St Michaels Manor

Based on record review and interview, the manager failed to ensure documentation of medication administered to the resident included the correct dosage administered, for one of two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. Record review of R1's medical administration record (MAR) revealed a medication order dated February 5, 2025 for Montelukost Sod. The order instructions were, "take 1 10 MG TAB PO QD" . The MAR instructions were "take 1 15 MG TAB PO QD". 2. The Compliance Officers observed a pill bottle of Montelukost Sod 10 MG tablet stored for administration at the facility. 3. In an exit interview, the findings were discussed with E2 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure an assisted living facility authorized to provide directed care services provided access to an outside area that 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. Documentation review revealed that the facility was licensed at the directed care level. 2. During an environmental inspection, the Compliance Officers observed non-operational door alerts on the front door and back door of the facility. The front door was equipped with a keyed lock, however, the key was stored in the door. 3. During an interview with E2, E2 reported the facility turned on the alerts at night. 4. In an exit interview, the findings were discussed with E2 and no additional information was provided.

Based on record review and observation, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a signed medication order dated February 5, 2025, for "Montelukast SOD, 10 MG 1 TAB PO QD". 2. A review of R1's medical record revealed a medication administration record (MAR) that stated "Montelukast SOD, 15 MG 1 TAB PO QD" was documented as administered at 5:00 p.m. on September 3, 2025 (the day of the inspection). However, the documentation was provided to the Compliance Officers at approximately 2:00 p.m. 3. In an interview, E2 reported the medication had not been given yet; however, acknowledged the MAR was signed. 4. In an exit interview, findings were discussed with E2 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's in-service education, for three of three personnel records sampled. The deficient practice posed a safety risk to residents if the Department was unable to verify personnel completed in-service education in compliance with the facility's policies and procedures, and the documentation was not provided within two hours after a Department request. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed a policy and procedure titled "Ongoing Training" (dated in August 2022). The policy and procedure stated, "All care staff will complete ongoing training every 12 months based on level of care provided by the facility... 12 hours of annual ongoing training requirements are mandatory for all caregivers each year." 2. A review of E1's personnel record revealed twelve hours of ongoing training every 12 months was not available for review. 3. A review of E2's personnel record revealed twelve hours of ongoing training every 12 months was not available for review. 4. A review of E3's personnel record revealed twelve hours of ongoing training every 12 months was not available for review. 4. In an interview, E1 acknowledged in-service education required by policies and procedures was not within E1's, E2's, and E3's personnel records.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility, and if the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of three residents sampled. The deficient practice posed a risk if R2 or R3 required a higher level of care as an assisted living facility cannot provide continuous medical services, or continuous and intermittent nursing services. Findings include: 1. A review of R2's medical record revealed a document titled, "Request for Continued Residency," signed and dated by a nurse practitioner on May 20, 2022. The document did not include whether R2 needed continuous medical services, continuous or intermittent nursing services, or restraints. 2. A review of R3's medical record revealed a document titled, "Request for Continued Residency," signed and dated by a nurse practitioner on May 20, 2022. The document did not include whether R3 needed continuous medical services, continuous or intermittent nursing services, or restraints. 3. In an interview, E1 reported the nurse practitioner had forgotten to fill out the form completely. However, E1 acknowledged R2's and R3's medical records were missing documentation signed and dated by a nurse practitioner which included whether R2 or R3 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on documentation review, record review, and interview, the manager failed to ensure the facility's residency agreements contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for three of three residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: R9-10-807(C): A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails. 1. A review of the facility's policy and procedures (dated August 2022) revealed a policy titled "Termination of Residency." The policy stated, "2. With a 14-day written notice of termination of residency for resident's non-payment of fees, charges, or deposit or with any of the following reasons: a. The individual requires continuous medical services b. The assisted living services needed by the individual are not within the facility's scope of services c. The facility does not have the ability to provide the assisted living services needed by the individual d. The individual requires restraints, including the use of bedrails..." 2. A review of R1's, R2's, and R3's medical records revealed residency agreements. The residency agreements stated, "2. With a 14-calendar days [sic] written notice of termination of residency: a. For non-payment of fees, charges, or deposits. b. The individual requires continuous medical service, nursing services (unless the facility complies with A.R.S. \'a7 36-401(C), or Behavioral health services. c. The assisted living services needed by the individual are not within the assisted living facility's scope of services. d. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or e. The individual requires restraints, including the use of bedrails." 3. In an interview, E1 acknowledged R1's, R2's, and R3's residency agreements did not include the correct provisions for an assisted living facility to terminate residency with a fourteen-day written notice which was required to include the primary condition for which the individual needs assisted living services is a behavioral health issue and a home health agency or hospice service agency is not involved in the care of the individual.

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. 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 service plan (dated in May 2023) for personal care services. The service plan stated "Ambulation Assistance... nonambulatory... wheelchair/chair bound..." 2. A review of R1's medical record revealed a document titled "Request for Continued Residency." The form was signed by a medical practitioner in May 2022 and in November 2022. However, documentation of an examination at least once every six months signed and dated by the resident's primary care provider or other medical practitioner was not available for review. 3. In an interview, E1 acknowledged the examination required from the resident's primary care provider or other medical practitioner every six months during R1's residency was not available for review.