Oasis at Fellowship Square Tucson, the

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of six resident records reviewed. Findings include: 1. A review of R5's medical record revealed a service plan dated November 19, 2024. The service plan indicated R5 was to receive the following assistance with showering: “Standard 2x a week” with “Preparation needed of shower temperature and/or supplies…” and “Standby,” “For safety reasons or unsteadiness….” 2. Further review revealed documentation of assisted living services provided to R5 on the monthly “ADL Log” form, dated March 2025. However, the documentation revealed R5 received assistance with R5’s shower on March 8, 15, and 22, 2025. There was no mark or note to indicate shower assistance was offered on any other day. 3. In an interview, E1 acknowledged the shower assistance provided for R5 was either not provided or not documented as provided two times per week.

Based on observation and interview, the manager failed to ensure medications stored by the facility were 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 could access the medication. Findings include: 1. During the on-site investigation, the Compliance Officer observed the nurse’s office unlocked and occasionally unoccupied by the nurse or other staff. The Compliance Officer observed multiple medications unsecured in the office. The Compliance Officer observed medications sitting on the nurse’s desk, unsecured. The medications included, “ASPIRIN 81MG”; “GLIMEPIRIDE 2MG”, “furosemide 40MG”; and “atorvastatin 40MG”. The Compliance Officer observed boxes of medications behind a curtain, which included boxes of old medication cards. Some of the medication cards included “SYNTHROID 0.175MG”; “guaiFENesin ER 600”; and “CYCLOBENZAPRINE 10MG”. There were other medications observed on the back counter of the nurse’s office including, “DayQuil”; “NyQuil”; and “Ipratropium Bromide and Albuterol Sulfate Inhalation Solution”. 2. In an interview, E2 reported the office was usually locked; however, the items were not in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. E2 reported most of the medications were waiting to be destroyed, and acknowledged the medications still have to be secured in a separate cabinet or self-contained unit. 3. In an interview, E1 acknowledged medications stored by the facility were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of first aid training, for one of six personnel records reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E4's personnel record revealed E4 was hired in 2019 as a caregiver. 2. A review of E4's personnel record revealed documentation of first aid training, which expired in August 2024. 3. A review of the facility's daily staffing schedule for November 2024 revealed E4 was scheduled to work from 6:30am to 3pm on November 2, 3, 4, 5, 6, 7, and 8, 2024. 5. In an interview, E1 acknowledged E4's personnel record did not include documentation of current first aid training for E4.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for five of six resident records reviewed. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement was not signed and dated by the manager. 2. A review of R3's medical record revealed a documented residency agreement. However, the residency agreement was not signed and dated by the manager. 3. A review of R4's, R5's and R6's residency agreements included the manager's signature, though did not include the date signed. 4. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R1 and R3 before or at the time of R1's and R3's acceptance.

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 the resident's date of acceptance for three of six resident records reviewed. Findings include: 1. A review of R2's medical record revealed an initial service plan for supervisory care level of services, with the following information; - Facility nurse signed and dated the document on October 1, 2024; - Facility manager signed and dated the document on October 25, 2024; and - Resident signed and dated the document on October 4, 2024. Based on R2's date of acceptance, the service plan was not completed within 14 calendar days of R2's date of acceptance. 2. A review of R4's medical record revealed an initial service plan for personal care level of services, with the following information; - Facility nurse signed and dated the document on April 22, 2024; - Facility manager signed and dated the document on October 23, 2024; and - Resident signed, though did not date the document. Based on R4's date of acceptance, the service plan was not completed within 14 calendar days of R4's date of acceptance. 3. A review of R5's medical record revealed an initial service plan for personal care level of services, with the following information; - Facility nurse signed and dated the document on January 17, 2024; - Facility manager signed and dated the document on October 25, 2024; and - Resident signed and dated the document on January 17, 2024. Based on R5's date of acceptance, the service plan was not completed within 14 calendar days of R5's date of acceptance. 4. In an interview, E1 acknowledged the service plans were not completed within 14 calendar days of the residents' date of acceptance.

Based on documentation review, and interview, the manager failed to ensure the service plans included how medication was stored and controlled for residents who stored medication in the resident's residential unit, for two of six resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan updated October 25, 2024, for supervisory care. The service plan stated R2 would self-administer medication. The service plan did not state how the medication would be stored and controlled. 2. In an interview, E2 confirmed R2 self-administered one medication, which R2 would store in R2's residential unit. 3. A review of R6's medical record revealed a service plan updated October 25, 2024, for supervisory care. The service plan stated R6 would self-administer medication. The service plan did not state how the medication would be stored and controlled. 4. In an interview, E2 confirmed R6 self-administered medication, which R6 would store in R6's residential unit. 5. In an interview, E1 acknowledged the service plans for R2 and R6, who self-administered and stored medication, did not include how the medication would be stored and controlled.

Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of six resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R4's medical record revealed personal care services were provided and R4 required bathing assistance twice per week. 2. A review of the "ADL Log", which included documentation of services provided, revealed a shower was not provided for R4 twice each week, in September and October. 3. In an interview, E1 acknowledged services provided to R4 had not been documented.

Based on interview and documentation review, the manager failed to ensure daily social, recreational, or rehabilitative activities were planned according to residents' preferences, needs, and abilities. Findings include: 1. In an interview, R1 reported the facility had not been planning and carrying out social or recreational activities daily. R1 reported sometimes residents arrived to find out the activity was canceled. 2. In an interview, E1 reported the facility was currently without an activities director. E1 further reported E9 was filling in sometimes to assist with activities. 3. In an interview, E1 acknowledged activities were not carried out daily and the facility was in the process of hiring another activities director.

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure to cover fall prevention and fall recovery. However, the policy did not include requirements for initial training and continued competency training in fall prevention and fall recovery. 2. A review of E4's, E6's, and E7's personnel records revealed documentation of fall prevention and fall recovery training on March 30, 2022. However, continued competency training after March of 2022 was not available for review. 3. A review of E9's and E10's personnel records revealed documentation of fall prevention and fall recovery training was not available for review. 4. In an interview, E1 and E2 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the on-site compliance inspection conducted on September 1, 2022.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of CPR training, including a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for two of seven sampled caregivers. The deficient practice posed a risk to the health and safety of residents if employees were unable to perform life saving measures in the event of an emergency. Findings include: 1. A review of the facility's policies and procedures, reviewed November 1, 2019, revealed a policy covering CPR training was not available for review. 2. A review of facility documentation revealed a work schedule for the month of October 2023. The work schedule indicated E9 worked at the facility on October 7, 2023 on a 6:30 a.m. to 3 p.m. shift, and indicated E10 worked at the facility on October 12th on a 6:30 a.m. to 3 p.m. shift. 3. A review of E9's and E10's personnel files revealed documentation of CPR certification from, "National CPR Foundation", an online-only CPR provider, which did not include a demonstration of each employee's ability to perform CPR. 4. In an interview, E1 and E2 acknowledged a policy and procedure covering CPR training had not been provided for review and acknowledged E9's and E10's CPR training did not include a demonstration of each caregiver's ability to perform CPR.

Based on record review, documentation review, observation, and interview, the manager failed to ensure for one of seven personnel members sampled, before providing assisted living services to a resident, a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) and First Aid training certification. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E7's personnel record revealed E7 was hired as a caregiver in February of 2012. 2. A review of E7's personnel record revealed an in-person CPR and First Aid training certification issued on October 25, 2021 and which had a marked expiration date of October 25, 2023. 3. A review of the facility work schedule for November 2023 revealed E7 worked as a "med tech," on November 1 and November 3, 2023 on a 10:30 p.m. to 7 a.m. shift, after the expiration of E7's CPR and First Aid training certification. 4. In an interview, E1 and E2 acknowledged E7's personnel file did not contain documentation of current CPR and first aid training certification.

Based on documentation review, interview, and record review, the manager failed to ensure a personnel record was established and maintained to include all required documents, for two of seven personnel records reviewed. The deficient practice posed a risk as required information could not be verified for E9 or E10. Findings include: 1. A review of facility documentation revealed a work schedule for the month of October 2023. The work schedule indicated E9 worked at the facility on October 7, 2023 on a 6:30 a.m. to 3 p.m. shift, and indicated E10 worked at the facility on October 12th on a 6:30 a.m. to 3 p.m. shift. 2. In an interview, E1 reported E9 and E10 were not regular employees of the facility and were caregivers supplied by a staffing agency. E1 reported the work schedules did not accurately include all agency-staffed shifts. 3. A review of E9's personnel record revealed the following documentation was not available for review: - E9's contact telephone number; - E9's starting date of employment and, if applicable, the ending date; - E9's qualifications including skills and knowledge; - E9's education and experience applicable to E9's job duties; - E9's completed orientation and in-service education; - E9's certification as a caregiver; - E9's evidence of freedom from infectious tuberculosis; - E9's First Aid Training; and - E9's documentation of compliance with the requirements in A.R.S. \'a7 36-411(C). 4. A review of E10's personnel record revealed the following documentation was not available for review: - E10's contact telephone number; - E10's starting date of employment and, if applicable, the ending date; - E10's qualifications including skills and knowledge; - E10's education and experience applicable to E9's job duties; - E10's completed orientation and in-service education; and - E10's documentation of compliance with the requirements in A.R.S. \'a7 36-411(C). 5. In an interview, E1 and E2 acknowledged the provided personnel files for agency staff did not include all required documentation.

Based on documentation review, record review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with Arizona Administrative Code (A.A.C.) R9-10-807(G), for six of six sampled residents reviewed. Findings include: 1. A review of the facility's policies and procedures, last reviewed, "11-1-2019," revealed a termination policy which stated, "(c) Owner may terminate this Agreement immediately with written notice to Resident if:..(ii) Resident's urgent medical or health needs require immediate transfer to another health care institution; or (iii) Residents's care and service needs exceed the services the Facility is licensed to provide." 2. A review of six sampled resident's medical records revealed each record contained a residency agreement which included the same immediate termination policy as found in the facility's policy and procedure. 3. In an interview, E1 and E2 acknowledged the facility's termination policy and residency agreements allowed the manager to terminate residency immediately in situations not allowed per R9-10-807(G).

Based on record review, and interview, for three of five sampled residents reviewed, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R1's medical record revealed a current service plan, dated May 20, 2023, for personal care services. However, the previous service plan was dated May 20, 2022, more than six months prior to the current service plan. A service plan dated on or before November 20, 2022 was not available for review. 2. A review of R2's medical record revealed a current service plan dated May 4, 2023, for personal care services. However, the previous service plan was dated May 202, 2022, and the service plan before that was dated May 31, 2021, a time frame of more than six months between updates. Service plans dated on or before November 31, 2021, November 20, 2022, and November 4, 2023 were not available for review. 3. A review of R6's medical record revealed a current service plan dated March 15, 2022. The service plan did not state R6's level of service, but did include medication administration, which would require at least a Personal care level of service. However, service plans dated on or before September 15, 2022, March 15, 2023, and September 15, 2023 were not available for review. 4. In an interview, E1 and E2 acknowledged service plans for R1, R2, and R6 had not been updated at least once every six months and documented.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of six residents sampled. Findings include: 1. A review of R1's, R2's, R3's, R4's and R6's medical records revealed each resident had a current service plan describing the services which would be provided by the facility staff to each resident. 2. A review of each resident's electronic medical record revealed documentation titled, "ADL Log," which listed the services provided to each resident and included boxes for caregivers to mark when services were provided. However, the services on the ADL Logs did not match the services listed in each resident's service plans, and each ADL Log contained multiple gaps indicating a caregiver had not accurately documented the services provided to each resident. 3. In an interview, E1 and E2 acknowledged the ADL logs for each resident had not been completed on each shift and did not list the same services required by each resident's service plan.

Based on record review, documentation review, and interview, the manager failed to ensure service plans for residents receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, offering sufficient fluids to maintain hydration, and incontinence care that ensures that a resident maintains the highest practicable level of independence, for four of five sampled residents who received personal care services. Findings include: 1. A review of R1's medical record revealed a service plan, dated May 20, 2023, for personal care services. However, the service plan did not include the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 2. A review of R2's medical record revealed a service plan, dated May 4, 2023, for personal care services, However, the service plan did not include the following: - Offering sufficient fluids to maintain hydration. 3. A review of R4's medical record revealed a service plan, dated August 1, 2023, for personal care services, However, the service plan did not include the following: - Incontinence care that ensured that R4 maintained the highest practicable level of independence. 4. A review of R6's medical record revealed a service plan, dated August 1, 2023, for personal care services, However, the service plan did not include the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 5. In an interview, E1 and E2 acknowledged the sampled service plans for personal care residents did not all include a description of the type, amount, and frequency of services each resident required regarding skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, offering sufficient fluids to maintain hydration, and incontinence care that ensures that a resident maintains the highest practicable level of independence.

Based on documentation review and interview, the manager failed to ensure a disaster plan review was documented according to R9-10-818(A)(3)(a-d). Findings include: 1. A review of the facility's policies and procedures revealed a disaster plan. The disaster plan had been signed and dated annually by the manager to indicate a review. However, the time of the review, the name of each employee who participated, and a critique of the review were not available. 2. In an interview, E1 and E2 acknowledged the annual disaster plan review was not documented as required by the rule.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a storage room located at the top of a stairwell outside the commercial kitchen. The storage room door had a lock, however, the door was found to be unlocked at the time of the inspection. Inside the room, the Compliance Officer observed various cleaning chemicals were stored by the facility. 2. During an environmental inspection of the facility, the Compliance Officer observed a gym in the basement. The gym door did not have a lock. Inside the gym, the Compliance Officer observed an unlabeled spray bottle of yellow liquid. 3. During an environmental inspection of the facility, the Compliance Officer observed a mechanical room in the basement. The door had a lock but the Compliance Officer observed the door was open and the area was unoccupied at the time of the survey. Inside the mechanical room the Compliance Officer observed various poisonous chemicals such as pool maintenance chemicals and drain openers. 4. In an interview, E1 and E2 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in labeled containers and in a locked area inaccessible to residents.