Nurse's Assisted Living LLC

Based on documentation review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of facility documentation revealed a standardized form for R2. However, the form did not include the address of R2’s current pharmacy. 2. In an interview, E2 acknowledged the form did not include the address of R2’s current pharmacy.

Based on documentation review and interview, the manager of an assisted living home failed to maintain a copy of the document provided to the emergency responder which included the items listed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “Emergency responders: Patient information; hospitals: discharge planning; Patient screenings; document discharge” dated July 10, 2024. The P&P stated, “Facility shall maintain a copy of the document provided to the emergency responder.” The review further revealed two incident reports dated January 2, 2025, and February 26, 2025, respectively. The incident reports indicated R1 had accidents, emergencies, or injuries that resulted in the facility requesting emergency responders for R1. However, the review revealed no copies of the documents provided to the emergency responders for the items listed in A.R.S. § 36-420.04(A)(2), (8), and (9). 2. In an interview, E2 stated: “It’s redundant for us. We don’t want to print our own copy.”

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually assessing the health care institution’s risk of exposure to infectious tuberculosis. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of facility documentation revealed no documentation demonstrating facility personnel assessed the health care institution’s risk of exposure to infectious TB within the last 12 months. 2. In an interview, E1 reported the facility had a blank form used to assess the health care institution’s risk of exposure to infectious TB. However, E1 reported the facility had not yet used the form. Technical assistance was provided on this rule during the compliance inspection conducted on August 14, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of three sampled applicable personnel members. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "FIRST AID/CPR TRAINING REQUIREMENTS" dated July 10, 2024. The P&P stated: "Assisted living facilities are required that facility staff members who provide care for residents, should have completed courses in First Aid and CPR and hold a currently valid card documenting completion of such courses in the facility at all times.” The review further revealed a series personnel schedule dated between February 2025 and April 2025 which indicated E3 worked on a regular basis. 2. A review of E3's personnel record revealed E3 was hired as a caregiver. The review revealed a printout of E3's first aid and CPR training certification from NationalCPRFoundation dated as issued on February 2, 2025, after E3 began providing services. 3. A review of the NationalCPRFoundation website revealed E3's CPR training was online-only and did not include a demonstration of E3's ability to perform CPR. 4. In an interview, E2 acknowledged pE3 did not provide current documentation of first aid and CPR training certification before providing assisted living services.

Based on documentation review, observation, interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING POLICY” dated July 10, 2024. The P&P stated: “Employees are required to accurately record all time worked, including the time they begin and end each shift. Staff should also record the beginning and ending time of any split shift or departure from work for personal reasons. Employees are responsible for completing their own name records on a daily basis. Altering, falsifying, tampering with time records, and/or recording time on another employee's time record will result in disciplinary action, up to and including termination.” 2. The Compliance Officer observed E2 at the facility when the Compliance Officer arrived. 3. A review of facility documentation revealed a personnel schedule dated April 2025. The schedule revealed E2 was not scheduled to work on the date of the inspection, April 22, 2025. The schedule did not include the hours worked by caregivers each day. 4. In a series of interviews, E2 reported E4 did not work in March 2025, stating, “[E4] took off that month.” E4 stated, “I don’t think I was here in March.” 5. A review of facility documentation revealed a personnel schedule dated March 2025 which indicated E4 was not scheduled to work in March 2025. 6. A review of R1’s medical record revealed a medication administration record (MAR) dated March 2025. The MAR indicated E4 administered medications to R1 on March 30, 2025, contrary to the personnel schedule and E2’s and E4’s statements. 7. A review of R2’s medical record revealed documentation of assisted living services provided to R2 (ADLs) in March 2025. The ADLs indicated E4 provided services to R2 on March 27 and 31, 2025, contrary to the personnel schedule and E2’s and E4’s statements. 8. In an interview, when the Compliance Officer showed the ADLs and MAR to E2 and E4, E4 confirmed the initials on March 27, and 30-31, 2025, were E4’s. E2 and E4 then reported E4 worked for a few days in March 2025, contrary to previous statements. 9. A review of facility documentation revealed a personnel schedule dated March 2025 schedule revealed the following: - E3 was not scheduled to work on March 9, 16, and 23, 2025; - E5 was not scheduled to work at 10:00 AM and 2:30 PM on March 11, 2025; and - E7 was not scheduled to work on March 1, 8, and 29, 2025. 10. A review of R1’s medical record revealed a medication administration record (MAR) dated March 2025 which indicated E7 administered medications to R1 on March 29, 2025, contrary to the personnel schedule. 11. A review of R2’s medical record rev

Based on documentation review, record review, and interview, the manager failed to ensure a written notice of termination of residency included all items required by this rule, for one of one applicable sampled resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “TERMINATION OF RESIDENCY (BY THE FACILITY)” dated July 10, 2024. The P&P stated: “1. The manager or manager’s designee shall ensure that a written notice of termination of residency includes: a. The date of notice; b. The reason for termination; c. The policy for refunding fees, charges or deposits; d. The deposition of a resident’s fees, charges and deposits; and e. Contact information for the State Long-Term Care Ombudsman.” 2. A review of R2’s medical record revealed a “NOTICE TO TERMINATE AGREEMENT.” The notice included the date of the notice and the reason for termination. However, the notice did not include the policy for refunding fees, charges, or deposits; the disposition of R2’s fees, charges, and deposits; and contact information for the State Long-Term Care Ombudsman. 3. In an interview, E2 acknowledged the notice of termination did not include all required items.

Based on documentation review, record review, and interview, the manager failed to provide a copy of the resident’s current service plan and documentation of the resident’s freedom from infectious tuberculosis to a resident when the manager provided the written notice of termination of residency, for one of one applicable sampled resident. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “TERMINATION OF RESIDENCY (BY RESIDENT)” dated July 10, 2024. The P&P stated: “2. Upon termination of the resident’s residency that includes the date and reason for termination, the manager shall provide the following to the resident or resident’s representative: a. A copy of the resident’s current service care plan [and] b. Documentation of the resident’s freedom from infectious tuberculosis.” 2. A review of R2’s medical record revealed a “NOTICE TO TERMINATE AGREEMENT.” However, the notice did not include a copy of R2’s current service plan and documentation of R2’s freedom from infectious tuberculosis. 3. In an interview, E2 confirmed the notice of termination did not include the two documents required by this rule. E2 stated facility personnel gave R2 a copy of R2’s service plan “A week after” giving the notice of termination.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated March 28, 2025. The service plan revealed R1 was to receive nail care daily, stating facility personnel were to “Check fingernails daily and clean as needed.” The review revealed documentation of assisted living services provided to R1 (ADLs) dated April 2025. However, the ADLs revealed no documentation of nail care. 2. A review of R2's medical record revealed a service plan dated February 3, 2025. The service plan revealed R2 was to receive nail care daily, stating facility personnel were to “Check fingernails daily and clean as needed.” The review revealed ADLs dated March 2025. However, the ADLs revealed no documentation of nail care. 3. In an interview, E2 reported facility personnel provided nail care to R1 and R2 every day but did not document the care. E2 stated, “The caregivers don’t chart” and “We don’t document every day.” This is a repeat citation from the compliance inspection conducted on August 14, 2023.

Based on record review and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility’s manager, caregivers, assistant caregivers, employees, or volunteers. Findings include: 1. A review of R2’s medical record revealed a “GRIEVANCE FORM / RESIDENT COMPLAINT” dated March 14, 2025. The form indicated R2 was missing personal property. The form stated: “Staff educated to not share [R2’s] snacks to other residents…Packets of green sugars: Was put in the center dining table and along with pink diabetes sugar and white sugar purchased by facility and another residents possible use it also. Manager Inservice staff to make sure green sugar for [R2] only.” The “Intervention and Conclusion” section of the complaint form stated: “[E2] spoke with [R2’s family member] all the concerns above will be fix…Facility manager [gave] staff up to 30-45 days to prevent this happening again.” 2. In an interview, E2 confirmed facility staff put R2’s green sugar packets purchased by R2’s family member out on the table for other residents to use.

Based on observation, record review, and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for one of two sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. The Compliance Officer observed E5 providing residents with an activity at approximately 10:00 AM. The Compliance Officer observed E4 was not participating in the activity or helping with the activity. 2. A review of R1’s medical record conducted at approximately 3:00 PM revealed documentation of assisted living services provided to R1 (ADLs) dated April 2025. However, the ADLs revealed documentation demonstrating E4 provided the activity instead of E5, as observed. The ADLs further revealed the services of ambulation, dressing, eating, toileting, tracking bowel movements, and transferring were completed for the entire day even though it was only 3:00 PM. 3. In an interview, E2 stated, “As long as it’s done, one of them can chart.”

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door leading from R8’s bedroom to the backyard. The Compliance Officer observed the door did not have a control installed but did have an alert installed. However, upon opening the door, the Compliance Officer heard no alert. The Compliance Officer removed the cover to the alert and observed one of the batteries was corroded. 3. In an interview, E2 acknowledged the alert was not sounding. 4. The Compliance Officer observed a door leading from R3’s bedroom to the backyard. The Compliance Officer observed the door did not have a control installed but did have an alert installed. However, the alert portion and the magnet portion were not properly vertically aligned and the alert was turned to the "Off" position. Upon opening the door, the Compliance Officer heard no alert. 5. In an interview, E2 stated, “We don’t use the alarm because [R3] doesn’t like the sound.” Technical assistance was provided on this rule during the compliance inspection conducted on August 14, 2023.

Based on documentation review, 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 two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION ADMINISTRATION" dated July 10, 2024. The P&P stated, "The manager or manager’s designee shall ensure that a medication administered to a resident is administered in compliance with a medication order." 2. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed a medication order dated February 21, 2025, for the following medications: - “ASPIRIN LOW 81 MG Oral Tablet [one tablet] QD - One Time Daily;” - “Buspirone 5 mg Oral Tablet [one tablet] BID - Twice a Day;” - “Isosorbide mononitrate er 30 MG Oral Tablet [one tablet] QD - One Time Daily;” - “Lidocaine patch 4% Topical Patch [one patch] BID - Twice a day;” - “Prednisone 10 Mg Oral Tablet [one tablet] QD - One Time Daily;” - “SETRALINE [sic] HCI 100 MG Oral Tablet [one tablet] QD - One Time Daily;” - “Tolterodine 4 mg Oral Capsule, extended release [one capsule] QD - One Time Daily;” and - “Tylenol Acetaminophen ER 500 MG Oral Capsule [two capsules] TID - Three Times Daily.” The review revealed a medication administration record (MAR) dated March 2025 which indicated R1 did not receive the eight aforementioned medications on March 27, 2025. The review revealed a medication order/recap dated April 9, 2025, for “Salonpas Pain Relieving Patch 4 % Topical Patch [one patch] Q12H - Every Twelve Hours” with a start date of March 28, 2025. The review relieved an medication order dated April 2, 2025, to discontinue “Elipta [sic] Aerosol powder 62.5-25mcg,” “Metoprolol 50mg,” and “Pantoprazole 40mg.” The review further revealed a MAR dated April 2025. The MAR revealed the following: - R1 did not receive the first and second Salonpas patches on April 5-12, 2025; - R1 did not receive the first Salonpas patch on April 13, 2025; - R1 received Ellipta on April 3-4, 2025, after the discontinue order; - R1 received metoprolol on April 3-4, 2025, after the discontinue order; and - R1 received pantoprazole on April 3-4, 2025, after the discontinue order. 3. In an interview, E2 acknowledged the aforementioned medications administered to R1 were not administered in compliance with R1’s medication orders.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility 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 the physical health and safety of residents with access to the medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "SAFE STORAGE OF MEDICATION" dated July 10, 2024. The P&P stated, "All medications centrally stored by the facility must be maintained in a separated locked room, closet, cabinet, or self-contained unit used only for medication storage." 2. The Compliance Officer observed an unlocked refrigerator in the kitchen. In the door of the refrigerator, the Compliance Officer observed a box of lorazepam. 3. In an interview, when the Compliance Officer asked if the facility had a locked storage area for the lorazepam, E2 stated, “Yes.” 4. The Compliance Officer observed a cabinet with magnetic laches installed. However, the Compliance Officer observed the magnet to unlatch the cabinet on the wall next to the cabinet. The Compliance Officer used the magnet to open the cabinet and observed a variety of resident medications inside, including the residents' medication organizers. The Compliance Officer further observed resident medical records and first aid kits stored with the medications. 5. The Compliance Officer observed a medicine cabinet in R8’s bathroom with magnetic latches installed. However, the Compliance Officer observed the magnet to unlatch the cabinet hanging from a string next to the cabinet. The Compliance Officer used the magnet to open the cabinet and observed ketoconazole shampoo, nystatin powder, and urea cream inside. 6. In an interview, E2 reported the magnets used to unlatch the medication cabinets should be in the caregivers’ pockets, stating the magnets “should not be accessible.” This is a repeat citation from the compliance inspection conducted on August 14, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to residents with access to the poisonous or toxic materials. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "SAFETY OF THE FACILITY AND GROUNDS" dated July 10, 2024. The P&P stated, "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas." 2. The Compliance Officer observed a medicine cabinet in a hall bathroom with magnetic latches installed. However, the Compliance Officer observed the magnet to unlatch the cabinet hanging from a string on the cabinet. The Compliance Officer used the magnet to open the cabinet and observed a spray can of air freshener inside. The Compliance Officer observed a cabinet under the sink in the kitchen with magnetic latches installed. However, the Compliance Officer observed the magnet to unlatch the cabinet hanging from a string on the cabinet. The Compliance Officer used the magnet to open the cabinet and observed a variety of poisonous or toxic materials inside, including dishwasher tablets, glass cleaner, hardwood floor luster, odor remover, oven cleaner, and wood polish. 3. In an interview, E2 reported the magnets used to unlatch the aforementioned cabinets should be in the caregivers’ pockets, stating the magnets “should not be accessible.” This is a repeat citation from the compliance inspections conducted on August 14, 2023, and August 4, 2022.

Based on documentation review and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, was maintained for at least 12 months after the last date on the documentation. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered. Findings include: 1. A review of facility documentation revealed a staffing schedule dated August 2023. The staffing schedule included E3 and E4, both hired as assistant caregivers. However, documentation of the assistant caregivers working each day including the hours worked was not provided on the schedule. 2. In an interview, E1 acknowledged documentation of the assistant caregiver working each day, including the hours worked by each, was not maintained. Technical assistance was provided on this Rule during the compliance inspection conducted on August 4, 2022.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of eight 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 R1's medical record revealed a service plan for personal care services dated in April 2023. The service plan stated R1 was to receive "Oral Care... daily... nail care... daily...comb hair... daily...dressing... assistance required... bowel... total incontinent... toileting... dependant..." However, the aforementioned services were not documented as provided to R1 on August 10, 2023 through August 13, 2023. 2. In an interview, E1 reported the caregiver or assistant caregiver did provide the services, but did not document when the services were provided.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for six of eight current residents sampled who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a medication administration record (MAR) dated August 2023. The MAR included the following medications: - Levetiracetam/Keppra 750 mg, one tablet every morning; - Levetiracetam/Keppra 1000 mg, one tablet every night; - Ketotifen Furmarate Ophthalmic 0.025% eye drops, twice a day; - Metformin 500 mg tab, take half a tab two times daily; - Memantine HCI 5 mg, one tablet daily; - Amlodipine Besylate 5 mg, one tablet daily; - Aspirin Low 81 mg, one tab daily; - Divalproex Sodium 500 mg, take one tablet by mouth at night; - Sertraline HCI 25 mg, one tablet daily; and - Docusate 100 mg, twice daily. However, the MAR did not indicate the aforementioned medications had been administered August 10, 2023 (if PM administration required) through August 14, 2023 (if AM administration required). 2. A review of R1's medical record revealed medication orders for the aforementioned medications. 3. A review of R4's medical record revealed a MAR dated August 2023. The MAR included the following medications: - Depakote Sprinkles 125 mg, one capsule three times a day; - Miralax oral powder 17 mg, once a day; - Acetaminophen 325 mg, take two tabs three times a day; and - Haloperidol 2mg'mL concentrate, one milligram oral two times daily. However, the MAR did not indicate the aforementioned medications had been administered August 10, 2023 (if PM administration required) through August 14, 2023 (if AM administration required). 4. A review of R4's medical record revealed medication orders for the aforementioned medications. 5. A review of R5's medical record revealed a MAR dated August 2023. The MAR included the following medications: - Nifedipine oral tab 600 mg, one tab once a day, hold if SBP less than 120; - Metoprolol Tartrate 25 mg, one tab twice a day, hold if SBP is below 120; - Isosorbide Mononitrate 30 mg, one tab a day, hold if SBP less than 120; - Atorvastatin Calcium 40 mg, one tab at bedtime; - Levothyroxine Sodium 125 mcg, one tab in the morning; - Duloxetine 60 mg, one capsule a day; - Advair Diskus, one inhale one time a day; - Omeprazole 20 mg, one capsule in the morning; - Amantadine 100 mg, two times a day; - Trazadone 50 mg, take 0.5 tab at bedtime; - Carbidopa - Levodopa 25-100 mg, one tab three times a day; - Gabapentin 400 mg, take one tablet at bedtime; and - Amiodarone 200 mg, one tab a day. However, the MAR did not indicate the aforementioned medications had been administered August 10, 2023 (if PM administration required) through August 14, 2023 (if AM administration required). 6. A review of R5's medical record revealed medication o

Based on observation and interview, the manager failed to ensure 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 not prescribed the accessible medication. Findings include: 1. The Compliance Officers observed ambulatory residents on the premises. 2. The Compliance Officers observed unlocked on R2's nightstand, Pheodoyo topical cream. 3. The Compliance Officers observed unlocked on R3's nightstand, Naproxen Sodium tablet, 220 mg. 4. In an interview, E1 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were in labeled containers and stored 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. The Compliance Officers observed disinfectant sprays, "Fabuloso", and laundry detergent in an unlocked laundry room. 2. The Compliance Officers observed an unlabeled spray bottle with a purple liquid inside on the floor in an unlocked bathroom. 3. The Compliance Officers observed hardwood floor cleaner in an unlocked cabinet in a bathroom. 4. In an interview, E1 reported the laundry room is usually locked with a pin code. E1 reported staff were cleaning in the morning. However, E1 acknowledged the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. This is a repeat deficiency from the compliance inspections conducted on August 4, 2022.