Scottsdale Quarter Care Assisted Living LLC

Based on documentation review and interview, the manager failed to annually assess the facility's risk of exposure to infectious tuberculosis. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) was available for review. 2. In an interview, E2 acknowledged that the health care institution had no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis per R9-10-113(A)(2)(d) available for review.

Based on interview and record review, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. In an interview, E2 reported R1 was non-ambulatory and received Directed Care Services. 2. A review of R1's medical record revealed a service plan dated July 15, 2025. The service plan stated "Resident is bed bound and does not ambulate." 3. A review of R1's medical record revealed no documentation indicating R1's medical practitioner examined R1 every six months, signed and dated a determination that stated R1's needs could be met by the facility, and reviewed the facility's scope of services. 4. In an interview, E2 reported that the facility had a determination but was unable to locate it during the inspection. E2 also acknowledged that R1’s medical practitioner did not provide a written determination at least once every six months, as required. This is a repeat deficiency from the compliance inspection conducted on June 5, 2024.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated July 15, 2025. This service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating that weighing R1 was contraindicated. 2. In an interview, E2 acknowledged R1's service plan did not include documentation of R1's weight, and documentation was not available in R1's record from a medical practitioner stating weighing R1 was contraindicated.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk if employees were unable to implement the disaster plan in an emergency. Findings include: 1. A review of facility documentation revealed no documented review of the facility's disaster plan conducted at least once every 12 months. 2. In an interview, E2 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months. This is a repeat deficiency from the on-site compliance inspections conducted on September 27, 2022, and June 5, 2024. 

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E2's and E3's personnel record revealed no documentation that showed E2 and E3 completed fall prevention and fall recovery training during orientation or after. 2. Review of facility training documentation revealed a document titled "Fall Prevention Training" dated September 28, 2023 which listed the employees present at the training, however, E2's and E3's name were not on this document. 3. In an interview, E1 reported that E2 and E3 were hired after this training, and that the manager was waiting until the next scheduled training to train E2 and E3 on fall prevention and recovery. E1 acknowledged E2's and E3's personnel record did not contain documentation that showed the health care institution had administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the on-site compliance inspection conducted on September 27, 2022.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. Review of facility's policy and procedure manual revealed a page titled "Review Timeframe for Policies and Procedures". This page stated "The facility manager will print name, sign and date on this page that the Policy Procedure Manual has been reviewed and updated as required." However, the most recent review was dated September 15, 2019. 2. In an interview, E1 acknowledged the facility's policies and procedures were not reviewed by the manager of the facility at least once every three years and updated as needed.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. . The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures manual (dated September 15, 2019) revealed a policy titled "Quality Management Program." The policy stated "The Manager submits a documented report to the governing authority on a quarterly basis..." 2. The Compliance Officer requested to review the facility's quality management reports submitted to the governing authority. However, the reports submitted to the governing authority were not provided for review. 3. In an interview, E1 acknowledged the quality management program and the quarterly reports had not been implemented.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver, for one of one assistant caregivers reviewed. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. The facility is licensed at the directed care level. 2. Review of A.R.S. \'a7 36-401.A.49 revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 3. Review of E3's and E4's personnel records revealed both held the position "assistant caregiver". 4. Review of E3's and E4's personnel records revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E3's and E4's records did not include documentation showing an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E3 and E4 were not qualified to be left alone with the residents based on the lack of caregiver training. 5. During the tour of the facility, and throughout the inspection, the Compliance Officer observed E3 alone with residents in resident bedrooms, and E4 providing assistance with food without the direct supervision of a manager or caregiver. 6. In an interview, E1 reported that the caregiver or manager was always assigned to supervise E3 and E4 by being on shift at the same time, however, this does not meet the A.R.S. \'a7 36-401.A.49 definition of "supervision". 7. In an interview, E1 reported E3 and E4 did not have caregiver training certificates and worked as assistant caregivers. E1 acknowledged E3 and E4 did not interacted with residents under the supervision of a manager or caregiver.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E1, E2, E3 and E4 were working at the facility. 2. Review of the posted personnel schedule dated June 2024 revealed E1 and E2 were scheduled to work the 7am - 7pm shift June 5th. E3 and E4 were not listed on the schedule. 3. During an interview, E1 reported that the facility only documents when caregiver work. E1 acknowledged documentation was not maintained of the assistant caregivers working each day, including the hours worked.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's medical record revealed a recent written service plan for personal care services dated January 1, 2024. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged R1's service plan did not include a signature and date from the resident or representative.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.201 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. During the facility tour, the Compliance Officer observed R1 in bed surrounded by half length bed rails in the upright position and R3 in bed surrounded with full length bed rails in the upright position. 3. A review of facility documentation revealed a procedure document titled "Acceptance" which stated "The manager shall not accept or retain an individual if [...] the individual requires restraints, including the use of bedrails." 4. In an interview, E1 reported that R1 and R3 required the use of bedrails to keep the residents in bed to prevent falls. E1 acknowledged that the bedrails were used to keep R1 and R3 from getting out of bed.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a document titled "Consent for Resident's Stay in Facility" dated and signed by a medical practitioner July 5, 2023. The document reported that R1 was wheelchair bound and "bed-ridden" and stated "We, the undersigned Primary Care Physician, and Resident's Representative/POA, do hereby conform and don't have objection of the following resident being placed in this facility. I have reviewed the facility's scope of service. The resident's needs are met." However, R1's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months. 2. In an interview, E1 acknowledged that a determination by R1's primary care provider or other medical practitioner stating that the resident's needs can be met by the assisted living facility for every six months during R1's residency was not available.

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 with E1, the Compliance Officer observed a door leading out to the backyard from the living room. 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 not turned on. 3. During the facility tour, the Compliance Officer observed a door leading out to the backyard from a resident's bathroom. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door was propped open, and did not alert employees of the egress of a resident from the facility. 4. In an interview, E1 reported the alarm on the living room door was turned off during the day to prevent it from making noise. 5. In an interview, E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility. This is a repeat deficiency from the on-site compliance inspection conducted on September 27, 2022.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the Casarett & Doull's Toxicology The Basic Science of Poisons 6th edition (published 2001) . 2. Review of the web site for the toxicology guide revealed that the current edition of this toxicology guide is the 9th edition (published 2018). 3. In an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on observation, documentation review, and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents. Findings include: 1. During the facility tour, the Compliance Officer observed the following in a kitchen cabinet: -an opened jar of relish which stated "Refrigerate after opening". -a McDonalds hamburger in a paper wrapper; -an open-topped dish of cooked meat. 2. In an interview, E2 reported that the hamburger and meat were leftovers for a resident to eat later. 3. Review of facility policy and procedures revealed a document titled "Food Services" which stated "Once the food is set on the plate, or on the table and served to the residents, the leftovers are not to be saved for later consumption, stored, or otherwise put back..." 4. In an interview, E1 acknowledged that foods requiring refrigeration were not maintained at 41\'b0 F or below.

Based on observation and interview, the manager failed to ensure that utensils were clean. Findings include: 1. During a tour of the facility, the Compliance Officer observed, in a kitchen drawer, the silverware was stored in a plastic tray, which was lined with a paper towel that was soiled with a greasy brown substance. 2. In an interview, E1 acknowledged that the silverware was not stored in a manner that kept it clean.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "DISASTER PLAN, RELOCATION, RECORDS, MEDS, FOOD AND WATER." The document stated, "This document was last reviewed by [O1]...Date: September 15, 2019." 2. During an interview, E1 acknowledged the facility's disaster plan was not reviewed within the last 12 months. This is a repeat deficiency from the on-site compliance inspection conducted on September 27, 2022.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1. During a facility tour, the Compliance Officer observed two rechargeable fire extinguishers in the facility with tags from, "AAA Smart Business." The tags indicated both fire extinguishers were last serviced in October 2022. 2. In an interview, E1 reported E1 called "AAA Smart Business" and the property's landlord to attempt to get the fire extinguishers inspected, with no success. E1 acknowledged the tags on the fire extinguishers indicated they were not serviced at least once every 12 months. This is a repeat deficiency from the on-site compliance inspection conducted on September 27, 2022.