Nananom Assisted Living

Based on observation, documentation review, and interview, the manager failed to ensure that a calendar of planned activities was maintained for at least 12 months after the last scheduled activity. The deficient practice posed a risk if residents were unable to participate in planned activities. Findings include: 1. During an environmental tour, the Compliance Officers observed a posted activity calendar in the dining room that did not include a date. 2. A review of the facility’s prior activity calendars revealed no documentation of activity calendars maintained for at least 12 months after the last scheduled activity. 3. A review of the facility’s policies and procedures revealed a policy titled "Program/Activity Calendar”. The policy stated, “A calendar of activities shall be maintained on the premises for 12 months after the last scheduled activity.” 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1's personnel record revealed no fall prevention and fall recovery training. Based on E1’s hire date, this documentation was required. 2. A review of E2's personnel record revealed no fall prevention and fall recovery training. Based on E2’s hire date, this documentation was required. 3. A review of E3's personnel record revealed no fall prevention and fall recovery training. Based on E3’s hire date, this documentation was required. 4. A review of the facility’s policies and procedures revealed a policy titled “Fall prevention and fall recovery training.” The policy did not contain the frequency of fall prevention and fall recovery training. 5. In an interview, E1 acknowledged that E1, E2, and E3 did not have fall prevention and fall recovery training. 6. 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 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., for two of two residents sampled. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1’s and R2’s medical records revealed no documentation of a standardized form. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. Based on E1's date of hire, this documentation was required. 2. A review of E2's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. Based on E2's date of hire, this documentation was required. 3. A review of E3's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. Based on E3's date of hire, this documentation was required. 4. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 5. In an interview, E1 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted, nor was the employee's annual training. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility's premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the on-site management of the assisted living facility. Findings include: 1. Upon arrival at the facility, the Compliance Officers were greeted by E1. 2. During the environmental inspection with E1, the Compliance Officers observed a posting titled “Manager’s Designee.” The posting listed E3 as the Manager’s Designee. 3. A review of E1’s personnel record revealed no documented designation of E1 as a manager designee. 4. In an interview, E1 acknowledged that E1 is the manager designee and the live-in caregiver. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program which included the frequency of submitting a documented report required in subsection (2) to the governing authority. Findings include: 1. A review of the facility’s quality management documentation revealed no completed documentation as all forms were blank. 2. A review of the facility’s policies and procedures revealed a policy titled "Quality Management”. The policy stated, “Documented report is submitted annually by the manager to the governing authority, unless they are the same individual. This report includes: a. An identification of each concern about the delivery of services related to a resident b. Any change made, or action taken because of the identification of a concern about the delivery of services related to resident care. c. The report and the supporting documentation for the report are maintained for 12 months after the date the report is submitted to the governing authority by the manager.” 3. In an interview, E1 reported 2025 documentation had not been completed. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for two of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. A review of the facility’s policies and procedures revealed the following: A policy titled “Applicant and Employee Requirements.” The policy stated “Orientation and in-service: It is that each employee and volunteer receives orientation before providing assisted living services to a resident. Annual training. In-service education after the first 12 months of employment will be required for all employees and volunteers that provide assisted living services to a resident.” No policy regarding the verification of a caregiver’s skills and knowledge. 2. A review of E1’s personnel record revealed a document titled “Caregiver Skills and Knowledge Documentation.” The “Caregiver Skills and Knowledge Documentation” was signed by E1. 3. A review of E3’s personnel record revealed a document titled “Caregiver Skills and Knowledge Documentation.” The “Caregiver Skills and Knowledge Documentation” was signed by E3. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation 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 assistance caregivers working each day, included the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival at the facility, the Compliance Officers were greeted by E1. E1 was alone with one resident. 2. A review of the facility’s personnel schedule revealed a “Staff Weekly Schedule” dated 2024. E3's name was listed, but there were no dates or times on the schedule. E1 was listed as the backup staff. 3. In an interview, E1 reported that E1 was the live-in caregiver. E1 also reported that E3 stops by to drive to appointments and bring food. 4. In an interview, E1 acknowledged that the employee work schedule did not include documentation of the caregivers who worked each day, and the hours worked by each. 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 a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of three personnel 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 "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1’s personnel record revealed the hire date of October 1, 2024. The personnel record revealed the following: A letter dated September 25, 2024, from O1 stated, “No further TB skin testing is advised.” One negative TB chest X-ray. A “Tuberculosis (TB) Screening and Risk Assessment Form for Newly Hired HCP” within 12 months of hire. No further documentation for “Tuberculosis (TB) Screening and Risk Assessment Form” was available. Based on the positive test results, this documentation is required. 4. A review of E3’s personnel record revealed the hire date of July 10, 2024. The personnel record revealed the following: A letter dated September 25, 2024, from O1 stated, “No further TB skin testing is advised.” One negative TB chest X-ray. A “Tuberculosis (TB) Screening and Risk Assessment Form for Newly Hired HCP” within 12 months of hire date. No further documentation for “Tuberculosis (TB) Screening and Risk Assessment Form” was available. Based on the positive test results, this documentation is required. 5. In an interview, E1 acknowledged that the “Tuberculosis (TB) Screening and Risk Assessment Form” has not been completed yearly. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, documentation, and interview, the manager failed to ensure that, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for two of three personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Upon arrival at the facility, the Compliance Officers were greeted by E1. E1 was alone with one resident. 2. A review of E1's personnel record revealed an expired CPR and First Aid card with an expiration date of July 27, 2025. However, there was no current CPR and First Aid Card. 3. A review of E3's personnel record revealed an expired CPR and First Aid card with an expiration date of August 16, 2025. However, there was no current CPR and First Aid Card. 4. A review of the facility’s personnel schedule revealed a “Staff Weekly Schedule” dated 2024. E3's name was listed on the schedule. E1 was listed as the backup staff. 5. In an interview, E1 reported that E1 is the live-in caregiver and provides physical health services at the facility. 6. 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 provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a potential illness 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 R1’s (admitted 2025) medical record revealed no documentation of a completed screening to assess R1’s risk of prior exposure to infectious TB and if R1 had signs or symptoms of TB signed and dated by a medical practitioner. Based on R1's date of admission, this documentation was required. 3. A review of R2’s (admitted 2025) medical record revealed no documentation of a completed screening to assess R2’s risk of prior exposure to infectious TB and if R2 had signs or symptoms of TB signed and dated by a medical practitioner. Based on R2's date of admission, this documentation was required. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, 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. A review of the facility’s documentation revealed a Pre-admission Determination form that contained the aforementioned information. However, the form was not completed. 2. A review of the facility’s policies and procedures revealed a policy titled "Admittance & Re-admittance of Residents”. The policy stated, “The facility shall conduct an assessment before accepting individuals as residents.” After further review, a policy titled Assessing Resident Needs was revealed. The policy stated, “Nananom Assisted Living, in consultation with the resident/resident’s representative and their PCP to determine the resident’s unique service requirements prior to implementing any services.” 3. A review of R1’s and R2’s medical records revealed no documentation of a pre-admission determination form. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review and interview, the manager accepted or retained an individual whose primary condition for which the individual needed assisted living services was a behavioral health issue, for two of two residents sampled. The deficient practice posed a risk as the facility was unable to meet residents' needs. Findings include: 1. A review of Department documentation revealed the facility was not licensed to provide Behavioral Health Services. 2. A review of the facility’s policies and procedures revealed a policy titled “Scope of Services.” The policy stated, “This facility does not provide Behavioral Health Services.” 3. A review of R1’s medical record revealed the following: No current service plan. A document titled “Authorization/Referral Management,” which listed R1’s diagnosis as Schizophrenia and Depression. A document titled “Behavioral Health Residential Treatment Facility.” The document stated, “Aftercare plan: Maintain sobriety; attend AA meetings; Continue medication regimen; Attend psychiatric and medical appointments; Develop support system in the community.” 4. In an interview, E1 reported that E1 is working on acquiring R1’s antipsychotic medication. 5. A review of R2’s medical record revealed the following: No current service plan. A document titled “Behavioral Health El Dorado,” which listed R2’s diagnosis as Schizoaffective disorder and bipolar. 6. In an interview, E1 reported that R2’s residency agreement was terminated because R2 would constantly exit seek and the staff were not able to provide the care R2 needed. 7. 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 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 the requirements in R9-10-807.D.1-10, for two of two residents sampled. 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 and R2’s medical records revealed no documentation of residency agreement that included the requirements in R9-10-807.D.1-10: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed. 2. A review of the facility’s policies and procedures revealed a policy titled "Residency and Residency Agreement and Awake Staff Policy and Procedure”. The policy stated, “Each resident will have a Residency Agreement completed before or at time of acceptance into the facility.” 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a written service plan that was completed no later than 14 calendar days after the resident’s date of acceptance, for two of two 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 R1’s and R2’s medical records revealed no documentation of a completed service plan. 2. A review of the facility’s policies and procedures revealed a policy titled "Service Plan”. The policy stated, “The Service Plan will be completed within 14 days of the residents admit by a registered nurse and updated at least every 12 months for a resident receiving supervisory services, 6 months for a resident receiving personal care services, 3 months for a resident receiving directed care services.” 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's complete medical record was maintained according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of two sampled residents. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states “A. Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider. 2. If the patient is a child, either for at least three years after the child's eighteenth birthday or for at least six years after the last date the child received medical or health care services from that provider, whichever date occurs later. 3. Source data may be maintained separately from the medical record and must be retained for six years from the date of collection of the source data.” 2. During an environmental inspection, the Compliance Officers observed R1 sitting on a couch in the dining room. 3. A review of R1’s medical record revealed the following: Medical records from previous placement. A Tuberculous (TB) test. A “Physician’s Orders” that lists R1’s current medication was not signed. No other required documentation. 4. In an interview, E1 acknowledged that R1 did not have medical records. 5. 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 a medical record contained the requirements in R9-10.811.C.1-24, for one of two residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. During an environmental inspection, the Compliance Officers observed R1 sitting on a couch in the dining room. 2. A review of R1’s medical record revealed the following: Medical records from previous placement. A Tuberculous (TB) test. A “Physician’s Orders” that lists R1’s current medication was not signed. No other required documentation. 3. In an interview, E1 acknowledged that R1 did not have medical records. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. The facility was licensed at the directed care level. 2. Upon arrival at the facility, the Compliance Officers observed no backdoor. 3. During the environmental inspection, the Compliance Officers observed no sliding backdoor. In place of no sliding backdoor, there was a painter's plastic wrap taped on the outside of the door with duct tape. There was no alert or monitor system. 4. During the environmental inspection, the Compliance Officers observed R1 alone in the living room while E1 walked around the facility. 6. During the inspection, E1 was observed teaching a class while sitting at the dining room table. 7. In an interview, E1 reported that the door just spontaneously broke a week or two ago. E1 also reported that the staff and residents just don't use the door. 8. In an interview, E1 acknowledged that the door was not alerted or monitored. 9. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed policies on medication administration. After further review, documentation of a review by a medical practitioner, registered nurse, or pharmacist was not available. 2. In an interview, E1 acknowledged the policy was unsigned and reported E1 would have the nurse review and sign. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that a food menu was maintained for at least 60 calendar days after the last day included in the food menu. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. During an environmental tour, the Compliance Officers observed a posted food menu in the dining room that did not include a date. 2. A review of the facility’s prior food menus revealed no documentation of food menus maintained for at least 60 calendar days after the last day included in the food menu. 3. A review of the facility’s policies and procedures revealed a policy titled "Food Services, Preparation, and Storage”. The policy stated, “The manager shall ensure a food menu is maintained for at least 60 calendar days after the last day included on the food menu.” 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility and was documented, for two of two residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1’s and R2’s medical records revealed no documentation of orientation to the exits of the facility. 2. A review of the facility’s policies and procedures revealed a policy titled "Emergency preparedness and relocation plan”. The policy stated, “Residents will be oriented to the emergency procedures of this facility within twenty-four hours of their admission.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental tour, the Compliance Officers observed a fire extinguisher mounted near the front door with a service tag dated June 2024. After further observation, the Compliance Officers observed a fire extinguisher mounted in the kitchen with a service tag dated June 2024. 2. A review of the facility’s policies and procedures revealed a policy titled "Fire Extinguisher Use”. The policy stated, “If a rechargeable fire extinguisher is utilized in this facility, it shall be serviced at least once every 12 months, and have a tag attached to the fire extinguisher that specifies the date of the last servicing and the identification of the person who serviced the fire extinguisher.” 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officers observed the following: Bleach, laundry scent booster, and Tide detergent in an unlocked hallway cabinet near the resident's rooms. Fabuloso, Lysol spray, and oven cleaner in an unlocked hallway closet behind the kitchen. Lysol wipes and Glad air freshener in a common bathroom. 2. A review of the facility’s policies and procedures revealed a policy titled "Emergency, Safety, and Environmental Standards”. The policy stated, “The facility manager/owner and staff will ensure that all poisonous or toxic materials (this is including all cleaning supplies) will be stored and maintained in labeled containers in a locked area separate from food preparation and storage, dining areas and medications.” 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.