Primavera Assisted Living LLC

Based on documentation review, observation, and interview, the manager failed to ensure that a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises was designated in writing. Findings include: 1. A review of the facility’s documentation contained a document titled “Delegation of Authority” dated November 1, 2023, which reflected that O1 was the manager and designated E1 as accountable for the assisted living facility while O1 was not present. There was no other written delegation available for review. 2. The compliance officer observed a document posted titled “Delegation of Authority” dated November 1, 2023. 3. In an interview, E1 reported O1 was no longer the manager of the facility and E1 was the new manager. E1 acknowledged E1 failed to ensure a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises was designated in writing.

Based on record review and interview, the manager failed to ensure that, before providing assisted living services to a resident, a manager or caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults, for two of six caregivers sampled. Findings include: 1. A review of the facility’s documentation contained a facility’s work schedule dated October 2025, which reflected that E5 and E6 worked various days as caregivers. 2. A review of E5's personnel record revealed CPR training certification dated May 26, 2025, from the NationalCPRFoundation. However, this was an online-only course that did not include a return demonstration of the employee's ability to perform CPR as required in A.A.C. R9-10-803.C.1.e.i. This training was therefore invalid. 3. A review of E6's personnel record revealed CPR training certification dated May 17, 2023, from the NationalCPRFoundation. However, this was an online-only course that did not include a return demonstration of the employee's ability to perform CPR as required in A.A.C. R9-10-803.C.1.e.i. This training was therefore invalid. 4. In an interview, E1 acknowledged that before providing assisted living services to a resident, a manager or caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults for E5 and E6.

Based on record review and interview, the manager failed to ensure that a resident had a service plan established and documented, which included the following: the amount, type, and frequency of assisted living services and ancillary services provided to the resident, for one of two sampled residents. Findings include: 1. A review of R1’s medical record contained a service plan dated October 22, 2025, which reflected R1 would be assisted with dressing and toileting; however, R1’s service plan did not establish the amount and frequency of assisted living services provided to R1. 2. In an interview, E1 acknowledged R1 did not have a service plan that established and documented the amount and frequency of dressing and toileting services to R1.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated October 22, 2025. However, R1's service plan did not contain the signature of R1 or R1's representative.  2. In an interview, E1 acknowledged R1's service plan did not contain the signature of R1 or R1's representative.

Based on record 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 two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated October 22, 2025. R1's service plan reflected that R1 required repositioning every two to three hours, both day and night. However, a review of R1's services provided between August 2025 and October 2025 activities of daily living (ADL) sheets reflected that R1 was repositioned once on September 18, 2025. There was no other documentation to reflect that R1 was repositioned from August 2025 to October 2025. 2. In an interview, E1 reported R1 was repositioned multiple times from August 2025 to October 2025; however, it was not documented. E1 acknowledged that a caregiver did not document the repositioning services provided to R1.

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for one of two residents sampled. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101.26. states: "Authenticate means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record". 2. A review of R1's medical record revealed documents titled "Medication Administration record (MAR)" dated October 2025. R1’s MAR contained check marks to reflect the medication provided to R1. However, the entries on R1’s MAR were not authenticated by the individual(s) who provided the services. 3. In an interview, E1 acknowledged that the manager failed to ensure an entry in a resident's medical record was authenticated.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. 1. A review of the facility's disaster plan revealed the most recent documented review date was November 1, 2023. 2. In an interview, E1 was unable to find documentation indicating a disaster plan review was conducted every 12 months.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the facility, for two of two sampled residents. Findings include: 1. A review of R1's and R2's medical records revealed no documentation to indicate the residents received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the residents' acceptance by the facility. Based on R1's and R2's dates of admission, this documentation was required. 2. In an interview, E1 acknowledged R1's and R2's medical records did not contain documentation of orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the residents' acceptance by the facility.