Rustic Ranch Senior Living

Based on record review, interview, and documentation review, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for two of two sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E6's personnel record revealed E6 was hired as a caregiver. The review revealed documentation of E6’s CPR training certification dated as issued on February 17, 2023, and expired at the end of February 2025. The review revealed a printout of E6’s current CPR training certification dated as issued on March 13, 2025. However, the certifications revealed E6 did not have CPR training certification for approximately two weeks. The review further revealed no documentation of first aid training certification specific to adults. 2. In an interview, when the Compliance Officer asked if E6 had CPR training certification between March 1, 2025, and March 12, 2025, E1 stated, “Not that I know of.” 3. A review of E7's personnel record revealed E7 was hired as a caregiver. The review revealed documentation of E7’s CPR training certification dated as issued on February 17, 2023, and expired at the end of February 2025. The review revealed a printout of E7’s current first aid training and CPR training certification dated as issued on March 14, 2025. However, the certifications revealed E7 did not have first aid training certification before March 14, 2025, and CPR training certification for approximately two weeks. 4. In an interview, when the Compliance Officer asked if E7 had CPR training certification between March 1, 2025, and March 14, 2025, E1 reported not being sure. However, E1 reported E1 removed E7 from the personnel schedule when E1 discovered E7 did not have first aid training and CPR training certification. 5. A review of facility documentation revealed a series of personnel schedules dated between February 9, 2025, and March 15, 2025, which indicated the following: - E6 worked without first aid training certification on February 9-13, 16- 20, and 23-27, 2025, and March 2-6 and 9-13, 2025; - E6 worked without CPR training certification on March 2-6 and 9-12, 2025; - E7 worked without first aid training certification on February 9-13, 16- 20, and 23-27, 2025, and March 2-6 and 9-11, 2025; and - E7 worked without CPR training certification on March 2-6 and 9-11, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for one of three sampled residents. The deficient practice posed a risk if a resident was not informed of the terms of residency. Findings include: 1. A review of Department documentation revealed the address had been licensed under “My Father’s Retirement Ranch, Inc., dba My Fathers Retirement Ranch” until the facility changed ownership on February 8, 2022. The review revealed the facility was then licensed as "My Father’s Wickenburg LLC, dba My Fathers Retirement Ranch" effective February 8, 2022. The review further revealed a request to change the name of the facility and an updated license with the new name of the facility being "My Father’s Wickenburg LLC, dba Rustic Ranch Senior Living," effective November 13, 2023. 2. A review of R1's medical record revealed a residency agreement between R1 and “My Father’s Retirement Ranch” dated before the change of ownership in 2022 and change of name in 2023. However, the review revealed no updated residency agreement between R1 and the new owner under either the old or new name. 3. In an interview, E1 stated, "[R1’s] is the original from the last owner. E1 confirmed R1’s residency agreement was between R1 and the previous owner, not between R1 and the current owner. Technical assistance was provided on this rule during the compliance inspection conducted on May 25, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for two of three sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated March 1, 2025. The service plan revealed R1 was to receive a “Shower…2 x per week” and “Complete Assist” with dressing. The review revealed documentation of assisted living services provided to R1 (ADLs) dated March-May 2025. The ADLs revealed the following: - R1 received showers on March 6, 8, 11, 15, 18, 21, 25, and 28, 2025; - R1 received showers on April 8, 15, 18, 25, and 28, 2025; - R1 received showers on May 2, 8, and 15, 2025; - R1 received zero showers on the week of March 31, 2025, through April 6, 2025; - R1 received one shower on the weeks of April 7-13 and 21-27, 2025; and - R1 received one shower on the week of May 5-11, 2025. 2. In an interview, E3 reported facility personnel did not assist R1 with dressing in the evening because R1’s family member assisted R1 with that task instead. Referring to dressing assistance on R1’s service plan, E1 stated, “If it says it, we have to be doing it.” E3 reported R1 was to receive showers on Tuesdays and Fridays. E1 and E3 acknowledged R1 did not receive showers every Tuesday and Friday and did not receive two showers per week. E3 reported R1 may have refused some showers which would have been documented on the back of the ADLs. 3. A review of R1’s ADLs revealed no documentation demonstrating R1 refused showers (on the front or back of the ADLs). 4. A review of R3's medical record revealed a service plan dated April 7, 2025. The service plan revealed R3 was to receive a “Shower…twice a week.” The review revealed ADLs dated April-May 2025. The ADLs revealed the following: - R3 received showers on April 10, 13, 17, 20, and 27, 2025; - R3 received showers on May 1, 4, 8, and 9, 2025; and - R3 received one shower on the week of April 21-27, 2025. 5. In an interview, E1 acknowledged a caregiver or an assistant caregiver did not provide R1 and R3 with the assisted living services in R1's and R3’s service plans. This is a repeat citation from the compliance inspection conducted on May 25, 2023.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. The review revealed a medication order for “Diclofenac Gel TID” and “Gent/Betameth/Ampho 0.75-10 Mg daily” dated November 20, 2024. The review revealed a series of medication administration records (MAR) dated between January 2025 and May 2025. The MARs revealed documentation demonstrating R1 received diclofenac one time per day instead of three as ordered. The MARs further revealed no documentation of R1 receiving Gent/Betameth/Ampho daily. 2. In an interview, E3 reported R1 received R1’s diclofenac each day at 7:00 AM and 8:00 PM, but facility personnel only documented it at 7:00 AM. E3 reported R1 received R1’s Gent/Betameth/Ampho each day, but facility personnel did not document it. However, E3 reported R1 ran out of Gent/Betameth/Ampho and last received it on May 12, 2025. E3 reported the facility was in the process of obtaining a refill. 3. A review of R3’s medical record revealed a service plan which indicated R3 received medication administration. The review revealed a medication order for “Crestor 20 mg [1 tab] po qd,” “Namenda 10 mg [1 tab] po qd,” and “Singulair 10 mg [1 tab] po qd” dated March 6, 2025. However, the review revealed no MARs and no order(s) to discontinue the three medications. 4. In an interview, E1 reported facility personnel sent R3’s medication orders to the pharmacy and received the medications in return, but never administered them. E1 reported R3’s family member requested R3 not take the medications. E1 acknowledged R3 did not have an order to discontinue the three medications. This is a repeat citation from the compliance inspection conducted on May 25, 2023.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance during inspection. Findings include: 1. A review of facility documentation revealed a policy and procedures (dated October 2021) titled "Fall Prevention and Fall Recovery." The policy stated, "1. New certified caregivers will be trained on the fall prevention and fall recovery program. 2. Annually all certified staff will be retrained in the fall prevention and fall recovery program." However, the policy did not include that the training program would be administered to all staff. 2. In an interview, E1, E2, and E3 acknowledged the facility's fall prevention and fall recovery documentation did not include the training for all staff.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover a quality management program to include incident reports and supporting documentation. The deficient practice posed a risk as the facility's standards were not followed, and Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of the facility's policy and procedures (dated February 2022) revealed a policy titled "Resident Incident Reports." The policy stated, " 2. The initial responder to the incident shall fill out a written accident/incident report form... 3. The department manager will complete the following sections:... Actions taken to prevent reoccurrence..." 2. A review of R1's medical record revealed an incident report dated March 15, 2023. However, the incident report did not include actions taken to prevent reoccurrence. 3. A review of R5's medical record revealed an incident report dated May 7, 2023. However, the incident report did not include actions taken to prevent reoccurrence. 4. In an interview, E1, E2, and E3 acknowledged the facility's policy and procedure was not implemented to cover incident reports and supporting documentation.

Based on observation, 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 A.R.S. \'a7 36-411(A), for one of nine employees sampled; and A.R.S. \'a7 36-411(C)(2), for three of nine employees sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population, and the Department was unable to determine substantial compliance during the inspection. Findings include: A.R.S. \'a7 36-411(A) states A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health 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 or beginning volunteer work or contracted work. A.R.S. \'a7 36-411(C)(2) states owners shall make documented, good faith efforts to:... 2. Verify the current status of a person's fingerprint clearance card. 1. The Compliance Officer observed E3 working on-site at the time of the inspection. 2. A review of facility documentation revealed a staffing schedule from April 23, 2023 - May 20, 2023. The staffing schedule revealed E3 was scheduled to work on-call Monday - Sunday. 3. A review of E3's (hired in February 2022) personnel record revealed E3 was hired as the Resident Care Director. E3's personnel record included a fingerprint clearance card. However, E3's fingerprint clearance card expired on March 10, 2023. 4. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website, revealed E3's fingerprint clearance card was expired. 5. A review of E1's, E4's, and E5's personnel records revealed documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 6. In an interview, E3 reported being unaware E3's fingerprint clearance card had expired. 7. In an interview, E1, E2, and E3 acknowledged E1's, E4's, and E5's personnel record did not include documentation of compliance with A.R.S. \'a7 36-411(C)(2).

Based on documentation review, record review, and interview, the manager failed to ensure the facility's residency agreements contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G). The deficient practice posed a risk if the resident was not informed of the terms of residency, and the Department was unable to determine substantial compliance during the inspection. Findings include: R9-10-807(C): A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails. 1. A review of the facility's policy and procedures (dated February 2022) revealed a policy titled "Termination of Residency." The policy stated, "The Residency Agreement may be terminated by My Father's Retirement Ranch upon fourteen (14) days written notice for: a. Documented failure of the Resident to pay fees or charges, b. The Resident's non-compliance with the Residency Agreement or facility rules." 2. A review of R1's and R2's medical records revealed residency agreements. The residency agreements stated, "7. Termination of Residency:... With a 14 day written notice of termination of the residency for nonpayment of fees, charges, or deposit; or if any of the following: i. The individual requires continuous medical nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C) or behavioral health services. ii. The assisted living services needed by the individual are not within the assisted living facility's scope of services. iii. The assisted living facility does not have the ability to provide the assisted living services needed by the individual. The individual requires restrains, including the use of bedrails." 3. A review of R3's, R4's, R5's, and R6's medical record revealed residency agreements. The residency agreements stated, "MFRR may terminate this agreement after providing fourteen (14) days written notice to The Resident or the Representative for: 1. If the individual requires: a. Medical Services b. Nursing Services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C) or c. Behavioral health service; 2. Resident has failed to pay fees or charges or deposits, or 3. The assisted living services needed by the individual are not within the assisted living facility's scope of services. 4. MFRR

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plans, for five of six residents sampled. The deficient practice posed a risk as the residents did not receive the expected services in their service plans, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed a service plan (dated in April 2023) for directed care services. The service plan revealed lotion assistance two times a week. 2. A review of R1's medical record revealed a document from a podiatrist dated April 2023. The document stated, "Chief Complaint: Pain in right and left feet, elongated thickened painful nails... multiple chronic lower extremity issues with the acute issue of painful, long, think and in-growing toenails that limit ambulation. Patient is unable to manage foot and nail care.... Recommend that patient/staff to check feet daily for any new problems or areas of concern and to contact the clinic with any... Recommendations for Patient: Lotion for dry skin, check feet daily and contact with any problems." 3. A review of R1's medical record revealed an activities of daily living (ADL) log for May 2023. The ADL included a section to sign off on fingernails weekly. However, the section was not filled out as having been completed and the ADL did not include daily foot checks or lotion two times a week. 4. A review of R2's medical record revealed a service plan (dated in March 2023) for personal care services. The service plan revealed lotion two times a week. 5. A review of R2's medical record revealed a document from a podiatrist dated April 2023. The document stated, "Chief Complaint: Pain in right and left feet, elongated thickened painful nails... multiple chronic lower extremity issues with the acute issue of painful, long, think and in-growing toenails that limit ambulation. Patient is unable to manage foot and nail care.... Recommend that patient/staff to check feet daily for any new problems or areas of concern and to contact the clinic with any... Recommendations for Patient: Lotion for dry skin, check feet daily and contact with any problems." 6. A review of R2's medical record revealed an ADL log for May 2023. The ADL included a section to sign off on fingernails weekly. However, the ADL did not include daily foot checks or lotion two times a week. 7. A review of R3's medical record revealed a service plan (dated March 2023) for directed care services. The service plan revealed lotion two times a day. 8. A review of R3's medical record revealed a document from a podiatrist dated April 2023. The document stated, "Chief Complaint: Pain in right and left feet, elongated thickened painful nails... multiple chronic lower extremity issues with the acute issue of painful, long, think and in-growing toenails that limit ambulation. Patient is unab

Based record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for two of six residents sampled. The deficient practice posed a risk as services provided could not be verified aganst a service plan, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R3's medical record revealed a service plan (dated March 2023) for directed care services. The service plan stated, "Shower... 2x per week." 2. A review of R3's medical record revealed an activities of daily living (ADL) log for May 2023. The ADL revealed R3 received showers on May 3, 2023, and May 10, 2023. However, documentation R3 received shower services two times a week was not available for review. 3. A review of R5's medical record revealed a service plan (dated May 2023) for directed care services. The service plan stated, "Shower... 2x per week." 4. A review of R5's medical record revealed an ADL log for May 2023. The ADL revealed R5 received showers on May 3, 2023, May 10, 2023, and May 15, 2023. However, documentation R5 received shower services two times a week was not available for review. 5. In an interview, E1, E2, and E3 reported R3 and R5 received shower services twice a week. E1, E2, and E3 acknowledged documentation of the services provided to R3 and R5 was not available for review.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of six residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed a signed medication order for Imodium, take one tablet by mouth after each loose stool up to eight tabs per day. 2. A review of R1's medical record revealed a document titled "BM Elimination Record" for May 2023. The document revealed R1 had loose stool on the following dates: - May 10, 2023; - May 11, 2023, at 5:30 AM and 11:00 AM; - May 14, 2023; - May 15, 2023; - May 20, 2023 ,at 1:45 PM and - May 21, 2023, at 9:00 AM and 3:15 PM. 3. A review of R1's medical record revealed a medication administration record (MAR) for May 2023. The MAR revealed Imodium was administered to R1 on May 11, 2023 at 9:00 AM. However, the medication was not administered in compliance with an order. 4. In an interview, E1, E2, and E3 acknowledged medication administered to a resident was not in compliance with a medication order.