Ocotillo Place

Based on documentation review, observation, and interview, the manager failed to ensure that cooling systems not controlled by a resident maintained the assisted living facility at a temperature between 70° F and 84° F at all times. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed a policy and procedures titled "Temperature Control In Assisted Living" that read as followed: "Purpose: To ensure that the heating and cooling systems maintain the assisted living facility at a comfortable and safe temperature in compliance with Arizona Administrative Code R9-10-819-A4. Policy: Temperature Range: A. The facility's heating and cooling systems must maintain a temperature between 70 degrees and 84 degrees F at all times. b. Temperature adjustments outside of this range are permitted only if individually controlled by a resident in their private living space." 2. During the environmental inspection, the Compliance Officer asked E4 to use E4's temperature gun to obtain the temperature reading in R10's room. The temperature gun registered a temperature of 97 degrees Fahrenheit. R10's room did not have an individual thermostat that could be adjusted. 3. During the environmental inspection, the Compliance Officer observed cooling fans in R3, R7, R8, R9, and R10's rooms. 4. In an interview, E4 reported that E4 had contacted a repair company but that the repair company would not be available until Monday, March 23, 2026. E4 reported that E4 was making the temperature adjustments manually on the air conditioning units on the roof of the facility. 5. In an interview, E1 and E2 reported being aware of the facility's inoperable air conditioner units and that E4 was working to repair the units, and that a repair company was scheduled to make repairs on Monday, March 23, 2026. 6. In an exit interview, findings were reviewed with E1, E2, and O1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer (CO) observed the presence of a strong urine smell and flying bugs throughout the facility. The CO also observed the presence of bugs in the closet, clutter, an uncovered basket of dirty laundry and large stains on the carpet in the shared apartment of R1 and R2. 2. A review of the facility's documentation revealed a policy titled, "Environmental Sanitation" that contained the following verbiage: "Housekeeping Services and Maintenance Services. Housekeeping, maintenance personnel, and equipment will be provided to keep the interior and exterior of the community in a clean, safe, and orderly manner." 3. A review of R1 and R2's medical records revealed a residency agreement for both residents that included the following verbiage: "Services Provided: Weekly housekeeping including laundering of personal linen and bed sheets." 4. In an interview with E6, the CO inquired about the facility's documentation of these weekly housekeeping services listed in the residents' residency agreements. E6 provided the CO with a document that revealed E1 and E2 were to receive housekeeping services on Fridays. The CO requested the documentation of housekeeping services completed on Fridays; however, no documentation of housekeeping cleaning was available. E6 reported having no knowledge of this verbiage in the residents' residency agreement. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 6. This is an uncorrected deficiency from the inspection conducted on January 21, 2026.

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 one 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 R2’s current service plan revealed R2 received weekly housekeeping and laundry services two times a week. 2. A review of R2’s activities of daily living for the month of January 2026 revealed that housekeeping and laundry services were not documented. No other documents were provided at the time of the inspection. 3. In an interview, E1 reported the services provided however were not documented. 4. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident that monitors or alerts employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed the following: A side gate on the ground level that lead to the front parking lot unlocked and open. A ground level door leading into the facility’s employee lounge propped open. A ground level door from outside to an inside hall propped open. 2. A review of Department documentation revealed the facility was licensed to provide directed care services. 3. In an interview, E1 reported that the staff did not monitor any of the ground level exit doors for egress. 4. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected according to policies and procedures to prevent, minimize, and control illness or infection. The deficient practice posed a potential risk to infection control. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: In R2’s room there a strong urine smell. In R2’s room yellow droplet stains on the bathroom floor. In R2’s room a wheelchair with a dried brown substance on the seat cushion. 2. A review of the facility's policies and procedures revealed the following policies: A policy titled, “Infection Control.” The policy stated “6. Community will provide “spill skits” and appropriate disposal containers for cleansing of blood and bodily fluid spills. Diseases classified as “ reportable” and/or the requirements of the community health department will be reported accordingly.” A policy titled, “Recommendations for Residents and Caregivers.” This policy stated, “11. Living space bathroom and other living areas should be disinfected regularly with a 1:10 solution of household bleach and water. Fresh bleach solutions should be made at least daily as these solutions begin to lose their effectiveness at the time of dilution. 12. Spills blood/bodily fluids put on gloves (and other personal protective equipment as needed). Wipe excess material with disposable towels. Clean with soap and water. Disinfect surfaces with 1:10 solution of household bleach and water.” 3. In an exit interview, the findings were reviewed with E1 and E3, and no additional information was provided.

Based on record review and interview, the manager failed to ensure compliance with A.R.S. \'a7 36-411.A, for one of three employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. Record review established that E2 did not possess a Department of Public Safety fingerprint clearance card. 2. Record review established that E2 had no history of possessing a Department of Public Safety fingerprint clearance card. Record review established that E2 had been employed by the facility since September 1, 2021. 3. In an interview, E1 confirmed that E2 did not possess a Department of Public Safety fingerprint clearance card. E1 also confirmed that E2 had no history of possessing a Department of Public Safety fingerprint clearance card. E1 also confirmed that record review established that E2 had been employed by the facility since September 1, 2021.

Based on observation, documentation review and interview, the manager failed to ensure that heating and cooling systems were maintained at the assisted living facility at a temperature between 70\'b0 F and 84\'b0 F at all times, unless individually controlled by a resident. The deficient practice posed a potential health risk to two of two residents sampled. Findings include: 1. The Compliance Officer observed that R1's room temperature was in excess of 84\'b0 F at 90\'b0 F. This was observed through a temperature gauge in the room. 2. Documentation review established that on August 4, 2024, R1 requested through a facility work order that the air conditioning unit in R1 and R2's bedroom be replaced due to its non-functioning status. 3. Documentation review established that the non-functioning air conditioning unit was replaced on October 17, 2024. This was confirmed through a work order filed on October 17, 2024. 4. Documentation review established a policies and procedures section titled "Temperature Control in Assisted Living Facility". A subsection within this section was titled "Temperature Range" and contained the following: "The facility's heating and cooling systems must maintain a temperature between seventy degrees Fahrenheit and eighty-four degrees Fahrenheit at all times". 5. In an interview, E1 confirmed that on August 4, 2024, R1 requested that the air conditioning unit in R1 and R2's bedroom be replaced due to it not functioning and that this request was submitted through a facility work order. E1 also confirmed that the non-functioning air conditioning unit was replaced on October 17, 2024. E1 also confirmed that the facility possessed a policies and procedures section titled "Temperature Control in Assisted Living Facility". A subsection within this section was titled "Temperature Range" and contained the following: "The facility's heating and cooling systems must maintain a temperature between seventy degrees Fahrenheit and eighty-four degrees Fahrenheit at all times". E1 also confirmed that R1's room temperature was in excess of 84\'b0 F at 90\'b0 F. This was observed through a temperature gauge in the room.

Based on document review and interview, the manager failed to ensure that equipment at the facility was maintained in working order. The deficient practice posed a potential risk to the health and safety of two of two residents sampled. Findings include: 1. Documentation review established that on August 4, 2024, R1 requested through a facility work order that the air conditioning unit in R1 and R2's bedroom be replaced due to its non-functioning status. 2. Documentation review established that the non-functioning air conditioning unit was replaced on October 17, 2024. This was confirmed through a work order filed on October 17, 2024. 3. Documentation review established a policies and procedures section titled "Temperature Control in Assisted Living Facility". A subsection within this section was titled "Temperature Range" and contained the following: "The facility's heating and cooling systems must maintain a temperature between seventy degrees fahrenheit and eighty-four degrees fahrenheit at all times". 4. In an interview, E1 confirmed that on August 4, 2024, R1 requested that the air conditioning unit in R1 and R2's bedroom be replaced due to it not functioning and that this request was submitted through a facility work order. E1 also confirmed that the non-functioning air conditioning unit was replaced on October 17, 2024. E1 also confirmed that the facility possessed a policies and procedures section titled "Temperature Control in Assisted Living Facility". A subsection within this section was titled "Temperature Range" and contained the following: "The facility's heating and cooling systems must maintain a temperature between seventy degrees fahrenheit and eighty-four degrees fahrenheit at all times".

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 assistant caregivers working each day, including the hours worked by each. Findings include: 1. The Compliance Officers observed medication cart five. On top of the medication cart, the Compliance Officers observed a narcotics count book. 2. A review of facility documentation revealed a narcotics count book for medication cart five. The review revealed a "Record of Narcotic Counts" dated August 18-24, 2024. The document revealed E6 worked from 6:00 AM to 6:00 PM on August 21, 2024. The review further revealed a personnel schedule for August 21, 2024, which indicated E6 worked from 7:00 AM to 7:00 PM. 3. In an interview, E1 reported E6 worked off the clock and not per the personnel schedule. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on May 15-17, 2024.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. The Compliance Officers observed resident medical records in an unlocked room with no personnel in sight. 2. In an interview, E1 acknowledged the room was left open and unattended. E1 reported the room was left open during the day. E1 further reported hospice had taken E8's hospice record and it was no longer in the facility. E1 acknowledged E1 failed to ensure residents' medical records were protected from loss, damage, or unauthorized use. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on May 15-17, 2024.

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies in a timely manner. Findings include: 1. The Compliance Officers observed multiple bedrooms used for residents receiving directed care services. In the bedrooms, the Compliance Officers observed devices used to alert employees to a resident's needs or emergencies in multiple bedrooms. In one of the bedrooms, one of the Compliance Officers pulled the cord of the device to test the system. The Compliance Officer waited for eight minutes and no employees came to check. The Compliance Officer then pulled the cord again several times over the next eight minutes for a total of 16 minutes and no employees came to check. 2. In an interview, the Compliance Officer who pulled the cord reported to E1 no employees came to check in the 16 minutes the Compliance Officer waited. E1 reported the call devices in the bedrooms were connected to a computer monitor which was watched by office personnel who would then radio to care personnel to check on the resident who called. E1 reported a previous nurse had thrown away the charger to the radios. E1 reported this may have been why no one came to check. E1 reported there were 26 residents receiving directed care services. 3. The Compliance Officers observed the aforementioned computer monitor. However, the monitor was not displaying the alerts. 4. In an interview, E7 told E1 and the Compliance Officers the monitor had not been working for two days.

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures (P&Ps) were implemented for inventorying controlled substances. The deficient practice posed a risk as the standards expected of employees to ensure resident safety were not followed. Findings include: 1. A review of facility documentation revealed a P&P titled "MEDICATION CONTROL AND ACCOUNTABILITY-CONTROLLED MEDICATIONS," dated March 1, 2023. The P&P stated: "Two staff members, one coming on shift and one leaving shift, will count controlled medications at least once per 24-hour period...Signatures indicating that both employees counted the narcotics, and all scheduled drugs were accounted for, including medications under double lock awaiting destruction, will be provided following each count, and maintained in a book specific to tracking narcotics." 2. The Compliance Officers observed medication cart five. On top of the medication cart, the Compliance Officers observed a narcotics count book. 3. A review of facility documentation revealed a narcotics count book for medication cart five. The review revealed two "Record of Narcotic Counts" documents dated August 18-28, 2024. The documents revealed only one staff member's signature on August 21, 23, and 28, 2024, as opposed to two staff members' signatures as required per P&P. The documents further revealed no documented narcotics counts on August 18-20, 22, 24, and 25-27, 2024, as required per P&P. 4. In an interview, E1 reported narcotics counts were typically done at the beginning and end of each shift. E1 reported two staff members should have signed the narcotics count book each time a narcotics count was conducted. 5. The Compliance Officers observed medication cart one. On top of the medication cart, the Compliance Officers observed a narcotics count book. 6. A review of facility documentation revealed a narcotics count book for medication cart one. The review revealed an untitled document which stated, "CAREGIVERS YOU ALL NEED TO SIGN ON COMING AND OFF GOING NARCOTIC COUNT SHEETS." The review revealed two "Record of Narcotic Counts" documents dated August 18-28, 2024. The documents revealed only one staff member's signature on August 23, 2024, as opposed to two staff members' signatures as required per P&P. The documents further revealed no documented narcotics counts on August 18-22, and 24-28, 2024, as required per P&P. 7. In an interview, E1 acknowledged E1 failed to ensure P&Ps were implemented for inventorying controlled substances.

Based on observation and interview, the manager failed to ensure the premises were clean. Findings include: 1. The Compliance Officers observed an intake air vent covered in dust near the dining room. 2. In an interview, E1 acknowledged the intake air vent was not clean. This is an uncorrected deficiency from the complaint and compliance inspection conducted on May 15-17, 2024.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. The Compliance Officers observed a missing door leading to a laundry area. 2. In an interview, E1 reported a dryer caught fire on Father's Day and the facility had to make runs to the laundromat for a time to compensate.

Based on documentation review, interview, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A) and (C), for four of five sampled personnel members. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution. Findings include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A.R.S. \'a7 36-411(C)(1)-(2) states: "C. Owners 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. A review of E3's personnel record revealed E3 was contracted as a caregiver. The review revealed a fingerprint clearance card (FCC). However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(1) and (2). 4. A review of the Department of Public Safety (DPS) FCC verification website revealed E3's FCC was valid. 5. In an interview, E1 reported the governing authority did not contact E3's previous employers or verify the status of E3's FCC. 6. A review of E4's and E5's personnel records revealed E4 and E5 were hired as caregivers more than 20 days prior to the inspection. However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(A) and (C) for E4 and E5. 7. A review of the DPS FCC verification website revealed FCCs for E4 and E5. However, the website revealed E4's FCC expired in 2021 and E5's FCC expired in 2023, more than 6 months before E5 was hired. The website indicated E4 and E5 did not have current FCCs. 8. In an interview conducted on May 16, 2024, E1 acknowledged E4 and E5 di

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident that covered orientation for employees and volunteers. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed no policy and procedure covering orientation for employees and volunteers. 2. In an interview, E1 reported caregivers went through orientation and shadowed other caregivers before providing services alone. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on August 15, 2023.

Based on interview, record review, and documentation review, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of five sampled caregivers. The deficient practice posed a risk if an employee was unqualified to provide caregiving services. Findings include: 1. In an interview, E1 reported E6 was hired as a caregiver. 2. A review of E6's personnel record revealed E6 was hired as a caregiver. The review revealed a caregiver certificate from "GSDM Healthcare Academy" (ALTP0102) dated November 19, 2012. 3. A review of the NCIA Board website revealed "GSDM Healthcare Academy" was active between September 13, 2004, and September 30, 2012. The review revealed "GSDM Healthcare Academy" was not an active caregiver training program on November 19, 2012, when the certificate was issued. 4. A review of facility documentation revealed a series of personnel schedules dated between May 2023 and May 2024. The schedules revealed E6 worked as a caregiver on a regular basis between May 1, 2023, and May 17, 2024. 5. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate issued after August 2013 under E6's name. 6. In an interview, E1 reported E6 came from outside of Arizona and likely signed up for a caregiver course not knowing the school was closed and could not issue certificates.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services and according to policies and procedures, for three of five sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a document titled "Job Description" for caregivers. The document stated the "Qualifications- Education, Experience, and Skills" required for caregivers included, "Successfully complete and approved skills competency evaluation and written skills test." The review further revealed a series of personnel schedules which indicated E3, E5, and E7 provided physical health services. 2. In an interview, E1 reported the facility was using a staffing agency for some of the facility caregivers, including E3. E1 reported E1 would have to request E3's personnel record from the staffing agency. 3. A review of E3's, E5's, and E7's personnel records revealed E3, E5, and E7 were hired as caregivers. However, the review revealed no documentation of E3's, E5's, and E7's skills and knowledge verification.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver before providing assisted living services to a resident, for one of five sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs. Findings include: 1. A review of E3's personnel record revealed E3 was contracted as a caregiver. However, the review revealed no documentation of E3's orientation. 2. A review of facility documentation revealed a series of personnel schedules dated between April 2024 and May 2024 which stated "Agency" provided services each Sunday between April 7, 2024, and the inspection. 3. In an interview, E1 reported the "Agency" individual on the schedule was E3. E1 reported E3 went through orientation and shadowed another caregiver but the orientation was not documented. E1 was unable to provide documentation of E3's orientation. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on August 15, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for three of five sampled caregivers. 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 titled "Personnel Records" dated August 1, 2016. The policy and procedure stated: "It shall be the policy of Villa Ocotillo [now Ocotillo Place] to maintain personnel files for each team member, which will contain the following: 2. Documentation of: Current training in CPR with hand on demonstration of techniques, a. Prior to deliver[ing] care to residents for care staff... Current first aid training through an accredited vendor, a. Prior to deliver[ing] care to residents for care staff." 2. A review of E3's personnel record revealed E3 was contracted as a caregiver. The review revealed a first aid training certificate dated May 16, 2024, more than one month after E3 began providing assisted living services to residents at the facility. 3. A review of E4's personnel record revealed E4 was hired as a caregiver. The review revealed a CPR training certificate from "NationalCPRFoundation" dated December 15, 2023. 4. A review of the "NationalCPRFoundation" website revealed E4's training was online-only and did not include a demonstration of E4's ability to perform CPR. 5. In an interview, E1 reported E1 was made aware "NationalCPRFoundation" courses did not include hands-on demonstrations during the complaint inspection conducted on April 16, 2024. 6. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed a first aid and CPR training certificate from "American Red Cross" dated May 6, 2024, more than six months after E5 began providing assisted living services to residents at the facility. However, the certificate stated the course was "Online" and E5 was "Eligible for Skills Session within 90 days." The review further revealed no first aid or CPR training certificate(s) dated before May 6, 2024. This is a repeat/uncorrected deficiency from the complaint inspection conducted on April 16, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for four of ten 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, Assistance, Storage and Disposal" dated August 1, 2016. The P&P stated, "Medications and treatments are administered to residents as determined by review of their medication status and in accordance with physician order, state laws and assisted living regulation." 2. In an interview, E1 reported a circle around initials on the medication administration records (MARs) meant the specific medication was not given at the allotted time. 3. A review of R3's medical record revealed a current service plan which indicated R3 required medication administration services. The review revealed medication orders for "Aspirin 81 Oral Tab Delayed Release PO 1 tab QD," "Furosemide Oral Tab 20 mg (milligrams) PO 1 tab QD," and "Lactobacillus Capsule [Culturelle Health and Wellness] PO 1 capsule BID" dated September 2023. The review revealed MARs dated November 2023 and April 2024. The MARs revealed the following: -R3 did not receive "ASPIRIN EC 81 MG" on November 4, 2023; -R3 did not receive "CULTURELLE HLTH & WELLNES" at 7:00 AM on November 1, 4-22, and 26-30, 2023; -R3 did not receive "CULTURELLE HLTH & WELLNES" at 5:00 PM on November 1, 4-22, 26-28, and 30, 2023; and -R3 did not receive "FUROSEMIDE 20 MG" on April 15, 2024. 4. In an interview, E1 reported R3's "Lactobacillus Capsule [Culturelle Health and Wellness]" was not given because R3's insurance did not cover it. 5. A review of R4's medical record revealed a current service plan which indicated R4 required medication administration services. The review revealed medication orders for "ACETAMINOPHEN 500 MG GELC TAKE 1 CAPSULE BY MOUTH TWICE DAILY IN THE MORNING AND AFTERNOON," "ASPIRIN EC 81 MG TABLET TAKE 1 TABLET NY MOUTH ONCE DAILY," and "VOLTAREN 1% GEL - OTC DICLOFENAC 1 % GEL -OTC APPLY 2 GRAMS TOPICALLY...TWICE DAILY IN THE MORNING AND AFTERNOON" dated November 18, 2023. The review revealed a MAR dated April 2024 which revealed the following: -R4 did not receive "ACETAMINOPHEN 500 MG" at 7:00 AM on April 2-3, 10, and 15-30, 2024; -R4 did not receive "ACETAMINOPHEN 500 MG" at 12:00 PM on April 15-30, 2024; -R4 did not receive "ASPIRIN EC 81 MG" on April 15, 2024; and -R4 did not receive "DICLOFENAC 1 % GEL" on April 15-17, 2024. 6. A review of R6's medical record revealed a current service plan which indicated R6 required medication administration services. The review revealed a medication order for "Gabapentin PO 100 mg BID" dated January 3, 2024. The review revealed a MAR dated April 2024 which revealed R6 did not receive "Gabapen

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of ten sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency. Findings include: 1. A review of R3's medical record revealed a medication administration record (MAR) dated April 2024. The MAR revealed R3 received "AMLODIPINE BESYLATE 5 MG...HOLD IF SBP IS LESS THAN 120" and "CARVEDILOL 12.5 MG...HOLD IF SBP IS LESS THAN 120" at 7:00 AM on April 9, 2024, even though R3's systolic blood pressure was 115. 2. In an interview, the caregiver who documented the medication administration reported the medications were not actually given. The caregiver reported it was a documentation error.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan, and the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed the facility became licensed on May 17, 2023, after going through a change of ownership (CHOW). 2. A review of facility documentation revealed a series of disaster drill documents dated between May 13, 2023, and September 27, 2024 (several months in the future). However, the dates, times, and names of participants on all but one document were changed from the original or identical to one or more other drill document(s) as follows: -The May 13, 2023, drill (dated before the CHOW) contained evidence of white corrective fluid over the date, time, type/scenario, and at least two participant names/signatures; -The June 14, 2023, drill contained participant names/signatures in pen written over nearly identical printed participant names/signatures, as if the original names were traced over; -The August 24, 2023, drill contained evidence of white corrective fluid over the date, time, and type/scenario, as well as participant names/signatures in pen written over nearly identical printed participant names/signatures, as if the original names were traced over. This drill was identical to the May 13, 2023, drill in multiple ways; -The October 13, 2023, and November 13, 2023 drills were identical in all ways other than the month. The month ("10") of the October drill appeared altered as if the second digit of the month ("11") of the November drill was written over to look like a zero; -The December 9, 2023, drill contained white corrective fluid over the month, evidence of white corrective fluid over the time, and participant names/signatures in pen written over nearly identical printed participant names/signatures, as if the original names were traced over. The original date of this drill appeared to be May 9, 2023 (before the CHOW); -The January 9, 2024, drill contained white corrective fluid over the month, time, and type/scenario. The original date of this drill appeared to be April 3, 2023 (before the CHOW). This drill was identical to the May 13, 2023, and August 24, 2023, drills in multiple ways; -The February 8, 2024, drill contained white corrective fluid over the year. The original date of this drill appeared to be February 8, 2023 (before the CHOW); -The March 27, 2024, drill contained white corrective fluid over the name of the person conducting the drill and the year. The name of the person conducting the drill was different and the original date of this drill appeared to be March 27, 2023 (before the CHOW); -The April 13, 2024, drill contained evidence of white corrective fluid over the date and time, as well as at least one participant name/signat

Based on observation and interview, the manager failed to ensure the premises were clean. Findings include: 1. During the environmental inspection of the facility, immediately upon entry into the facility, the Compliance Officer observed a strong smell of urine. The Compliance Officer further observed the strong scent near rooms 101, 118, and 129. 2. In an interview, E1 reported not being able to smell the urine in some areas and smelling it in others. Technical assistance was provided on this rule during the complaint inspection conducted on April 16, 2024.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed garbage in uncovered containers lined with plastic bags in multiple resident rooms, the facility kitchen, a dining room, a hallway, and a hall bathroom. The Compliance Officer observed garbage in plastic bags not in containers in a dining room. 2. In an interview, E1 reported the containers should have covers. E1 reported E1 did not know why the garbage bags observed in a dining room were not in containers. Technical assistance was provided on this rule during the complaint inspection conducted on April 16, 2024.

Based on documentation review, interview, and record review, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for three of five sampled personnel members and one of ten sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of Department documentation revealed this rule went into effect on May 4, 2022. 2. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of E3's and E5's personnel records revealed E3 was contracted as a caregiver and E5 was hired as a caregiver. The review revealed a TST for E3 dated as read on January 24, 2024, and a TST for E5 dated as read on December 23, 2023. However, the review revealed no blood tests or second-step TSTs for E3 and E5. 5. A review of E6's personnel record revealed E6 was hired as a caregiver. However, the review revealed no blood test or TSTs. 6. A review of facility documentation revealed a series of personnel schedules which indicated E3, E5, and E6 provided physical health services to residents at the facility. 7. A review of R6's medical record revealed R6 was admitted to the facility more than seven days prior to the inspection. The review revealed a valid TST. However, the review revealed no baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if R6 had signs or symptoms of TB. 8. In an interview, E1 reported R6's baseline screening (apart from the TST) was not completed. Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on August 15, 2023.

Based on record review, and interview, for four of four staff records reviewed, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. In record review, the personnel records for E2, E3, E4, and E5 did not include documention the staff received training on fall prevention and fall recovery. 2. During an interview, the findings were reviewed with E1, who acknowledged the personnel records did not include documentation the personnel received training on fall prevention and fall recovery. E1 reported the staff were trained on fall recovery.

Based on record review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid training (FA) and cardiopulmonary resuscitation training (CPR) certification specific to adults which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR. Findings include: 1. In record review, E2's personnel record (hired as a caregiver on May 1, 2023) included documentation of CPR certification from the NationalCPR Foundation, which was an online training program, and did not include a demonstration. 2. In record review, E5's personnel record (hired as a caregiver on December 29, 2019), included documentation of a FA and CPR card, which expired on March 1, 2024. 3. During an interview, the findings were reviewed with E1, who acknowledged E2's CPR was provided by an online training program, and did not include a demonstration, and E5's record did not include documentation of current FA and CPR training.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; The deficient practice posed a risk to residents, if the service plan did not accurately reflect the resident's condition and services to be provided for the resident. Findings include: 1. In observation, R1 was observed to have a rash under the right armpit. 2. During an interview, E1 reported R1 had a recurring skin condition which had been treated in the past by a dermatologist. 3. In record review, R1's medical record included documentation R1 received treatment for a recent skin rash. However, R1's service plan dated February 6th, 2024, (received directed care services), did not include documentation of R1's recurrent skin condition. 4. During an interview, E1 acknowledged R1's service plan did not include a description of R1's skin problems.