Monte Manor Assisted Living

Based on record review, documentation review, and interview, the health care institution failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1's personnel record revealed no documentation of initial competency training in fall prevention and fall recovery. Based on E1's date of hire, this documentation was required. 2. A review of E2's personnel record revealed fall prevention and fall recovery training dated April 2, 2024. However, current documentation of fall prevention and fall recovery training was not available. 3. A review of the facility's documentation revealed a policy titled, "Policy on ARS 36-420.01 Health Care Institutions; Fall Prevention and Fall Recovery Training Policy" with the following verbiage included, "POLICY: In compliance to Section 36-420.01, as one of the Health Care Institutions, we have included Fall Prevention and Fall Recovery Training for all staff prior to providing services to our residents. This will be included in their Orientation Training, completed upon date of hire. Fall Prevention and Fall Recovery Training will be part of the Ongoing Continued Education for all staff and required to be completed at least once every 12 months." 4. In an exit interview, the findings were reviewed with E1, no additional information was provided.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1 and R2's medical records revealed there was no standardized form to be used if an emergency responder was contacted. 2. 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 health care institution failed to ensure that the health care institution implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of TB and annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of E1's personnel record revealed no documentation of training in recognizing the signs and symptoms of infectious TB. 2. A review of E2's personnel record revealed no documentation of training in recognizing the signs and symptoms of infectious TB. 3. A review of the facility's documentation revealed no documentation of assessing the health care institution's risk of exposure to infectious TB. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A.R.S. § 36-401.A.49. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 2. During an environmental inspection of the facility, the Compliance Officer (CO) observed E3 and E4 assisting R1, R4, and R6 with various care needs, including assistance with incontinence care. The CO observed no manager or caregiver supervision during these interactions. 3. In an interview, E1 reported E3 and E4 were assistant caregivers who lived at the facility. E1 also reported E1 and E2 were present in the facility to assist residents during nighttime hours when E1 was not present at the facility. 4. A review of E3's and E4's personnel records 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. Therefore, E3 and E4 were not qualified to be left alone with the residents based on the lack of caregiver training. 5. 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 caregiver who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility for one of 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 the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a TB skin test dated less than 12 months from the date of hire showing evidence of freedom from infectious TB. However, there was no documentation of a second TB skin test available. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before or at the time of an individual’s acceptance by an assisted living facility there was a documented residency agreement with the assisted living facility that included whether the manager or a caregiver is awake during nighttime hours, for two of two residents sampled. Findings include: 1. A review of R1 and R2's medical records revealed a residency agreement for both residents at the time of admission to the facility, however, there was no clear verbiage in the residency agreement that stated whether or not a caregiver was awake during nighttime hours. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that included the amount, type, and frequency of assisted living services and ancillary services that were provided to the resident. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1 and R2's medical records revealed a service plan for both that included the following services to be provided to both residents: dressing room maintenance laundry checking feet checking fluid intake checking pressure areas checking skin and applying lotion daily 2. These services stated in their service plan did not include the amount, type, and frequency of which the service should be provided to the residents. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2’s medical record revealed a service plan dated June 10, 2025. This service plan stated: Nail care, check nails daily, trim as needed, and check every bath; Oral care, two times daily; Blood pressure checks three times a day starting November 21, 2025; and Check blood sugar daily, if blood sugar less than 70, give [R2] 4 oz of fruit juice or give 1 tablespoon of sugar in water and recheck every 15-20 mins. 2. A review of R2’s activities of daily living sheet for November 2025 revealed no documentation of the following: No documentation of nail care; Oral care documented as done once a day instead of twice; No documentation of blood pressure readings on November 21-30, 2025; and blood pressure only checked twice a day instead of three times on November 27-30, 2025; and No documentation of blood sugar checks. 3. In an interview, E1 reported they believed these services were provided. 4. 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 notification of the resident of the availability of vaccination for influenza and pneumonia for one of two 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 licensee 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 R2's medical record revealed R2 refused the flu vaccination in 2022. However, current documentation was not available that showed the flu vaccination was received or refused. Additionally, documentation was not available that showed the pneumonia vaccination was received or refused. Based on R2’s acceptance date, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that if pets or animals were allowed in the assisted living facility, pets or animals were licensed consistent with local ordinances; and for a dog or cat, vaccinated against rabies. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer (CO) observed a dog was present at the facility and greeted the CO at the door. 2. In an interview, E1 acknowledged the dog was currently living at the facility. 3. A review of the dog's medical record revealed there was no current license or current vaccination against rabies. The dog's latest license was obtained on September 4, 2020. The dog was last vaccinated against expired on January 13, 2025. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the facility for one of two sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record contained an ALTCS (Arizona Long Term Care System) provider contract. However, there was no residency agreement between R1 and the facility. 2. In an interview, E1 acknowledged a facility residency agreement for R1 was not available for review. E1 agreed the residency agreement between the ALTCS provider did not meet the rule for residency agreements.

Based on record review and interview, before or within five working days after a resident's acceptance by an assisted living facility, the manager failed to obtain on the residency agreement, the signature of the resident, the resident's representative, the resident's legal guardian, or another individual who has been designated by the individual under A.R.S \'a7 36-3221 to make health care decisions on the individual's behalf for one of two residents sampled. The deficient practice posed a risk if the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under A.R.S. \'a7 36-3221 was not informed of the terms of residency. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, the residency agreement was not signed and dated by R2 or R2's representative before R2's acceptance or within five working days after acceptance. 2. In an interview, E2 acknowledged R2's residency agreement was not signed and dated by the resident or the resident's representative before or within five working days after R2's acceptance.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that complied with R9-10-808.A. The deficient practice posed a risk to residents and staff if false or misleading information was provided to show a resident's service plan was reviewed and updated. Findings include: 1. A review of R2's medical record revealed three service plans dated February 5, 2023; May 6, 2023; and August 1, 2023. 2. A review of R2's medical record revealed the following vital signs recorded on the February 5, 2023 service plan: -Blood pressure: 134/78; -Pulse: 78; -Respiration Rate: 21; -Temperature: 96.9\'b0F; and -Weight: 131 lbs. 3. A review of R2's medical record revealed the following identical vital signs recorded (with identical handwriting) on the August 1, 2023 service plan: -Blood pressure: 134/78; -Pulse: 78; -Respiration Rate: 21; -Temperature: 96.9\'b0F; and -Weight: 131 lbs. 4. The aforementioned identical vital signs prompted the Compliance Officer to conduct a closer comparison between all three service plans. 5. Further review of R2's medical record revealed the aforementioned three service plans appeared to be photocopied, with some information being altered by using correction tape. However, the majority of the information between the three service plans was identical with the same handwriting used on all three service plans. The Compliance Officer observed numerous instances in all three service plans where the documentation appeared altered. 6. In an interview, E1 acknowledged R2's vital signs were identical in the two aforementioned service plans and acknowledged the writing was identical. However, E1 reported R2 had no changes in condition between the February 5, 2023 and August 1, 2023 service plans and maintained that R2's vital signs were identical on the two service plans. 7. In an interview, the Compliance Officer informed E1 that the photocopying and altering of any medical record was unacceptable. E1 responded, "OK."

Based on documentation review, record review, and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Resident Medical Records Including Electronic Records." Under the title, "Procedure," the policy stated, "...An entry in a resident's medical record is: ...b. Dated, legible, and authenticated; and c. Not changed to make the initial entry illegible." 2. A review of R2's medical record revealed a service plan dated August 1, 2023. 3. Further review of R2's August 1, 2023 service plan revealed correction tape had been used on page 1, page 2, and page 5, which rendered the initial entry illegible. 4. A review of R2's medical record revealed a service plan dated February 5, 2023. 5. Further review of R2's February 5, 2023 service plan revealed correction tape had been used on page 1, page 2, and page 5, which rendered the initial entry illegible. 6. In an interview, E1 acknowledged several entries in R2's medical record contained correction tape that made the initial entry illegible.

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), for one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk to R1's safety. Findings include: 1. A review of R1's medical record revealed a "Determination for Admission," dated August 18, 2022. The document stated R1 was "confined to a chair or bed and is unable to ambulate on their own." 2. A review of R1's medical record revealed a document titled, "Approval for Continued Residency," signed by a medical practitioner. However, the document was not dated. 3. Based on R1's date of admission, R1 was not examined at least once every six months throughout the duration of the resident's condition. 4. In an interview, E2 acknowledged R1 was not examined at least once every six months throughout the duration of the resident's condition.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled 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. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed when exiting from the back patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. However, there was an alert sensor system on the door. 3. During a tour of the facility, the Compliance Officer observed an alert sensor system located on the door in R1's bedroom. However, there was a piece missing which rendered the alert inoperable. 4. In an interview, E2 acknowledged the back patio door and R1's bedroom door did not alert employees of the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. 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 medication administration record (MAR) dated August 2023. The MAR indicated R2 received several medications, including the following: -Calcitriol 0.25 micrograms, one capsule every day; -Glipizide 5 milligrams (mg), 1/2 tablet two times a day; -Metoprolol 25 mg, 1/2 tablet twice a day; -Ropinirole 0.25 mg, one tablet two times a day; -Senna 8.6 mg, one tablet every bed time; and -Carbidopa Levodopa 25-100 mg, one tablet three times a day. 2. A review of R2's medical record revealed no signed medication orders for the aforementioned medications. 3. E2 acknowledged the aforementioned medication administered to R2 was not administered in compliance with a medication order as no signed orders were available for review.

Based on documentation review and interview, the manager failed to ensure the facility had a disaster plan that was developed, documented, maintained in a location accessible to caregivers and assistant caregivers, and, if necessary, implemented that included when, how, and where residents would be relocated, how a resident's medical record would be available to individuals providing services to the resident during a disaster, a plan to ensure each resident's medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility's relocation site during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. During the facility inspection, the compliance officer requested the facility's disaster plan. E2 was unable to locate the disaster plan for review. 2. In an interview, E2 acknowledged the facility did not have a disaster plan maintained in a location accessible to caregivers.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan and evacuate the residents during an emergency. Findings include: 1. A review of the facility's employee and resident evacuation drills revealed the last evacuation drill was conducted on October 17, 2022. 2. In an interview, E2 acknowledged an evacuation drill was not conducted at least once every six months as required.