Solana at the Park Assisted Living

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of one resident sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R1's medical record revealed a service plan dated July 2025 for personal care services. 2. R1's file contained notes with a date range of October 15-19, 2025, that indicated R1 "was not feeling well, coughing get worse, went to the hospital..." The note on October 23, 2025, indicated a case manager from the company used by the resident for private caregiving stopped by to check on R1. The note read "Case Manager came and asked if it was ok now to call Faith Hospice to come and start Palliative Care." The note referenced R1 agreed. 3. In an interview with R1, R1 indicated receiving services from Faith Hospice and showed the Compliance Surveyor the folder that was sitting on the dining room table in R1's apartment. Services began in October 2025. 4. In an interview, E1 and E2 acknowledged that R1’s service plan was not updated no later than 14 calendar days after a significant change.

Based on documentation review and interview, the assisted living center failed to provide a written document that covered A.R.S § 36-420.04.A.1-9. when the assisted living center contacted an emergency responder on behalf of the resident, for one of of one record sampled. Findings include: 1 . A review of R1's medical record revealed a note that R1 had an unwitnessed fall on November 23, 2025. The notation read "Resident's POA came to visit and requested to send resident out to the hospital for pain caused from fall." E1 reported R1 was transported by ambulance. 2.A review of the Hospital/Facility Transfer Form dated November 25, 2025, did not contain documentation of a written document presented to emergency medical services (EMS) that included all items covered under A.R.S § 36-420.04.A.1-9. 3 . In an exit interview, the finding was discussed with E1 and E2, and no additional information was provided.

Based on documentation 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 R1's medical record contained a note dated November 23, 2025, at 9:00 pm that read "Resident had a fall today resident states was organizing and suddenly felt as if falling backwards. Fell on bottom did not hit head. Care staff and writer helped resident to sofa, upon assessment resident had 2 small skin tears to right of hand. Bandage was applied, dry blood was peeling away from right side of back. Patch was applied and redness noted to left butt cheek. Resident complaining of right side back pain, left side back soreness and soreness to left butt cheek. Tramadol taken...Tylenol was given after fall. POA aware." 2. Notation dated November 24, 2025, read "Checked on resident later in the morning around 2-3am and awake on the couch. Writer asked if needed help to go to the bathroom and reported did not want to get up because was sore from the fall. Writer asked if she needed anything. Resident said going to try to get back to sleep." 3. Notation dated November 24, 2025, read "resident stated ribs hurt especially when I take a deep breath." There was documentation that R1 spoke with POA, who told R1 was going to come to pick R1 up and take them to the hospital or urgent care. The notation read "Resident's POA came to visit and requested to send resident out to the hospital for pain caused from fall." E1 reported R1 was transported by ambulance. 4. Progress note dated November 25, 2025, reported: "Case Manager at [hospital] reported resident has fractured ribs." 5. In interview, E1 and E2 confirmed the aforementioned notes. E1 and E2 reported that when there was an unwitnessed fall, the resident was put on alert charting for 48 hours. However, no additional notes or information were provided. 

Based on record review and interview, the manager failed to ensure that a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services. The deficient practice posed a health and safety risk if the employee did not know how to properly perform CPR. Findings include: 1. Review of E8 's personnel record revealed a CPR card that was obtained from www.NationalCPRFoundation.com, which was an online course. E8's CPR online certificate was issued on July 12, 2023. There was no other current documentation of CPR training available for review that would document that E8 had attended an approved CPR training course that included a hands-on demonstration of the employee's ability to perform CPR. 2. The compliance officer contacted a representative from NationalCPRFoundation who stated, "Our courses are online only." 3. During an interview, E1 acknowledged E8 did not have current documentation of CPR training that included a hands-on demonstration of the ability to perform CPR.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of eight residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan dated September 2024 for personal care services. This service plan stated, "assistance with bathing twice a week...has fallen in the shower before so needs standby assist for safety". However, in review of the Activities of Daily Living (ADLs) sheet from the period of September - November 2024, there was no documentation of this service available for review. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of the above-listed service.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents. 3. During the environmental tour with E1, the Compliance Officer observed the following poisonous and toxic materials in an unlocked cart outside of the dinning room area: - one can of Raid Multi Insect Spray - one bottle of Red Relief Stain Remover 4. In an interview, E1 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for four of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a document titled "Resident Assistant Record" dated December 2023, January 2024, and February 2024. This document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." However, this document did not indicate care was provided for R1 as follows: -December 2023 - on the "NOCS" shift, "DAYS" shift, and "EVES" shift December 20th-31st. -January 2024 - on the "NOCS" shift January 14th-15th and 26th-28th, on the "DAYS" shift January 1st-2nd and 28th-29th, and on the "EVES" shift January 6th, 9th-13th, 25th-28th, and 30th-31st. -February 2024 - on the "NOCS" shift February 2nd, 6th, 16th-17th, and 23rd-24th, on the "DAYS" shift February 3rd-4th and 16th-17th, and on the "EVES" shift February 1st-3rd, 8th, 12th, 20th, and 22nd-present. 2. Review of R2's medical record revealed a document titled "Resident Assistant Record" dated December 2023, January 2024, and February 2024. This document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." However, this document did not indicate care was provided for R2 as follows: -December 2023 - on the "NOCS" shift December 3rd-4th, 8th-9th, and 22nd-26th, on the "DAYS" shift December 4th, 26th-27th, and 30th, and on the "EVES" shift December 9th and 25th-26th. -January 2024 - on the "NOCS" shift January 14th-15th and 26th-28th, on the "DAYS" shift January 13th and 28th-29th, and on the "EVES" shift January 6th, 9th-13th, 25th-28th, and 30th-31st. -February 2024 - on the "NOCS" shift February 2nd, 6th, 16th-17th, and 23rd-24th, on the "DAYS" shift February 3rd and 16th-17th, and on the "EVES" shift February 1st-3rd, 8th, 12th, 20th, and 22nd-present. 3. Review of R3's medical record revealed a document titled "Resident Assistant Record" dated December 2023, January 2024, and February 2024. This document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." However, this document did not indicate care was provided for R3 as follows: -December 2023 - on the "NOCS" shift December 3rd-4th and 22nd-26th, on the "DAYS" shift December 4th, 26th-27th, and 30th, and on the "EVES" shift December 11th and 25th-26th. -January 2024 - on the "NOCS" shift January 14th-15th and 26th-28th, on the "DAYS" shift January 28th-29th, and on the "EVES" shift January 6th, 9th-13th, 25th-28th, and 30th-31st. -February 2024 - on the "NOCS" shift February 2nd, 6th, 16th-17th, and 23rd-24th, on the "DAYS" shift February 3rd and 16th-17th, and on the "EVES" shift February 1st-3rd, 8th, 12th,

Based on observation and interview, the manager failed to ensure food was protected from potential contamination which posed a health and safety risk. Findings include: 1. During an environmental tour of the facility's kitchen, the Compliance Officer observed the walk-in refrigerator and the dry storage area. The walk-in refrigerator contained a pan of uncovered jello, a pan of uncovered mashed potatoes, and a large open bag of shredded cheese. The dry storage area contained an open box of pancake mix, an opened box a white chocolate chips, and an opened box of rice. The observation was not during mealtime. The uncovered and opened food items were not protected from the potential contamination. 2. In an interview, E2 acknowledged the uncovered foods posed a potential for contamination. E1 acknowledged food was not protected from potential contamination.

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 facility documentation revealed training material for fall prevention. 2. Review of E2's personnel record revealed E2 worked as the facility nurse and had a hire date of October 27, 2018. The personnel record did not include documentation showing E2 completed fall prevention and fall recovery training. 3. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of January 7, 2016. The personnel record did not include documentation showing E3 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of April 12, 2014. The personnel record did not include documentation showing E4 completed fall prevention and fall recovery training. 5. Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of April 26, 2023. The personnel record did not include documentation showing E5 completed fall prevention and fall recovery training. 6. Review of E8's personnel record revealed E8 worked as a caregiver and had a hire date of July 27, 2023. The personnel record did not include documentation showing E8 completed fall prevention and fall recovery training. 7. In an interview, E1 and E2 acknowledged documentation was not available showing E2, E3, E4, E5, and E8 had completed a training program for fall prevention and fall recovery. 8. This is a repeat deficiency from the compliance inspection conducted September 15, 2022.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for six of eight employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card..." 2. Review of E1's personnel record revealed E1 currently worked as the manager and had a hire date of August 12, 2015. The personnel record revealed a fingerprint clearance card, however, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution. 3. Review of E2's personnel record revealed E2 currently worked as the facility nurse and had a hire date of October 27, 2018. The personnel record revealed a fingerprint clearance card, however, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 4. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of January 7, 2016. The personnel record revealed a fingerprint clearance card, however, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 5. Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of April 26, 2023. The personnel record revealed a fingerprint clearance card issued October 23, 20218, however, the per

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of eight caregivers reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of E6's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E6 had signs or symptoms of TB. Based on E6's hire date, this documentation was required. 3. Review of E7's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E7 had signs or symptoms of TB. Based on E7's hire date, this documentation was required. 4. Review of E8's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E8 had signs or symptoms of TB. Based on E8's hire date, this documentation was required. 5. In an interview, E1 and E2 acknowledged E6, E7, and E8 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if E6, E7, and E8 had signs or symptoms of TB. 6. Technical assistance was provided on this Rule during the compliance inspection conducted September 15, 2022.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of one resident reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of R7's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R7 had signs or symptoms of TB. Based on R7's acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R7 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if R7 had signs or symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 15, 2022.

Based on record review and interview, the manager failed to ensure a documented residency agreement was available for one of eight residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. Review of R2's medical record revealed no residency agreement. Based on R2's acceptance date, this documentation was required. 2. In an interview, E1 and E2 acknowledged R2's medical record did not have a documented residency agreement.

Based on record review, documentation review, and interview, the manager failed to ensure the policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for two of seven residents reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R4's record revealed a residency agreement. This residency agreement stated "...C. The Manager may terminate this Agreement and issue a: *3-day (or such longer period of time as required by law) Move-Out/Eviction notice to you under the following circumstances: -You fail to pay the Monthly Charge or any other charges promptly when due; -You vacate your Suite without notifying the Community; or -You otherwise fail to comply with any terms or conditions of this Agreement. Based on R4's acceptance date, this documentation was required. 2. Review of R8's record revealed a residency agreement. This residency agreement stated "...C. The Manager may terminate this Agreement and issue a: *3-day (or such longer period of time as required by law) Move-Out/Eviction notice to you under the following circumstances: -You fail to pay the Monthly Charge or any other charges promptly when due; -You vacate your Suite without notifying the Community; or -You otherwise fail to comply with any terms or conditions of this Agreement. Based on R8's acceptance date, this documentation was required. 3. Review of the facility's policy and procedure titled "Terminating Residency Agreement Policy." This policy stated: "...The Community can terminate the residency agreement by: A. Without notice, if the resident exhibits a behavior that is an immediate threat to the health and safety of the resident or other individuals in the community; B. With a fourteen (14) days written notice of termination of residency: a. For nonpayment of fees, charges or deposits; b. The resident's condition has changed requiring continuous medical services; c. The resident's condition requires continuous nursing services without complying with A.R.S.36-401 C; or d. The resident's condition requires behavioral health services. e. The resident requires services not within the assisted living's scope of services; f. The assisted living does not have the ability to provide the services needed by the resident; or g. The resident requires restraints, including the use of bedrails. C. With a thirty (30) day written notice, a resident may be given a discharge notice for any reason." 4. Rule review of R9-10-807(G) on or after October 1, 2019 stated: "A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency:

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every six months, for one of five residents receiving personal care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated July 3, 2022. However, a service plan after July 3, 2022 was not available for review. 2. In an interview, E1 and E2 acknowledged R1 received personal care services and the service plan was not updated at least once every six months.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of eight residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. Review of R7's medical record revealed no documentation of a written service plan. Based on R7's date of acceptance, a service plan was required. 2. In an interview, E1 and E2 acknowledged R7's record did not include a written service plan.

Based on documentation review, record review, and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, the nurse or medical practitioner, and the behavioral health professional, for seven of seven residents reviewed. The deficient practice posed a health and safety risk if the required individuals did not acknowledge the services that were to be provided. Findings include: 1. R9-10-808.A(3)(d) states "For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner." 2. R9-10-808.A(3)(e)(ii) states "For a resident who requires behavioral care review by a medical practitioner or behavioral health professional." 3. Review of R1's medical record revealed a current written service plan for personal care services dated July 3, 2022. This service plan indicated R1 received medication administration. However, this service plan did not include a signature and date by the resident or resident's representative, the manager, or the nurse or medical practitioner. 4. Review of R2's medical record revealed a current written service plan for supervisory care services that was not dated. This service plan indicated R2 self administered medications. However, this service plan did not include a signature and date by the resident or resident's representative or the manager. 5. Review of R3's medical record revealed a current written service plan for personal care services that was not dated. This service plan indicated R3 received medication administration. However, this service plan did not include a signature and date by the resident or resident's representative, the manager, or the nurse or medical practitioner. 6. Review of R4's medical record revealed a current written service plan that did not include a level of care service and was not dated. This service plan indicated R4 received medication administration. However, this service plan did not include a signature and date by the resident or resident's representative, the manager, or the nurse or medical practitioner. 7. Review of R5's medical record revealed a current written service plan for personal care services that was not dated. This service plan indicated R5 received medication administration. However, this service plan did not include a signature and date by the resident or resident's representative, the manager, or the nurse or medical practitioner. 8. Review of R6's medical record revealed a current written service plan for personal care services dated April 28, 2023. This service plan indicated R6 received medication administration and behavioral care. However, this service plan did not include a signature and date by the resident or resident's representative, the manager, the nurse or medical practitioner, or behavioral health professional. 9. Review of R8's medical record revealed a current written service plan for personal care serv

Based on documentation review, record review, and interview, the manager failed to ensure the facility obtained a written determination from a behavioral health professional or medical practitioner, upon acceptance and every six months thereafter, stating the resident's needs were 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 receiving behavioral care. The deficient practice posed a health and safety risk to the resident if the facility retained a resident who received behavioral care and the resident's needs were not met. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. Review of R6's medical record revealed a current written service plan for personal care services dated April 28, 2023. This service plan revealed R6 had a diagnosis of Schizophrenia. In addition, R6's medical record revealed R6 had a behavioral health professional, had psychosocial behaviors requiring assistance, and received administration of psychotropic medications. 3. Review of R6's medical record revealed no documentation indicating R6's behavioral health professional or medical practitioner examined R6 at least once every six months, signed and dated a determination stating R6's needs were being met by the facility, and reviewed the facility's scope of services. 4. In an interview, E2 reported R6 required redirection for behaviors and acknowledged R6's behavioral health professional or medical practitioner did not provide a written determination at least once every six months.

Based on record review, interview, and documentation review, the manager failed to ensure a facility authorized to provide personal care services did not accept or retain a resident who was unable to direct self-care. The deficient practice posed a health and safety risk if the facility was unable to meet the resident's needs. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide personal care services. 2. Review of R4's medical record revealed a service plan that was not dated and did not include a level of care service. This service plan stated "...Cognition - Frequent help due to disorientation, memory loss, and difficulty completing tasks. Provide interventions to manage and reduce sundowning. Provide extensive intervention and care coordination to support dementia-related conditions. Disoriented to person/time/place...has trouble making needs known at times, confused frequently, difficulty completing thoughts at times..." and "...Wandering and Elopement - Occasional redirection if wandering or approaching exits. Provide ongoing redirection for exit seeking behavior. Wanders throughout the building. Wanders in residents' room..." 3. In an interview, R4 stated "I don't know where I am or what I am doing." R4 was unable to answer questions related to daily activities or environmental safety, and only answered "I don't know." During the interview, R4's telephone rang and R4 did not know how to answer the telephone. 4. A.R.S. \'a7 36-401.38 defines "Directed care services" as programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 5. In an interview, E1 and E2 agreed R4 met the definition of directed care and was not appropriately placed at the facility.

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, upon acceptance or upon the onset of the condition and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for two of two residents reviewed who were 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. Review of R3's medical record revealed a written determination from R3's medical practitioner signed and dated July 20, 2022. However, documentation was not available stating R3's needs could be met by the facility and R3's needs were within the facility's scope of services, at least once every six months. 2. Review of R5's medical record revealed a written determination from R5's medical practitioner signed and dated July 20, 2022. However, documentation was not available stating R5's needs could be met by the facility and R5's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E1 reported R3 and R5 were unable to ambulate even with assistance for at least two years and E1 and E2 acknowledged R3's and R5's medical practitioner did not provide a written determination at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of six residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 3, 2022. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated July 23, 2023. This medication order stated "Atenolol 25mg tab sig: 1 PO Q day hold for SBP [systolic blood pressure] <120 or HR [heart rate] <55". 3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Atenolol 25mg Tablet take 1 tablet by mouth once daily (hold for SBP <120, HR <55)" and indicated the following: -R1's SBP was recorded as 113 at 8am on September 12th, however, indicated one tab was administered. -R1's SBP was recorded as 109 at 8am on September 13th, however, indicated one tab was administered. 4. During an observation of R1's medications, Atenolol 25mg was observed. 5. In an interview, E1 and E2 acknowledged R1's medication was not administered in compliance with the available medication order.

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. Review of the facility's policies and procedures revealed a policy titled "Disaster Policies and Procedures". 2. Review of the facility documentation revealed no documentation showing this plan was reviewed every 12 months. 3. In an interview, E1 and E2 acknowledged documentation was not available showing the facility's disaster plan was reviewed at least once every 12 months. 4. Technical assistance was provided on this Rule during the compliance inspections conducted September 17, 2021 and September 15, 2022.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of facility documentation revealed fire drills conducted every month, however documentation was not available showing disaster drills were conducted on each shift at least once every three months. 2. In an interview, E1 and E2 acknowledged employee disaster drills were not conducted on each shift at least once every three months. 3. Technical assistance was provided on this Rule during the compliance inspections conducted September 17, 2021 and September 15, 2022.

Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department according to the time-frame established by the local fire department. Findings include: 1. Review of the facility's fire inspection reports revealed the most current inspection from the City of Surprise was conducted March 5, 2019. 2. In an interview, E1 and E2 acknowledged the most current fire inspection was conducted March 5, 2019. 3. Review of Department documents revealed the City of Surprise required annual fire inspections. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 15, 2022.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documentation revealed no policy and procedure that covered TB infection control activities. 2. Review of E1's, E2's, E3's, E4's, E5's, E6's, E7's, and E8's personnel records revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 4. In an interview, E1 and E2 acknowledged the employees had not completed training and education related to recognizing the signs and symptoms of TB and an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 5. Technical assistance was provided on this Rule during the compliance inspection conducted September 15, 2022.

Based on documentation review, record review, observation, and interview, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for two of two residents reviewed who received an opioid. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Opioid Use in the Assisted Living" that stated "...c. The pain scale either using the numeric pain distress scale or the Wong-Baker faces pain rating scale with be used at each PRN administration. d. Documentation should describe pain at request for PRN and again at follow up, at around an hour, of how medication worked..." 2. Review of R1's medical record revealed a signed medication order dated September 12, 2023. This medication order stated "Oxycodone-Acetaminophen 7.5-325mg tablet 1 tablet orally at 8am, 12pm, 4pm, 8pm". 3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Oxycodone-APAP 7.5-325mg Tab Take 1 tablet by mouth four times daily" and indicated one tab was administered at 8am, 12pm, 4pm, and 8pm September 12th - present. However, documentation was not available showing the identification of R1's need for the opioid and the effect of the opioid administered. 4. During an observation of R1's medications, Oxycodone-Acetaminophen 7.5-325mg was observed. 5. Review of R1's medical record revealed no documentation stating R1 had an end of life condition or an active malignancy. 6. Review of R5's medical record revealed a signed medication order dated June 21, 2023. This medication order stated "Tramadol HCL 50mg tablet 1.5 tablet oral every 6 hours". 7. Review of R5's medical record revealed a September 2023 MAR. This MAR stated "Tramadol HCL 50mg tabs give 1 1/2 tablets (75mg) by mouth every 6 hours" and indicated one and a half tabs were administered at 8am, 2pm, and 8pm September 7th - present (the 2am dose was refused daily). However, documentation was not available showing the identification of R5's need for the opioid and the effect of the opioid administered. 8. During an observation of R5's medications, Tramadol HCL 50mg one and a half tablets were observed. 9. Review of R5's medical record revealed no documentation stating R5 had an end of life condition or an active malignancy. 10. In an interview, E1 and E2 acknowledged the caregiver did not document in R1's and R5's medical records the identification of the need for the opioid and the effect of the opioid administered and that the information was required for routine and as needed opioid medication administration. 11. Technical assistance was provided on this Rule during the compliance inspections conducted September 17, 2021 and September 15, 2022.