Red Mountain Assisted Living at Gateway INC

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of facility documentation did not include a standardized form that included the aforementioned information for each resident of the facility. 3. A review of R1's and R2's medical records revealed all required information, however, a standardized form with all aforementioned information was not available for review. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of two personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed E3 on-site and providing services to residents. 2. A review of E3's personnel record revealed a CPR and First Aid certification with an expiration date of November 18, 2027, from the American Health Care Academy. 3. A review of the American Health Care Academy website revealed that their CPR and First Aid certification did not include a hands-on skills demonstration. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that included for a resident who required behavioral care: the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of two residents sampled. Findings include: 1. A review of R2’s medical record revealed a service plan, dated September 19, 2025, that indicated R1 required behavioral care. However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. 2. In an interview, E1 reported that E1 was unaware of the requirements for residents receiving behavioral care. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, document review, and interview, the manager failed to ensure resident medical records were protected from loss, damage, or unauthorized use. - The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During an environmental inspection, the Compliance Officers observed all of the resident records located on a countertop in a common area near the kitchen. 2. A review of the facility’s policies and procedures revealed a policy titled “Resident Medical Records (including electronic records) and Documentation,” which stated, “Resident records are protected from loss, damage, or unauthorized use. 3. In the 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 that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record did not include a signed medication order for Polyethylene Glycol 3350 Powder. 2. A review of R1's medication administration record (MAR) for January 2026 revealed R1 was administered Polyethylene Glycol 3350 Powder on the following dates and times: January 12, 2026, at 8:00 AM; and January 13, 2026, at 8:00 AM. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one 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 list, dated January 8, 2026, which included the following medications: Metoprolol Tartrate 25 milligrams (mg) 1 tablet by mouth (po) three times a day (tid) as needed (PRN), if systolic blood pressure (SBP) is greater than 150, or distal pulse (DP) is greater than 90; Latanoprost 0.005% Ophthalmic Solution, 1 drop in both eyes daily (qd) in the evening; and Anora Ellipta 6.25/25 micrograms (mcg) inhaler, 1 puff qd. 2. A review of R1's medication administration record (MAR) for January 2026 revealed R1 was not administered Metoprolol Tartrate 25 mg, 1 tablet po on the following dates and times: January 5, 2026, at 7:00 AM; and January 9, 2026, at 1:00 PM. However, the documentation of R1's vital signs indicated the medication should have been administered based on parameters. 3. A review of R1's MAR for January 2026 revealed R1 was not administered Latanoprost 0.005% Ophthalmic Solution and Anora Ellipta 6.25/25 mcg, as ordered. 4. In an interview, E1 reported R1 was recently placed on hospice, and many medications were discontinued. However, discontinue orders for the aforementioned medications were not available for review. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, document review and interview, the manager failed to ensure hot water temperatures were maintained between 95° F and 120° F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental inspection, the Compliance Officers observed the hot water temperature reached over 127° F in a common area bathroom used by the residents. 2. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety” which stated, “Hot water temperature will be maintained between 95° F and 120° F at all times. A. Hot water will be checked monthly by the manager or assisted caregiver at the tap closest to and farthest from the hot water heater and recorded on the Maintenance Record. B. Water temperature outside the prescribed range will be reported to the Manager for correction immediately.” 3. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, document review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of the residents. Findings include: 1. During an environmental inspection, the Compliance Officers observed one bottle of Febreze in an unlocked cabinet in the kitchen area. 2. During an environmental inspection, the Compliance Officers observed one unattached empty propane tank next to the grill in the backyard. 3. A review of the facility’s policies and procedures revealed a policy titled "Environmental and Physical Plant Safety” which stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and storage areas, dining areas, and medications and are inaccessible to residents.” 4. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was switched off. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident. This is an uncorrected deficiency from the on-site compliance inspection conducted on August 8, 2024.

Based on documentation review and interview, the manager failed to immediately report suspected abuse, neglect, or exploitation according to A.R.S. \'a7 46-454. The deficient practice posed a risk as the facility did not immediately report suspected abuse of a resident by a personnel member. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.111 stated "Immediate" means without delay. 3. Review of Department documentation revealed an alleged incident that occurred on January 3, 2024. The incident documentation reported an unnamed perpetrator was stealing from R1. 4. In an interview, E1 reported that R1 reported to E1 and E2 that R1 was concerned R1's family members were stealing R1's money. E1 reported not contacting Adult Protection Services (APS) because E1 was not sure that what R1 said was true. E1 acknowledged E1 failed to immediately report suspected abuse, neglect, or exploitation according to A.R.S. \'a7 46-454.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour, the Compliance Officers observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had part of a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not alert caregivers when the door was opened. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure that medication was 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 environmental inspection, the Compliance Officers observed one unlocked drawer of the medicine cart containing three resident's medications. 2. In an interview, E1 acknowledged the drawer was unlocked at the time of the inspection.