 and E3 had already reported, and the MARs. When the Compliance Officer again explained the schedule did not match what E1 and E3 had already reported or the MARs, E1 offered no comment. 7. A review of R1’s medical record revealed a MAR dated August 2025. The MAR indicated E3 administered

Based on observation, interview, record review, and documentation review, the governing authority failed to designate, in writing, an acting manager who has the qualifications established in R9-10-803(A)(3), when the manager was not present on the assisted living facility's premises for more than 30 calendar days. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. During a tour of the facility, the Compliance Officer observed E2's assisted living facility manager's license posted on the wall in the office area. 2. In an interview, E1 reported E2 was last at the facility in February 2023. E1 reported E1 and E2 spoke over the phone about the facility often. When the Compliance Officer brought up this rule, E1 changed E1's statement and reported E2 had been at the facility when R1 was admitted in late May 2023. 3. A review of R1's medical record revealed admission documents, including R1's residency agreement. All documents requiring the manager's signature were signed by E1 and not E2. 4. A documentation review revealed a series of daily staffing schedules dated between August 1, 2022, and August 16, 2023. The schedule revealed no documentation of E2 having worked at the facility between August 1, 2022, and August 16, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure a list of resident rights was conspicuously posted. The deficient practice posed a risk if residents were not properly informed of their rights. Findings include: R9-10-101(54) states conspicuously posted means "placed at a location that is visible and accessible; and unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 1. During a tour of the facility, the Compliance Officer observed a document titled "RESIDENT RIGHTS" posted in the office area. The Compliance Officer observed the office area was not within the area where the public entered the premises of a health care institution. 2. A review of the facility's "RESIDENT RIGHTS" posting revealed it stated: "A resident has the following rights: To receive a referral to another health care institution if the assisted living in [ sic ] unable to provide physical health services or behavioral health services for the residents." However, the aforementioned statement was contrary or inconsistent with the required resident rights listed in R9-10-810(C)(7) which states: "A resident has to following rights: To receive a referral to another health care institution if the assisted living facility is not authorized or not able to provide physical health services or behavioral health services needed by the patient." 3. In an interview, when the Compliance Officer asked if the aforementioned resident rights posting was the same as the one posted during the compliance inspection conducted on March 10, 2022, E1 stated, "Looks like it." Technical assistance was provided on this rule during the compliance inspection conducted on March 10, 2022.

Based on documentation review, interview, and record review, the manager 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. Findings include: 1. A documentation review revealed a policy and procedure titled "STAFFING: JOB DESCRIPTION: CAREGIVERS" dated February 2020. The policy and procedure stated, "A caregiver must be 18 years of age [and] must have documentation of completion of a caregiver training program approved by the NCIA Board." 2. In an interview, E1 reported E3 was hired as a certified caregiver. 3. A review of E3's personnel record revealed E3 was hired as a caregiver in mid 2022. The review revealed a caregiver certificate from Comfort Givers Assisted Living LLC dated June 9, 2014. The document stated the course was "Presented by Comfort Givers Assisted Living LLC . . . [and was] Coordinated by: Assisted Living Trainers Curriculum AITP [ sic ] # 0050." 4. A review of Department documentation revealed Comfort Givers Assisted Living LLC was a contracted training program but was not an active caregiver training program on June 9, 2014, when the certificate was issued. The review revealed the programs associated with ALTP 0050 were also not active caregiver training programs on June 9, 2014, when the certificate was issued. 5. A review of az.tmuniverse.com revealed no documentation of E3's completion of a caregiver training program approved by the Department or the NCIA Board after 2013. 6. A documentation review revealed a series of personnel schedules dated between August 1, 2022, and August 16, 2023. The schedules revealed E3 worked alone as a caregiver multiple times each month between August 2022 and August 2023. 7. In an interview, E1 acknowledged E3's caregiver certificate was issued after the aforementioned training programs were no longer active and could not be considered valid.

Based on interview and record review, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included whether the manager or a caregiver would be awake during nighttime hours, for six of ten total residents. The deficient practice posed a risk if a resident was not informed of the terms of residency. Findings include: 1. In an interview, E1 reported the facility did not have awake staff throughout the night. 2. A review of R3's medical record revealed a residency agreement which stated, "LAUREL ASSISTED LIVING HOME is a 24 hour/7 days awake staffed at night facility." Based on E1's aforementioned statement, the residency agreement did not accurately state whether a manager or a caregiver would be awake during nighttime hours. 3. In an interview, E1 acknowledged R3's residency agreement did not accurately state whether a manager or a caregiver would be awake during nighttime hours. E1 stated, "So we need to update [it]." Technical assistance was provided on this rule during the compliance inspection conducted on March 10, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included the type of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication, for nine of ten total residents. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of the medical records of R2, R3, R4, R5, R6, R7, R8, and R7 revealed current service plans which stated the facility was to "Assist with Administration" of medications. The service plans included a place for the individual(s) creating the service plans to choose "Administer Medication." However, none of the service plans indicated this option was chosen. 2. In an interview, E1 reported all residents received medication administration. E1 acknowledged the aforementioned service plans did not include the correct type of medication services provided to the residents. Technical assistance was provided on this rule during the compliance inspection conducted on March 10, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A documentation review revealed a policy and procedure titled "RESIDENT MEDICAL RECORDS AND DOCUMENTATION" dated October, 2018. The policy and procedure stated: "A Manager shall ensure that [a] resident's medical record is protected from loss, damage, or unauthorized use." 2. During a tour of the facility, the Compliance Officer observed an open office area. In the open office area, the Compliance Officer observed resident medical records, including medication administration records, medication orders, skin assessments, transportation records, progress notes, and other resident information. 3. In an interview, E1 stated the records were "in [a] different spot last year" during the compliance inspection conducted on March 10, 2022. E1 reported having moved the records from one spot in the open office area to another after that inspection. This is a repeat deficiency from the compliance inspection conducted on March 10, 2022.

Based on record review, interview, and observation,the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan dated June 8, 2023. The service plan stated the facility was to "Assist with Administration" of medications. 2. In an interview, E1 reported R2 received medication administration services and not assistance in the self-administration of medication services as stated on R2's service plan. 3. A review of R2's medical record revealed a medication order for "Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler Inhale 2 puff(s) 3 times a day by inhalation route for 90 days" dated July 28, 2023. 4. In an interview, the Compliance Officer requested to see R2's albuterol sulfate 90 mcg. 5. The Compliance Officer observed E1 give the Compliance Officer R2's Trelegy as well as R2's albuterol sulfate 1.25 mg/3 mL (both of which were included on the medication order separately from the albuterol sulfate 90 mcg). After being informed E1 provided the incorrect medications, E1 gave the Compliance Officer R2's albuterol sulfate 90 mcg. 6. A review of R2's medical record revealed a medication administration record dated August 2023. The record included no documentation demonstrating R2's albuterol sulfate 90 mcg had been administered between August 1, 2023, and August 16, 2023, nor did the record include a place to document its administration. 7. In an interview, E1 reported facility personnel had not been administering R2's albuterol sulfate 90 mcg.

Based on observation, documentation review, and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. During a tour of the facility, the Compliance Officer observed E5 cooking. 2. A documentation review revealed a menu posted in a hallway near the kitchen. The menu was dated between July 29, 2023, and August 5, 2023. Behind this first menu was a second menu dated August 6-12, 2023, and a third menu dated August 13-19, 2023. The third menu revealed the facility was to serve corn dogs, potato salad, soda, ice cream, and soup for lunch on August 16, 2023. The three menus revealed no documentation of any food substitutions. 3. In an interview, E5 reported E5 was cooking beef soup for lunch. E5 reported the posted menu was for the current week. The Compliance Officer informed E5 the posted menu was for dates in the past. 4. The Compliance Officer observed E5 remove the menus from the wall, look at the two menus behind the first one, and repost them precisely as they had been before E5 removed them (with the menu dated between July 29, 2023, and August 5, 2023, being the one visible). The Compliance Officer observed E5 write "BEEF SOUP" and "Juice" in the spot for lunch on August 2, 2023, so the menu for that date read "Corn dog, BEEF SOUP, Juice cream, [and] soup." The Compliance Officer observed the menu for lunch on August 16, 2023, still contained no documentation of any food substitutions. 5. The Compliance Officer later observed facility personnel serve beef soup for lunch, contrary to what was on the menu for lunch on August 16, 2023. Technical assistance was provided on this rule during the compliance inspection conducted on March 10, 2022.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During a tour of the facility conducted at 9:27 AM, the Compliance Officer observed a refrigerator near the open office area. Inside the refrigerator, the Compliance Officer observed yogurt, whipped cream, and other items. The Compliance Officer measured the refrigerator temperature in multiple places and observed readings between 47.7\'b0 F and 50.9\'b0 F. 2. At 2:20 PM, the Compliance Officer again measured the refrigerator temperature in multiple places and observed readings between 50.7\'b0 F and 52.1\'b0 F. 3. In an interview, E1 acknowledged foods requiring refrigeration were not maintained at 41\'b0 F or below. This is a repeat deficiency from the compliance inspection conducted on March 10, 2022.