Serenity of North Scottsdale

Based on documentation review, record review, and interview, for two of three residents reviewed, the manager failed to ensure there was a documented residency agreement with the assisted living facility. Findings include: 1. A review of Department documentation revealed a change of ownership on September 8, 2022. 2. In record review, the medical records for R2 and R3 included a residency agreement signed by E5, the prior owner. An updated residency agreement for R2 and R3, and the new facility ownership, was not available for review. 3. During an interview, E1 and E5 reported an understanding that a new residency agreement was not required, and acknowledged a new residency agreement, under the new ownership, had not been documented for R2 and R3. 4. Technical assistance was provided in an email to E2, dated September 8, 2022.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. In observation, R1 had a wound on the top of two toes on one foot. 2. In record review, R1's medical record (received personal care services) included documentation of diagnoses as "heart failure, Muscle weakness, pain in right hip, chronic kidney disease and Parkinson's Disease. R1's service plan, dated August 16, 2023, did not include documentation of the wounds observed on R1's foot, the muscle weakness, kidney disease, hip pain or Parkinson's Disease. 3. During an interview, the findings were reviewed with E1, who E1 reported the R1 had a recent surgical procedure to improve circulation, that caused the wounds on the toes, and no care instructions were provided for facility staff. E1 reviewed R1's service plan and acknowledged the service plan did not include a description of all of the resident's medical and health problems