Mardon Assisted Living Homes I

Based on record review, documentation review, and interview, the assisted living home failed to maintain written documentation of emergency responder information that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary. Findings include: 1. A review of R1, R2, and R3's medical records revealed a standardized form that was not filled in with each resident's required information. 2. In an interview, E1 reported having a standardized form available, but none prefilled in with resident information as required in A.R.S. 36-420.04.A. 3. 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 resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for two of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record did not include documentation of R1's notification of the availability of vaccinations for flu and pneumonia. Based on R1's date of admission, this documentation was required. 3. A review of R2's medical record included documentation of R2's notification of the availability of vaccinations for flu and pneumonia for 2024, but no documentation for 2025. Based on R2's date of admission, this documentation was required. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three 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 R1 and R3's medical records revealed the following: A service plan dated January 5, 2026, which indicated R1 received medication administration services; and A service plan dated February 24, 2026, which indicated R3 received medication administration services. 2. A review of R1's medical record revealed a medication order sheet that included the following medications: Lorazepam Tablet 1 milligram (mg). Directions: Administer 1.5 tablets by mouth every four hours for anxiety/agitation/restlessness; and Trazodone HCL tablet 150 mg. Directions: Administer 1 tablet by mouth once daily at bedtime for sleep. 3. A review of R1's medication administration record revealed the following: Lorazepam 1 mg tab; 1 tab by mouth every 2 hours per request needed. The medication was given twice on February 7, 2026, and February 22, 2026. Trazodone 100 mg tab 1 tab by mouth every five hours. The medication was administered from February 1, 2026, through February 26, 2026. 4. A review of R3's medical record revealed a medication order sheet that included the following medications: Midodrine HCL tablet 10 mg. Directions: Administer 1 tablet by mouth three times daily for orthostatic hypotension; and Eliquis tablet 5 mg. Directions: Administer 1 tablet by mouth two times daily for anticoagulation. 5. A review of R3's medication administration record indicated that Midodrine HCL tablet 5 mg was administered, not the 10 mg tablet, per the order. The Eliquis tablet 5 mg was not included on R3’s medication administration record. 6. A review of R3’s pill organizer revealed one Midodrine HCL tablet, 5 mg prefilled Monday through Friday in the evening slot; Eliquis 5 mg tablet was not prefilled in R3’s pill organizer. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 8. This is a repeat deficiency from the complaint and compliance inspection conducted on February 11, 2025.

Based on observation, record review, and interviews, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. Upon arrival at the facility, the Compliance Officers (CO) were greeted by E2. E2 took the CO to the dining room table where the employee asked if it was ok to continue documenting the morning Medication Administration Records (MARS). After a few moments, the CO noticed the E2 was backfilling the MARS. 2. The CO asked E2 if the employee was backfilling the MARS. E2 acknowledged that the entries from February 10, 2025 were not entered and that E2 was filling in the MARS for February 10, 2025 and February 11, 2025 (current date). 3. The MARS book was removed from E2 by the CO. Re A record review for three of eight sampled residents revealed that the MARS were not documented for February 10, 2025. 4. In an interview with E4, E2 acknowledged that E2 was documenting the MARS for the day of February 10, 2025 in the presence of the CO.

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 unable to self-administer medications. Findings include: 1. During the environmental inspection, the Compliance Officers (CO) observed that there were two bottles of medication with syringes sticking out the tops sitting on two different shelves inside the refrigerator door. 2. During the environmental inspection, the CO observed medications wrapped in plastic on the inside shelve of the refrigerator. 3. During the environmental inspection, the CO observed a prescribed bottle of Metronidazole (generic for Flagyl) 500 mg (that did not belong to any resident or employee of the facility), laying in the top left drawn in the kitchen next to the refrigerator. 4. In an interview with E4, E4 asked E2 why the medications were not stored in their lock box? E2 went and grabbed the lock box and started put the medications inside the box. 5. E4 acknowledged that the medications were not stored properly as per R9-10-816.F.1.

Based on observation 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 area and medications are inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officers (CO) observed a bottle of Clorox Disinfecting Cleaner, Easy-Off Oven Cleaner, Dawn Dish Detergent, and Cascade Dishwasher Detergent inside an unlocked kitchen sink cabinet. 2. During the environmental inspection, the CO observed a bottle of Metronidazole (generic for Flagyl) 500 mg, in the top left kitchen draw next to the refrigerator. This bottle of medication did not belong to the residents on the census nor any of the employees. 3. In an interview, E4 acknowledged that the unlocked poisons or toxins and medication in the kitchen area were in violation of R9-10-819.A.11.

Based on observation and interview the manager failed to ensure that combustible or flammable liquids and hazardous materials stored by the assisted living facility are stored in the original labeled containers or safety containers in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officers observed a bottle of Tiki Torch Fuel stored outside in an unlocked shed in the backyard next to the home. 2. During an interview, E4 acknowledged that the bottle should not have been on the property and that it was in violation of R9-10-819.A.12.

Based on documenttation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed O1 was the facility's manager as of March 8, 2023. 2. The Compliance Officer observed E4's assisted living manager's license posted on the premises. 3. A review of E4's personnel record revealed E4 was hired as the facility's manager on July 1, 2023. 4. A review of Department documentation revealed the governing authority failed to notify the Department of E4's name and qualifications when E4 became the facility's manager. 5. In an interview, E1 reported an email had been sent to the Nursing Care Institution Administrators and Assisted Living Managers and not to the Department. 6. In an interview, E1 acknowledged the facility did notify the Department when E4 became the facility's manager.

Based on documentation review, observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom. The deficient practice posed a risk if residents were unable to summon help from personnel members. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies in two resident bedrooms. 3. In an interview, E2 reported a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available in two directed care resident's bedroom due to the residents misplacing the bells or buttons. 4. In an interview, E1 acknowledged E1 failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom.

Based on observation, documentation review, and interview, the manager of an assisted living facility authorized to provide directed care services failed to implement policies and procedures to ensure the safety of a resident who may wander. The deficient practice posed a risk id the facility was not aware of the general or specific whereabouts of a resident. Findings include: 2. The Compliance Officer observed a gate leading to the side of the house. However, the gate was not locked. 3. The Compliance Officer observed a gate leading to the neighboring house yard. However, the gate was not locked. 4. A review of policies and procedures (dated January 2022) revealed a policy titled "Safety of Wandering Residents." The policy stated "Caregivers will maintain securely of locks on the front door, yards and hazardous areas at all times." 5. In an interview, E1 acknowledged E1 failed to implement the facility's policy and procedure.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. Findings include: 1. The Compliance Officer observed an unlocked metal storage container in the backyard of the facility. The container was held closed by a brick placed in front of the doors. The inside of the container had a can of WD-40 and paint thinner. 2. In an interview, E1 acknowledged E1 failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents.