Silver Birch of Avondale

Based on documentation review, observation, record review, and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident. Findings include: 1. A review of Department documentation revealed a self-report stated “… R1 was found approximately 4:19 pm on 7/21/25 with labored breathing. 911 was contacted and R1 became unresponsive while being attended to by care staff. CPR was started. MedTech received notification that R1 passed away on 7/21/25.” 2. A review of Department documentation revealed the facility is licensed to provide directed care services. 3. The Compliance Officer observed multiple ambulatory residents in the secured memory unit of the facility. 4. In an interview, E4 reported seeing R1 pass by around 3:20 to 3:40 PM; however, E4 did not check R1's whereabouts until 4:00 PM for dinner. E4 reported finding R1 outside in the courtyard of the memory care unit around 4:19 PM. R1 had labored breathing and then became unresponsive. Care staff then provided Cardiopulmonary resuscitation (CPR) until emergency services arrived and took R1 to the hospital. E4 also reported that the residents in the memory care unit turn off the alerts for the door that leads to the outside common area, and the staff are unaware if a resident has exited to the outside common area of the memory care unit. 5. A review of R1’s service plan stated “resident wandering: resident will be monitored and will remain in designated areas.” However, the service plan did not specify the frequency of monitoring of R1. 6. A review of facility documentation incident reports revealed R1 was last seen around 3:20 PM or 3:30 PM by care staff. Around 4:00 PM, care staff began looking for R1 for dinner services and located R1 at 4:19 PM in the outside designated area of the memory care unit. R1 had labored breathing and then became unresponsive. Care staff then provided Cardiopulmonary resuscitation (CPR) until emergency services arrived and took R1 to the hospital. 7. A review of facility documentation revealed a policy titled “Awareness of Residents Whereabouts.” The policy states, “To be aware of the general or specific whereabouts of a resident, based on their individual level of care. • Directed Care Residents: a. receive frequent checks throughout each 24-hour period, b. are encouraged to stay in common areas during the day, C. must sign in and out of the community and be accompanied by a responsible party, d. must be accompanied by a staff member or responsible party when in the general community.” 8. In an interview, E1 reported that the alerts that led to the outside common area are sometimes turned off by the resident in the memory care unit, and the staff is unaware if a resident has exited to the outside common area of the memory care unit.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures that covered methods by which the 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. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of facility documentation revealed a policy titled “Awareness of Residents Whereabouts.” The policy states, “To be aware of the general or specific whereabouts of a resident, based on their individual level of care. • Directed Care Residents: a. receive frequent checks throughout each 24-hour period, b. are encouraged to stay in common areas during the day, C. must sign in and out of the community and be accompanied by a responsible party, d. must be accompanied by a staff member or responsible party when in the general community.” However, the policy was not sufficient to ensure the whereabouts or safety of the residents, as it could not be verified that frequent checks were conducted throughout each 24-hour period. 3. In an interview, E1 acknowledged that the policy was not sufficient to ensure the whereabouts or safety of residents, as it could not be verified that frequent checks were conducted throughout each 24-hour period, and R1 was outside without staff monitoring, experienced a medical emergency, and later passed away.

Based on record review and interview, the manager failed to ensure service plans included the amount, type, and frequency of assisted living services and ancillary services being provided for one of two sampled residents. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated May 2025. The service plan stated, “Resident Wandering: Resident will be monitored and will remain in designated areas.” However, the service plan did not Include the frequency of monitoring of R1. 2. In an interview, E1 acknowledged that R1's service plan did not include the amount, type, and frequency of the services being provided to R1.

Based on documentation review, observation, record review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, which provided access to an outside area which monitored 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. A review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents in the secured memory care unit of the facility. 3. In an interview, E4 reported seeing R1 pass by around 3:20 to 3:40 PM; however, E4 did not check R1's whereabouts until 4:00 PM for dinner. E4 reported finding R1 outside in the courtyard of the memory care unit around 4:19 PM. R1 had labored breathing and then became unresponsive. Care staff then provided Cardiopulmonary resuscitation (CPR) until emergency services arrived and took R1 to the hospital. E4 also reported that the residents in the memory care unit turn off the alerts for the door that leads to the outside common area, and the staff were unaware if a resident has exited to the courtyard. 4. A review of R1’s service plan stated “resident wandering: resident will be monitored and will remain in designated areas.” However, the service plan did not include the frequency of monitoring of R1. 5. A review of facility documentation incident reports revealed R1 was last seen around 3:20 PM or 3:30 PM by care staff. Around 4:00 PM, care staff began looking for R1 for dinner services and located R1 at 4:19 PM in the outside designated area of the memory care unit. R1 had labored breathing and then became unresponsive. Care staff then provided CPR until emergency services arrived and took R1 to the hospital. 6. In an interview, E1 reported that the door alerts leading to the secured courtyard in the memory care unit are sometimes turned off by residents. As a result, staff may be unaware when a resident exits to the outside common area. E1 acknowledged that R1 was outside without staff monitoring, experienced a medical emergency, and later passed away.

Based on record review, documentation review and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all of the requirements of this rule, which posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed progress notes. Progress notes on June 26, 2024 and June 27, 2024 as well as on July 1, 2024 detail abuse suspected by facility from R1's POA to R1, and actions taken to stop the abuse. 2. A review of facility documentation revealed documentation of a investigation of the suspected abuse within five working days of the report was not available for review at the time of inspection. 3. In an interview, E1 reported E1 did not have a documented investigation of the suspected abuse within five working days of the report to APS on July 1, 2024. 4. In an interview, E1 acknowledged E1 did not have a documented investigation of the suspected abuse.