Mesa Adult Care Home II

Based on observation and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.199 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. A review of R1's medical record revealed a service plan for directed care services dated September 8, 2025. This service plan reported that R1 was "bed-bound" and "does not walk." 3. During an environmental inspection of the facility, the Compliance Officer observed R1 lying in bed with a half bedrail positioned on the top half of the bed, and a Geri Chair was moved up against the bed near the foot of the bed. The other side of the bed was pushed up against the wall. 4.In an interview, E1 and E4 acknowledged R1 had been subjected to restraints. 5. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on July 25, 2023.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2)(b)(iii), for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2)(b)(iii) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated September 8, 2025) revealed R1 received directed care services and was confined to a bed or chair. 3. A review of R1's medical record revealed documentation of the determination required dated October 3, 2024. However, additional documentation signed by R1's primary care provider was not available for review. 4. A review of R2's service plan (dated July 29, 2025) revealed R2 received directed care services and was confined to a bed or chair. 5. A review of R2's medical record revealed documentation of the determination required dated January 7, 2025. However, additional documentation signed by R2's primary care provider was not available for review. 6. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure the service plan, for a resident receiving directed care services, included documentation of the resident's weight. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated September 8, 2025. However, the service plan did not include documentation of R1's weight. 2. A review of R2's medical record revealed a service plan dated July 29, 2025. However, the service plan did not include documentation of R2's weight. 3. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.

Based on documentation review, observation, record review, and interview, the licensee failed to maintain a health care institution within the licensed capacity of five residents. The deficient practice posed a risk if the Department was unable to assess and approve an increased occupancy. Findings include: 1. A review of Department documentation revealed the license for AL8194 was effective on February 17, 2011, and was approved for a licensed capacity of five residents. 2. The Compliance Officer observed six residents at the facility. 3. A review of six medical records revealed the facility admitted the sixth resident on June 27, 2023. 4. In an interview, E1 reported the facility currently had six residents. E1 reported E1 was in the process of finding a new facility for R1. 5. In a joint interview, E1 and O1 acknowledged the licensee failed to maintain a health care institution within the licensed capacity of five residents.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to cover medication administration. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Opioid Prescription and Treatment" (dated in June 2022). The policy and procedure stated " ...3. Inventory must be kept for all opioid medication and the name of the caregiver administering the medication will be on patient's Narcotic Administration Record form (NAR)..." 2. A review of R3's service plan revealed R3 received medication administration. 3. The Compliance Officer observed a medication bottle for Tramadol HCL 50 mg, take 1 tablet by mouth twice daily belonging to R3. 4. A review of R3's medication administration record (MAR) revealed documentation of the above medication. However, a NAR was not available for review. 5. In an interview, E1 reported E1 does not document medication administration of opioids on a NAR. 6. In an interview, O1 acknowledged policies and procedures for documenting medication administration were not implemented.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for three of three employees sampled. The deficient practice posed a TB exposure risk to residents, and the Department was provided false or misleading information. Findings include: 1. A review of E1's personnel record revealed four documents titled "TB Skin Test" dated December 4, 2019; November 21, 2020; November 18, 2021; and November 12, 2022. However, the documentation of the "TB Skin Test" revealed the following: -"TB Skin Test" (December 4, 2019 and November 21, 2020):E1's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2021) were photo copied; -"TB Skin Test" (November 18, 2021 and November 12, 2022):E1's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2023) were photo copied. 2. A review of E2's personnel record revealed documentation of freedom from infectious TB was not available for review. 3. A review of E3's personnel record revealed two documents titled "TB Skin Test" dated November 18, 2021 and November 12, 2022. However, the documentation of the "TB Skin Test" revealed the following: -E3's name, date administered, care home, date read, and test result were filled in with wet ink and appeared to be photo copied; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2023) were photo copied. 4. A review of the Centers for Disease Control and prevention website (https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html) revealed "If a multi-dose has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial." 5. A review of a text message received on July 25, 2023, O2 stated O2 used the stamp referenced in the "TB Skin Test" "many years ago. Currently [O2] use [sic] TB form with Agape primary care. The TB lot nr [sic] it is an old one, [O2] believed this was copied and modified." 6. In an interview, O1 acknowledged the documentation was altered and no additional comment or documentation was provided for review. 7. In an interview, O1 acknowledged E2 did not provide documentation of freedom from infectious TB.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation and in-service education, for three of three personnel records sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery Training Program" (dated in June 2022). The policy and procedure stated "Upon being hired...staff will complete the Facility's Fall Prevention and Fall Recovery Training Program. Once a year, all staff will either re-complete the Facility's Fall Prevention and Fall Recovery Training Program..." 2. A review of facility documentation revealed a policy and procedure titled "Administration" (dated in June 2022). The policy and procedure stated "1. All employees will complete orientation before providing services to residents..." 3. A review of E1's (hired in 2019) personnel record revealed initial training in fall prevention and fall recovery dated in June 2022. However, continuing training in fall prevention and fall recovery was not available for review. 4. A review of E2's (hire date unavailable) personnel record revealed initial training in fall prevention and fall recovery and orientation was not available for review. 5. A review of E3's (hired in 2008) personnel record revealed initial training in fall prevention and fall recovery dated in June 2022. However, continuing training in fall prevention and fall recovery was not available for review. 6. In an interview, O1 acknowledged E1's, E2's, and E3's training in fall prevention and fall recovery were not completed according to the facility's policies and procedures. O1 acknowledged E2's orientation was not completed according to the facility's policies and procedures.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation in compliance with R9-10-806(C)(1)(a-c.i-iii.vi.), for one of three employees sampled. Findings include: 1. The Compliance Officer observed E2 working at the facility upon arrival at 10:45 AM. 2. In an interview, E1 stated E2 was hired as the "housekeeper." 3. A review of E2's personnel record revealed the following documentation: -Current cardiopulmonary resuscitation training and first aid training; and -A valid fingerprint clearance card. However, documentation of compliance with R9-10-806.C.1.a-c.i-iii.vi. was not available for review. 4. In an interview, O1 acknowledged documentation of E2's compliance with R9-10-806.C.1.a-c.i-iii.vi. was not available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after a resident's date of acceptance, for one of six residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R3's (accepted in 2023) medical record revealed a written service plan was not available for review. Based on R3's date of acceptance, a written service plan was required. 2. In an interview, O1 acknowledged a written service plan for R3 was not completed within 14 calendar days after acceptance.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of three resident sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R5's medical record revealed a written service plan for directed care services dated in March 2023. However, a reviewed and updated service plan was not available for review. 2. In an interview, O1 reported to be unsure if an updated service plan for R5 was completed.

Based on observation, record review and interview, the manager failed to ensure a resident was not subjected to restraint, for one of three residents sampled. The deficient practice posed a health and safety risk to R3 if R3's legs were to get caught between the rails. Findings include: 1. The Compliance Officer observed R2's bed to have one bedrail measuring approximately the length of the bed, on the resident's right side of the bed. The left side of the bed was pushed against the wall. 2. In an interview, E1 stated R2 was "bedbound." 3. A review of R2's medical record revealed a service plan for directed care services dated in May 2023. The service plan revealed R2 was "wheelchair" bound and was "at risk for falls." 4. A further review of R2's service plan revealed strategies to ensure R2's personal safety was not documented. 5. In an interview, E1 reported the bedrail attached to R2's bed was used to prevent R2 from getting out of bed. E1 reported R2 moved around a lot in bed and was able to move R2's feet out of the bed. E1 reported R2 was not able to lower the bedrail or maneuver around the bedrail. E1 reported E1 would put a blanket over the bedrail at night to prevent R2's legs from getting stuck in between the rails. 6. In an interview, O1 acknowledged R2's bed contained a bedrail and the bedrail was used as a restraint.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's needs required in R9-10-807(B), for two of six residents sampled. The deficient practice posed a risk as the required information could not be verified. The deficient practice posed a risk as the facility admitted R2 and R3 without knowing if R2 and R3 required a higher level of care. Findings include: 1. A review of R2's and R3's medical records revealed documentation to include whether R2 and R3 did or did not require continuous medical services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. In an interview, O1 acknowledged R2's and R3's medical records did not contain documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant within 90 calendar days before or when the individual was accepted by the facility.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for five of six residents sampled. The deficient practice posed a TB exposure risk to residents, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed two documents titled "TB Skin Test" dated March 10, 2022 and March 1, 2023. However, the documentation revealed the following: -"TB Skin Test" (March 10, 2022):R1's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2023) were photo copied; -"TB Skin Test" (March 1, 2023) R1's name, date administered, care home, date read, and test result were filled in with wet ink and appeared to be photo copied; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2023) were photo copied. 2. A review of R2's medical record revealed documentation titled "TB Skin Test" with no date of administration. However, the documentation revealed the following: -R2's name, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2024) were photo copied. 3. A review of R4's medical record revealed documentation titled "TB Skin Test" dated August 14, 2021. However, the documentation revealed the following: -R4's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2024) were photo copied. 4. A review of R5's medical record revealed two documents titled "TB Skin Test" dated August 20, 2020 and July 28, 2021. However, the documentation revealed the following: -"TB Skin Test" (August 20, 2020):R5's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2021) were photo copied; -"TB Skin Test" (July 28, 2021) R5's name, date administered, care home, date read, and test result were filled in with wet ink; and O2's signature and stamp, site, manufacturer, lot number (C4861AB) and expiration date (December 2024) were photo copied. 5. A review of R6's medical record revealed documentation of freedom from infectious TB was not available for review. 6. A review of the Centers for Disease Control and prevention website (https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html) revealed "If a multi-dose has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial." 7. A review of a text message received on J

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for four of six residents sampled. The deficient practice posed a risk as services provided could not be verified against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated in October 2022 for personal care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for July 19, 2023 through July 24, 2023 was not available for review. 2. A review of R2's medical record revealed a service plan dated in May 2023 for directed care services. The service plan stated R2 was to receive assistance in activities of daily living. However, documentation of assisted living services for July 19, 2023 through July 24, 2023 was not available for review. 3. A review of R4's medical record revealed a service plan dated in February 2023 for personal care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for July 18, 2023 through July 24, 2023 was not available for review. 4. A review of R5's medical record revealed a service plan dated in March 2023 for directed care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for July 1, 2023 through July 24, 2023 was not available for review. 5. In an interview, E1 reported assisted living services were provided to R1, R2, R4, and R5, and E1 did not document the assisted living services provided.

Based on observation, record review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner, for two of six residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed the following medication bottled belonging to R2: -Senna Tab 8.6 mg, take 1 tablet by mouth two times a day scheduled; and -Loratadine Tab 10 mg, take 1 tablet by mouth every day. 2. A review of R2's medical record revealed medication orders for Senna Tab 8.6 mg and Loratadine Tab 10 mg were not available for review. 3. The Compliance Officer observed a medication bottle for Tramadol HCL 50 mg, take 1 tablet by mouth twice daily belonging to R3. 4. A review of R3's medical record revealed a medication order for Tramadol HCL 50 mg was not available for review. 5. In an interview, O1 acknowledged medication orders for the observed medications belonging to R2 and R3 were not in the medical records.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, for one of six residents sampled. Findings include: A.R.S. \'a7 36-406(1)(d) 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. 1. A review of R1's medical record revealed documentation of notification of the availability of vaccination for flu and pneumonia vaccination dated in 2021. However, documentation of the notification for the flu and pneumonia vaccinations available to R1 on site on a yearly basis was not available for review. 2. In an interview, O1 acknowledged documentation of R1's notification of the availability of the vaccination for flu and pneumonia on a yearly basis was not available for review. Technical assistance was provided on this Rule during the onsite compliance inspection completed on June 13, 2022.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included strategies to ensure a resident's personal safety, for three of three residents sampled who received directed care services. Findings include: 1. A review of R2's record revealed a service plan dated in May 2023. However, the service plan did not include strategies to ensure R2's personal safety. 2. A review of R5's medical record revealed a service plan dated in March 2023. However, the service plan did not include strategies to ensure R5's personal safety. 3. A review of R6's medical record revealed a service plan dated in June 2023. However, the service plan did not include strategies to ensure R6's personal safety. 4. In an interview, O1 acknowledged R2's, R5's, and R6's service plans did not include strategies to ensure R2's, R5's, and R6's personal safety.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of six residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed the following medication bottled belonging to R2: -Senna Tab 8.6 mg, take 1 tablet by mouth two times a day scheduled; and -Loratadine Tab 10 mg, take 1 tablet by mouth every day. 2. A review of R2's medical record revealed medication orders for Senna Tab 8.6 mg and Loratadine Tab 10 mg were not available for review. 3. A review of R2's medication administration record (MAR) dated July 2023 revealed R2 received medication administration of the above mentioned medication on July 1-25, 2023. 4. In an interview, O1 acknowledged R2 received medication administration of the above mentioned medications without medication orders.

Based on observation and interview, the manager failed to ensure a refrigerator used by the assisted living facility to store food or medication contained a thermometer. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen. However, the refrigerator did not contain a thermometer. 2. In an interview, O1 acknowledged the refrigerator did not contain a thermometer. Technical assistance was provided on this Rule during the onsite compliance inspection completed on June 13, 2022.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. Compliance Officer observed a common bathroom contained a toilet without a toilet seat. 2. In an interview, E1 reported the toilet seat broke yesterday (July 24, 2023). 3. In an interview, O1 acknowledged equipment used at the assisted living facility was not maintained in working order.