Santorini Villas Assisted Living, LLC

Violation cited

Violation cited

Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation, initiate an ivestigation of the suspected abuse, neglect, or exploitation, and maintain documentation including all requirements of this rule for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if a resident was not protected from abuse, neglect, or exploitation. Findings include: 1. In an interview, E1 reported being aware of an incident involving R1 on March 16, 2024. E1 stated the incident was not reported by the facility in compliance with A.R.S. \'a7 46-454. 2. A review of facility incident reports revealed a report created for the incident involving R1 on March 16, 2024. However, the report did not indicate the manager or any other employee reported the suspected abuse according to A.R.S. \'a7 46-454. 3. In an interview, E1 acknowledged the incident was not reported as required.

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of four sampled caregivers. The deficient practice posed a risk if the employees were not qualified to provide the required services. Findings include: 1. In an interview, E1 reported E4 and E5 both worked at the facility as caregivers. 2. A review of facility personnel records revealed E4 was hired as a caregiver. However, E4's personnel record contained no documentation of completion of a caregiver training program approved by the NCIA Board. 3. A review of facility personnel records revealed no personnel record, including documentation of completion of a caregiver training program approved by the NCIA Board, was available for review for E5. 4. In an interview, E1 acknowledged there was no documentation available for review at the time of the survey to indicate E4 and E5 completed a caregiver training program approved by the NCIA Board. This is a repeat citation from the compliance inspection conducted on March 9, 2023.

Based on record review and interview, the manager failed to ensure a personnel record was established and maintained, for one of four sampled employees. The deficient practice posed a risk as required information could not be verified. Findings include: 1. A review of facility personnel records revealed no personnel record for E5 available for review. 2. In an interview, E1 acknowledged there was no personnel record for E5.

Based on documentation review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. A review of Department documentation revealed a reported incident on March 16, 2024. The documentation indicated R1 was restrained in R1's bed by E4. E4 reportedly placed two fall mats between R1's bed and a dresser and tied the mats to the bed with an oxygen cord. 3. A review of facility documentation revealed no documented report of the aforementioned incident. 4. In an interview, E1 and E6 acknowledged R1 was restrained in R1's bed by E4.

Based on 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 one of three 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 no documentation of assisted living services provided to R2. 2. In an interview, E1 acknowledged R2's medical record contained no documentation of any assisted living services provided to R2.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility required in Arizona Administrative Code (A.A.C.) R9-10-818(B), for one of three sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation route to be used in an emergency. Findings include: 1. A.A.C. R9-10-818(B) states: "B. A manager shall ensure that: 1. A resident receives 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 assisted living facility, and 2. The resident's orientation is documented." 2. A review of R2's medical record revealed no documentation of R2's orientation to exits from the assisted living facility. Based on R2's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility. This is a repeat citation from the compliance inspection conducted on March 9, 2023.

Based on documentation review and interview, the manager failed to ensure required smoke detectors were tested at least once a month. The deficient practice posed a potential fire hazard. Findings include: 1. A review of facility documentation revealed no documentation to indicate the facility's smoke detectors were tested at least once a month. 2. In an interview, E2 reported smoke detectors were tested each month as required. E2 acknowledged documentation of the testing was not available for review at the time of the survey.