Oakwood Assisted Living LLC

Based on documentation review, record review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of three sampled staff. Findings include: 1. A.R.S. § 36-411(C) states: " C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2 . A review of E1's, E2's, and E3's personnel records did not contain verification that E1, E2, and E3 were not on the adult protective services registry. 3 . In an interview, E1 acknowledged not being in compliance with A.R.S. § 36-411.

Based on record review and interview, the manager failed to ensure that there was a documented residency agreement with the assisted living facility for two of two sampled residents. Findings include: 1. A review of R1's and R2's medical records did not contain a documented residency agreement with the assisted living facility. 2. In an interview, E1 acknowledged that R1's and R2's medical records did not contain a documented residency agreement with the assisted living facility.

Based on observation and interview, the manager failed to ensure there was 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 that provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility, or used a mechanism that met the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01. Findings include: 1. The compliance officer observed a vacant bedroom that contained a door leading to the facility's backyard. The door did not monitor or alert employees when opened. 2 . In an interview, E1 acknowledged that residents were not provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility if a resident exited from the vacant bedroom.

Based on observation and interview, the manager failed to ensure food was stored free from spoilage, filth, or other contamination and was safe for human consumption. Findings include: 1. The compliance officer observed the following inside the facility's refrigerator: turkey meat with an expiration date of April 2025, variety cheese expiration July 2025, and a block of cheese with green and white spots on the cheese. 2. In an interview, the manager acknowledged food was not stored free from spoilage, filth, or other contamination and was safe for human consumption.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. Findings include: 1. A review of R1's medical record revealed a document titled "Facility Visit Note" dated September 13, 2024 reflected E4 was the designated caregiver at the facility at the time of R1's hospice visit. 2. A reviewed facility's documentation revealed a document titled "Employee Work Schedule" dated September 2024 did not reflect the hours worked by E4. 3. In an interview, E1 acknowledged E4's hours worked was not reflected on the facility's September 2024 work schedule.

Based on record review and interview, the manager failed to ensure 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 which included the requirements in R9-10-807(D)(1)-(10), for two of three residents sampled. Findings include 1. A review of R1's medical record revealed a residency agreement with another facility. There was no documentation to reflect an agreement between R1 and the facility. Based on the resident's date of acceptance, this documentation was required. 2. A review of R2's medical record revealed a residency agreement with another facility. There was no documentation to reflect an agreement between R2 and the facility. Based on the resident's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledge R1's and R2's residency agreements did not reflect an agreement with AL12939.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, which posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the facility tour with E1, the surveyor observed there was no thermometer in the refrigerator in the kitchen. The refrigerator contained items such as milk, eggs, and other perishable items. 2. During an interview, E1 reported the refrigerator was used to store food for the residents and acknowledged the refrigerator did not contain a thermometer.