Prestige Assisted Living LLC

Based on documentation review and interview, the manger failed to ensure that a plan was implemented for an ongoing quality management program that, at a minimum, included the frequency of submitting a documented report to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided and the Department was provided false or misleading information. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports" reviewed and signed by E1 on August 25, 2024. This policy stated "The manager will review all residents' narrative notes, unusual occurrence reports, complaints in regards to the residents' care, the facility manager's reports and caregivers' communication logs, will document the collection of data on a monthly basis in the Quality Management Monthly Reporting form..." 2. Documentation review revealed a document titled "Quality Management - Monthly Recordings" dated 2025. This document showed that the quality management monthly recording was completed for the entire month of September; however, the inspection was conducted on September 22, 2025. There were eight calendar days left of the month of September 2025 in which a quality management parameter incident could have occurred and required documentation. 3. In an exit interview finding were discussed with E1 and no additional information was provided.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record was available for each employee as required. The deficient practice posed a risk as required information could not be verified for E2. Findings include: 1. When the Compliance Officers arrived at the facility, E1 and E2 were the only employees present. 2. A review of the employee work schedule revealed E1 and E2 were the only employees scheduled for September 2025. 3. A review of E2’s personnel record revealed a hire date of June 15, 2024. This record included a fingerprint card that showed E2 had a date of birth of 1997 and was 5'6. 4. In an interview, E2 reported E2's date of birth was 1967 and E2 was 5’3. A form of identification was requested. E2 stated E2 didn't have any. 5. During the inspection, E1 referred to E2 by a different name than what was documented in E2's personnel record. 6. During an interview, R1 referred to E2 by a different name than what was documented in E2's personnel record. R1 reported E1 and E2 were the normal caregivers and did not know of a person with the name documented in E2's personnel record and false or misleading information was provided to the Department. 7. During the interview with E1 and E2 regarding the identity of E2, E2 left the facility and did not return during the inspection. 8. In an interview, E1 reported the documentation provided to the Compliance Officers for E2 was the documentation E2 presented at the time of hire, and E1 was unaware that it was not the same person. 9. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of R1's medical record revealed that there was no documentation of risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. Review of R2's medical record revealed that there was no documentation of risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

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, for one of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R2's medical record revealed no residency agreement. Based on R2's date of acceptance, this documentation was required. 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of two residents sampled. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. A review of R2's medical record revealed a service plan dated August 27, 2025. This service plan stated "Integumentary: Dry skin, sensitive skin - The following are performed to prevent, & treat bruises, injuries, pressure ulcers, and infections: keep resident's skin clean and dry, apply hydrating lotion, ensure good hygiene and nutrition, if incontinent, check the resident's brief and provide hygiene care as needed to prevent skin breakdown every hour". 2. In an interview with E1, E1 reported that R2 had a wound to the right heel that started at the beginning of August 2025. 3. A review of R2's medical record revealed R2's service plan was not updated to show this change of condition. 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for one of two residents sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R1's medical record did not contain a photographic consent form signed by the resident or the resident's representative. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure documentation of medication administered to the resident included the correct dosage administered, for one of two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a signed medication order dated June 16, 2025. This order stated "Zoloft, 100mg Tablet 1 tablet, Oral, daily at bedtime". 2. A review of R1's medical record revealed a September 2025 medication administration record (MAR). This MAR stated "Sertraline 50mg 1 tab Po HS" and indicated 1 tab was administered at 8pm, September 1st - present. 3. In an observation of R1's medications, Zoloft 100mg was available and 1 tab was prefilled in the medication organizer. 4. In an interview, E1 reported that Zoloft 100mg was administered to R1. 5. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include, 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R2's acceptance date, this documentation was required. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered to a resident in compliance with the medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication order dated June 16, 2025. This order stated, "Trazodone Hydrochloride 50 mg tablet by mouth at bedtime." 2. A review of R1's medical record revealed a September 2025 medication administration record (MAR). This MAR did not include documentation Trazodone was administered. 3. In review of R1's medications, Trazodone was not available. 4. A review of R1's medical record revealed a signed medication order dated August 21, 2025. This order stated "Midodrine 5mg tablet three times a day by mouth. hold medication if systolic blood pressure is greater than 100." 5. A review of R1's medical record revealed a September 2025 medication administration record (MAR). This MAR stated "Midodrine 5 MG 1 Tab Po TID hold if SBP>100" and did not indicate the medication was administered. 6. A review of R1's medical record revealed a "Resident Vital Signs chart" dated September. This chart showed R1's systolic blood pressure was recorded twice a day, September 1st-19th. R1's systolic blood pressure was not recorded on September 20th - present, and not recorded three times a day, September 1st - present. 7. In an interview, E1 reported R1's blood pressure was not taken three times a day. E1 acknowledged it was unknown if R1's medication was administered in compliance with the available medication order due to not taking R1's blood pressure daily. 8. A review of R2's medical record revealed no signed medication orders for the following medications: Mirtazapine TAB, 7.5 MG, 1 TAB, PO, HS Senna TAB, 8.6 mg, 1 TAB, PO, BID Cholestyramine for oral use only, 4 grams, BID Lactulose SOL, 10 GM/15, Take 2 TSP (30ML) D=QD 9. A review of R2's medical record revealed a September 2025 MAR. This MAR revealed the following: Mirtazapine TAB, 7.5 MG, 1 TAB, PO, HS, administered September 1-21, 2025, at 8PM Senna TAB, 8.6 mg, 1 TAB, PO, BID, administered September 1-22, 2025, at 8AM and administered September 1-21, 2025, at 8PM Cholestyramine for oral use only, 4 grams, BID, administered September 1-22, 2025, at 8AM Lactulose SOL, 10 GM/15, Take 2 TSP (30ML) D=QD, administered September 1-22, 2025, at 8AM 10. In a review of R2's medications, the above listed medications were available. 11. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. Findings: 1. Review of R1's directed care service plan dated August 13, 2023, identified the following services to be provided to R1; "oral care twice daily, hair care daily, bathing twice a week." A review of R1's record revealed no documentation to demonstrate R1 received the identified services September 12, 2023, through the time of the inspection. 2. Review of R2's directed care service plan dated August 7, 2023, identified the following services to be provided to R2; "oral care twice daily, hair care, dressing two times a day, checked on every 2-4 hours at night." A review of R2's record revealed no documentation to demonstrate R2 received the identified services September 12, 2023, through the time of time of the inspection. 3. In an interview, E1 reported E1 and E3 provided the identified services to R1 and R2 on the identified dates. E1 acknowledged E1 and E2 did not document the services in the medical records. E1 acknowledged the manager failed to ensure a caregiver documented the services provided in the resident's medical record.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for one of two residents reviewed receiving directed care services. Findings include: 1. Review of R2's record revealed written service plans for directed care services dated August 7, 2023, and May 27, 2023. The service plans revealed no documentation of R2's weight. A review of R2's record revealed no documentation from a medical practitioner stating weighing R2 was contraindicated. 2. During an interview, E1 reviewed the identified medical record. E1 acknowledged the service plans did not include documentation of the residents weight. E1 acknowledged additional documentation was not available from a medical practitioner stating weighing the identified resident was contraindicated.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does 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 general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the compliance officers observed a patio door that led to an outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard did have a means of alerting employees of the egress of residents to the outside area. However, the alarm was not working. 3. During an interview, E1 acknowledged the patio door exiting to the outside area did not have a working means of controlling or alerting employees to egress. E1 reported E1 believed the alarm needed new batteries. E1 acknowledged the manager failed to ensure the means of exiting the facility for a resident who does 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.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of R1's medical record revealed R1 receives medication administration. 2. A review of R1's medical record revealed signed medication orders for the following medications; Amlodipine 5 mg 1 tab PO QD, Gabapentin 300 mg 1 tab PO every 8 hours, Hydralazine 10 mg, 1 tab PO, Baclofen 10 mg 1 1 tab every 12 hours, Atorvastatin 20 mg 1 tab PO HS, . A review of R1's medical record revealed the identified medications were not documented as administered to R1 the evening of September 12, 2023, through the present. 4. The compliance officer observed R1's medications were available at the facility. 5. In an interview, E1 reported E 1 and E3 provided medication administration to R1 for all of the medications identified. E1 reported E1 did not document the administration of medication for the time identified. E1 acknowledged the manager failed to ensure medication administered to a resident was documented in the resident's medical record. This is a repeat deficiency from the compliance inspection conducted on October 25, 2022.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the facility tour with E1, the compliance officer observed Lorazepam vial and pre-filled pens located in the facility's refrigerator door. The medication was unlocked and accessible to residents. The refrigerator did contain a locked medication box that stored the residents' medications. 2. During an interview, E1 acknowledged the medication was stored unlocked. E1 acknowledged the manager failed to ensure medications stored by the facility were stored in a locked area.

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. Findings include: 1. Review of facility disaster drills revealed drills revealed the last documented disaster drills were conducted on; April 4, 2023, at 7pm, and April 7, 2023, at 9 am. 2. In an interview, E1 acknowledged the disaster drills provided to the Department reflected the last documented disaster drills occurred in April 2023. E1 acknowledged disaster drills were not conducted on each shift at least once every three months.