Reanna's Assisted Living Home

Based on documentation review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9), for two of two sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of facility documentation revealed standardized forms for R2 and R3. However, the forms did not include the following: -The name, address and telephone number of the residents’ current pharmacies; -A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive; -The name and contact information for the residents’ primary care physicians and powers of attorney or authorized representatives; -Basic information about the residents’ physical and mental conditions and basic medical histories; and -The point-of-contact information for the assisted living home, including the email address. 2. In an interview, E1 acknowledged the facility did not maintain a standardized form that included all information required by this statute.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for three of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of E1’s personnel record revealed E1 was hired as a caregiver. The review revealed E1 received training and education related to recognizing the signs and symptoms of TB on August 5, 2024, and August 16, 2025, more than one year after August 5, 2024. 3. A review of E2’s personnel record revealed E2 was hired as the manager. The review revealed E2 received training and education related to recognizing the signs and symptoms of TB on July 7, 2023, and August 16, 2025. However, the review revealed no documentation of said training within one year after July 7, 2023, or within one year before August 16, 2025. 4. In an interview, E1 reported E1 believed E2 had received the training in 2024. However, E1 stated, “I don’t think [E2] find it.” 5. A review of E5’s personnel record revealed E5 was hired as an assistant caregiver. The review revealed E5 received training and education related to recognizing the signs and symptoms of TB on February 25, 2025, after E5 began providing services at the facility. 6. A review of facility documentation revealed a personnel schedule which indicated E5 worked on February 19-22, 2025. 7. In an interview, E1 acknowledged E5 did not receive training and education related to recognizing the signs and symptoms of TB before providing services. E1 reported E1 could not get the trainer to schedule E5’s training before E5 began providing services. Technical assistance was provided on this rule during the compliance inspection conducted on Au

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 to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees and facility personnel were unaware of the whereabouts of a resident. Findings include: 1. A review of facility documentation revealed no policy and procedure (P&P) in compliance with this rule. 2. In an interview, E1 reported the facility had a sign in and sign out sheets for the residents. However, E2 reported E1 did not know whether the facility had a P&P covering this rule. 3. In a telephonic interview, E2 stated, “I don’t think there’s a specific policy.”

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that was signed and dated by the manager, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan dated May 2025. However, the service plan was not signed by the manager. 2. In an interview, when the Compliance Officer showed E1 the unsigned service plan, E1 stated, “Okay” and “I think it’s my fault.” This is a repeat citation from the compliance inspections completed on August 10, 2023.

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 two 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 medical record revealed a current service plan which indicated R2 was to receive assistance with showers twice per week. The review revealed documentation of assisted living services provided to R2 (ADLs) dated September 2025 which indicated R2 did not receive assistance with showers in August 2025. Instead, the ADLs revealed documentation demonstrating R2 received bed baths twice per week. 2. In an interview, E3 reported R2 received assistance with showers and not bed baths in August 2025 as stated on the ADLs. E3 reported facility personnel documented the showers as bed baths in error, stating, “It’s an error.” 3. A review of R3's medical record revealed a current service plan which indicated R3 was to receive assistance with showers. The review revealed ADLs dated September 2025 which indicated R3 did not receive assistance with showers in August 2025. Instead, the ADLs revealed documentation demonstrating R3 received bed baths twice per week. 4. In an interview, E3 stated R3 received assistance with showers “twice” per week. E3 reported R3 received assistance with showers and not bed baths in August 2025 as stated on the ADLs. E3 reported facility personnel documented the showers as bed baths in error. This is a repeat citation from the compliance inspections completed on August 10, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented that ensured the safety of a resident who may wander. 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 a policy and procedure (P&P) titled “WANDERING RESIDENTS.” The P&P stated, “As directed by City of Glendale Fire Marshall, the front door will not be locked but will have an alarm to alert staff if door is opened.” 2. The Compliance Officer observed the front door was locked during the inspection.. 3. In an interview, E1 and E3 acknowledged the front door was locked and facility personnel did not implement the P&P.

Based on interview and observation, the manager failed to ensure the premises was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. Upon exiting the facility through the back door, E3 told the Compliance Officer to watch out for the ladder and wood lying on the ground in the path. 2. The Compliance Officer observed a walkway outside leading from the back door to the north side of the facility. In the path of the walkway, the Compliance Officer observed a ladder and wood lying on the ground. On the east side of the facility, the Compliance Officer observed a garden house unraveled onto the walking area. On the south side of the house, the Compliance Officer observed an extension cord lying in the walkway, a ladder standing up in the walkway, and a metal pole with one end in the walkway and the other leaning against the facility. 3. In an interview, E3 reported the aforementioned items were blocking the walkway. 4. In an interview, the Compliance Officer overheard a resident state, “I’m gonna go for a stroll.” 5. The Compliance Officer observed the resident exit the facility through the back door. This is a repeat citation from the compliance inspection completed on July 30, 2024.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. 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. The Compliance Officer observed garbage in an uncovered garbage container in an occupied bedroom. 2. In an interview, when the Compliance Officer asked if E3 had a lid for the garbage container, E3 stated, “Yes.” However, E3 acknowledged the garbage was not stored in a covered container at the time of the inspection. Technical assistance was provided on this rule during the compliance inspection conducted on August 10, 2023.

Based on documentation review and interview, the governing authority failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection. 2. A review of E1, E2, and E3 personnel files revealed fall prevention and fall recovery training was last completed on June 5, 2023. However, no documentation was provided to show continued competency training. 3. In an interview, E2 acknowledged documentation of a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed two ambulatory residents. 3. During the environmental tour, the Compliance Officer observed a back door leading to the backyard and a door leading to the backyard in the laundry room. However, both doors were not secured and the door chimes were not functioning. 4. In an interview, E2 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on observation, interview, and record review, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to the resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R3's bed with half bed rails on both sides of the bed. 2. A review of R3's medical record revealed a document titled "Authorization for continued residency." The document stated "The resident is considered to be bedbound..." In addition, R3's medical record revealed a service plan completed on July 30, 2024 that indicated R3 received directed care services. 3. In an interview, E2 reported the bed rail was up to prevent R3 from falling out of bed. E2 acknowledged the situation may cause the resident to suffer physical injury.

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 the resident's representative, for three of four residents sampled. The deficient practice posed a risk if the resident or the resident's representative were unaware of the services to be provided to the resident at the facility. Findings include: 1. A review of R1's medical record revealed a current written service plan dated in July 2023, for personal care services. However, the service plan was not signed and dated by R1. 2. A review of R2's medical record revealed a current written service plan dated in July 2023, for directed care services. However, the service plan was not signed and dated by R2's representative. 3. A review of R3's medical record revealed a current written service plan dated in July 2023, for directed care services. However, the service plan was not signed and dated by R3's representative. 4. In an interview, E2 acknowledged R1's, R2's, and R3's service plans were not signed and dated by the resident or the resident's representative.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the manager, for three of four residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a current written service plan dated in July 2023, for personal care services. However, the service plan was not signed and dated by the manager. 2. A review of R2's medical record revealed a current written service plan dated in July 2023, for directed care services. However, the service plan was not signed and dated by the manager. 3. A review of R3's medical record revealed a current written service plan dated in July 2023, for directed care services. However, the service plan was not signed and dated by the manager. 4. In an interview, E2 acknowledged R1's, R2's, and R3's service plans were not signed and dated by the manager.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for four of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated in July 2023. The service plan stated R1 was to receive "partial bath... On days when complete bath is not given (Partial bath consists of face, hands, underarms, perineal area - front and back)... Dependent." However, the aforementioned services were not documented as provided to R1 on days when a complete bath was not given. 2. A review of R2's medical record revealed a service plan for directed care services dated in July 2023. The service plan stated R2 was to receive "partial bath... On days when complete bath is not given (Partial bath consists of face, hands, underarms, perineal area - front and back)... Dependent." However, the aforementioned services were not documented as provided to R2 on days when a complete bath was not given. 3. A review of R3's medical record revealed a service plan for directed care services dated in July 2023. The service plan stated R3 was to receive "partial bath... On days when complete bath is not given (Partial bath consists of face, hands, underarms, perineal area - front and back)... Dependent." However, the aforementioned services were not documented as provided to R3 on days when a complete bath was not given. 4. A review of R4's medical record revealed a service plan for personal care services dated in April 2023. The service plan stated R4 was to receive "partial bath... On days when complete bath is not given (Partial bath consists of face, hands, underarms, perineal area - front and back)... Dependent." However, the aforementioned services were not documented as provided to R4 on days when a complete bath was not given. 5. In an interview, E2 reported partial baths were given to R1, R2, R3, and R4, on days when a complete bath was not given. However, E2 acknowledged services were not documented as provided to R1, R2, R3, and R4.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of four 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 current service plan dated in July 2023. The service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order dated April 18, 2023, for Tramadol 50 mg, one tablet by mouth three times a day scheduled for pain. 3. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. The MAR stated, "Tramadol 50 mg, one tab by mouth three times daily as needed" and indicated three tabs were administered at 4:00 PM on August 3, 2023, 9:00 PM on August 7, 2023, and 5:00 PM on August 9, 2023. 4. In an interview, E2 reported Tramadol was only administered as needed to R1. E2 called the prescriber who informed E2 the Tramadol was prescribed as a scheduled medication and not as needed. E2 acknowledged R1's medications were not administered in compliance with the available medication order.

Based on documentation review, record review, and interview, the health care institution failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of four residents sampled. Findings include: 1. A review of facility documentation revealed a policy and procedure manual dated January 5, 2020. The manual did not include policies and procedures regarding authorizing an individual to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid. 2. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. The MAR stated "Tramadol 50 mg, one tab by mouth three times daily as needed" and indicated three tabs were administered at 4:00 PM on August 3, 2023, 9:00 PM on August 7, 2023, and 5:00 PM on August 9, 2023. However, documentation was not available showing the identification of R1's need for the opioid and the effect of the opioid administered. 3. A review of R1's medical record revealed documentation stating R1 had an end of life condition or an active malignancy was not available for review. 4. In an interview, E2 acknowledged the caregiver did not document in R1's medical record the identification of R1's need for the opioid and the effect of the opioid administered.