River Valley Estates

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) § 36-411, for one of eight personnel records reviewed. The deficient practice posed a health and safety risk to the residents if personnel members were a danger to vulnerable populations. Findings include: 1. A.R.S. § 36-411 states: - "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, ... and as a condition of employment in a residential care institution, ... employees and owners of residential care institutions, ... who provide ... health-related 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 ..."; - "H. For the purposes of this section: 1. "Direct supportive services": (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including: ... (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.". 2. A review of E2's personnel record revealed E2 was employed, more than twenty working days, as a housekeeper and included no evidence of a fingerprint clearance card or application for a fingerprint clearance card, as required in A.R.S. § 36-411 (A). 3. In an interview, E1 acknowledged E2's personnel record did not include documentation of compliance with the requirements in A.R.S. § 36-411.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which, was completed no later than 14 calendar days after the resident's date of acceptance, and when initially developed and when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for four of eight resident records reviewed. Findings include: 1. A review of R4's medical record revealed an initial directed care service plan, which included medication administration, dated April 30, 2025. The service plan was signed by the resident's representative on “April 2025”, by the manager on April 30, 2025, and by the nurse on May 2, 2025. Based on the date of R4’s admission, the manager and nurse signed the service plan more than 14 days after admission, and it is unclear what date the resident‘s representative signed the service plan. 2. A review of R7's medical record revealed updated personal care service plans, which included medication administration, dated October 1, 2024, and March 31, 2025. The service plans included the required signatures; however, none of the signatures included the dates signed. 3. A review of R8's medical record revealed an initial service plan and an updated service plan for personal care services, dated January 3, 2025 and April 30, 2025. The service plans included the required signatures; however, none of the signatures included the dates signed. 4. A review of R9's medical record revealed an initial directed care service plan, which included medication administration, dated November 4, 2024. The service plan did not include the required signatures of the resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan. In an interview, E1 reported the representative refused to sign the service plan. 5. In an interview, E1 acknowledged the service plans for R4 and R9 were not completed within 14 days of acceptance and the service plans for R7 and R8 did not include dates the document was signed.

Based on documentation review, record review, and interview, 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. Review of the staff personnel records revealed E7 who was hired on January 4, 2024, and E8 who was hired on May 13, 2024, had no documentation in their records of completing fall prevention and fall recovery training as required. 2. During an interview, E1 acknowledged that E7 and E8 had not completed the required fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive, which posed a health and safety risk for two of six residents' records reviewed. Findings include: 1. Review of R5's current service plan dated May 14, 2024 and R6's current service plan dated April 20, 2024 did not include the residents' required level of service. 2. The compliance officer observed R5 and R6 residing in an area of the facility that was secured. 3. In an interview, E1 reported R5 and R6 required "directed" level of care services. E1 acknowledged the current service plans did not state the level of service each resident required.

Based on record review and interview, the manager failed to ensure the written service plan when initially developed and when updated, for four of five sampled residents receiving medication administration and or directed care services, was signed and dated by a nurse or medical practitioner when updated which could pose a health risk to the resident if the service plan was not reviewed and signed as required.. Findings include: 1. Review of R1's current service plan dated March 19, 2024 and R3's current service plan dated March 27, 2024 stated each resident required personal care and medication administration services. However, the service plans were not signed and dated by a nurse or medical practitioner as required. 2. Review of R5's current service plan dated May 14, 2024 and R6's current service plan dated April 20, 2024 stated the residents required medication administration services. E1 stated both residents required directed care services. However, the service plans were not signed and dated by a nurse or medical practitioner as required. 3. In an interview, E1 acknowledged the residents' service plans had not been signed and dated by a nurse or medical practitioner as required. This is a repeat deficiency from the compliance inspection conducted on July 13, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that caregivers were only assigned to provide the assisted living services the caregivers had the documented skills and knowledge to perform, which posed a health and safety risk. Two of four caregivers' personnel records were reviewed. Findings include 1. In an interview at the beginning of the compliance inspection, E1 reported the facility allowed a resident to have a catheter if it was medically necessary. E1 reported that R1 required a catheter. The compliance officer requested and was not provided with verified documentation that the sampled caregivers had the skills and knowledge to provide catheter care. 2. Review of the sampled caregivers' personnel record found no documentation in two caregivers' personnel records of any verified documentation of their skills and knowledge to provide catheter care. E5 was hired November 15, 2023 and E8 was hired May 13, 2024 as caregivers. 3. In an interview, E1 acknowledged there was no documentation of skills and knowledge for catheter care that had been verified and documented before these two caregivers provided catheter care services nor anytime since.

Based on record review and interview, the manager failed to ensure that a service plan for a resident who is receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections which posed a health and safety risk; for one of one sampled resident. Findings include: 1. In an interview, E1 reported that R1 had a cast on R1's arm. The cast has been removed however, R1 now has a stage two wound where the cast was. 2. Review of R1's current service plan dated March 19, 2024 did not address any skin maintenance to prevent injuries or pressure sores, did not address the care of the skin with the cast on the arm, and did not address the wound after the cast was removed. 3. In an interview, E1 acknowledged the R1's service plan did not document the required skin maintenance to prevent wounds, the care of the arm with the cast, nor the care if the arm with the wound after the cast was removed.

Based on record review and interview, the manager failed to ensure that for one of one sampled resident who was unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at the onset or at the time of acceptance or within 30 days prior to acceptance and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met. This determination was to be based upon a current resident examination and the assisted living facility's scope of services that the resident's needs could be met, which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. In an interview, E1 reported that R3 had a fractured foot. Upon returning to the facility a few weeks ago from rehab R3 was now unable to ambulate even with assistance. E1 reported that R3 could bear weight in a boot, however was unable to ambulate. 2. Based on the date of the onset and review of R3's medical record found no documented determination completed at the time of the onset by the resident's PCP or medical practitioner that the resident's needs could be met. The determination should have been based on a current examination of the resident, the facility's scope of services, and should have included a statement that the residents' needs could be met by the facility. 3. In an interview, E1 acknowledged there was no documentation of the required determination.

Based on document review and interview, the manager failed to ensure the facility had a disaster plan that was developed and documented, that included when, how, and where residents would be relocated, how a resident's medical record would be available to individuals providing services to the resident during a disaster, s plan to ensure each resident's medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility's relocation site during a disaster. Findings include: 1. At the beginning of the complaint investigation, E1 was notified that the facility's disaster plan needed to be reviewed for the investigation. Later the compliance officer requested and was not provided with the facility's disaster plan. 2. In an interview, E1 reported there was no developed and documented disaster plan as required in this rule.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. During a tour of randomly selected residents' units and bedrooms, E1 and the compliance officer observed R5's bedroom had a pungent urine odor. The resident was in the bedroom walking around. The bathroom door was locked so the resident could not enter the bathroom. There was no visible reason for this urine odor. E1 commented that E1 did not understand why the bathroom door was locked unless the resident accidentally locked it. 2. In an interview, E1 acknowledged that R5's bedroom had a pungent urine odor.

Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an 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 which is a health and safety risk. Findings include: 1. The compliance officer observed residents residing at the facility. 2. The compliance officer requested and was not provided with the facility's policy and procedure that cover the methods by which the facility was aware of the general whereabouts of a resident. 3. In an interview, E1 acknowledged there was no policy and procedure that covered the whereabouts of all the assisted living residents.

Based on record review and interview, the manager failed to ensure six of seven sampled residents' written service plans reviewed when initially developed and updated were signed and dated by the resident or resident's representative and the nurse or medical practitioner who reviewed the service plans, as required. Finding included: 1. Review of R1's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated June 22, 2023 was never signed by the resident or the representative and the nurse or medical practitioner who had reviewed this service plan. 2. Review of R2's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated May 30, 2023 was never signed by the nurse or medical practitioner who had reviewed this service plan. 3. Review of R4's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated June 15, 2023 was never signed by the nurse or medical practitioner who had reviewed this service plan. 4. Review of R5's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated June 19, 2023 was never signed by the resident or the representative and the nurse or medical practitioner who had reviewed this service plan. 5. Review of R6's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan dated May 13, 2023 was never signed by the nurse or medical practitioner who had reviewed this service plan. 6. Review of R7's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan dated May 25, 2023 was never signed by the nurse or medical practitioner who had reviewed this service plan. 7. In an interview, E1 acknowledged that the sampled residents' service plans had not been signed and dated as required.

Based on observation and interview, the manager failed to ensure a medication stored by the facility was stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During facility tour of the memory care unit, E1 and the compliance officer observed the unlocked medication cart setting in the unlocked med room with no caregiver the area. 2. In this medication cart there was stored the memory care residents' medications. Metoprolol Tartrate, Namenda, Exelon Tart, Hyoscyamine, Sinemet, Lipitor, Levothyroxine, Norvasc, Hydralazine, Proamatine, Aricept, Seroquel, and Coreg along with over-the- counter medications. 3. In an interview, E1 acknowledged the unlocked medications that were left unattended.

Based on observation and interview, the manager failed to ensure that garbage and refuse are stored in covered containers. Findings include: 1. During a tour of the facility, E1, E2, and the compliance officer observed on a housekeeping cart, in the facility's common hallway where the residents' apartments are located, there was a large uncovered bin of trash and refuse. 2. In an interview, E1 acknowledged the uncovered trash.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were maintained in a locked area and inaccessible to residents which posed a health and safety risk.. Findings include: 1. During a facility tour, E1 and the compliance officer observed several areas at the facility where poisonous or toxic materials were stored unlocked and unattended. 2. In the facility's unlocked utility room there was stored furniture polish, toilet bowl cleaner, CLR cleaner, glass and all-purpose cleaner, odor eliminator, and stainless steel cleaner. In the unlocked beauty shop there was stored window cleaner. On the unattended housekeeping cart setting in the hall near apartment 133 there was stored on top of this housekeeping cart spray bottles of CLR cleaner, urine remover, glass cleaner and multi-propose cleaner, disinfectant cleaner. There was no means to lock these poisonous or toxic materials on this cart. In the unlocked team laundry room there was stored in an unlocked cabinet odor neutralizer, stain remover, furniture polish, and carpet cleaner. 3. In an interview, E1 acknowledged all the unlocked poisonous or toxic materials stored by the assisted living facility.