Stetson Hills Assisted Living LLC

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could be found, was conspicuously posted. Findings include: 1. During the environmental tour, the Compliance Officers observed no posting indicating where the most recent inspection report could be located. 2. In an interview, E1 and E2 acknowledged documentation of the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was not posted.

Based on documentation review and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no employee was present to meet the residents' needs. Findings include: 1. A review of E3's, E4's, E5's and E6's personnel records revealed they were hired as assistant caregivers. 2. A review of facility documentation revealed the work schedules for the month of December 2024 and January 2025. E1 and E2 worked as a backup (On Call), and E3, E4, E5 and E6 worked day/night (D/N) shift caregivers according to the work schedule. 3. A review of E3's, E4's, E5's and E6'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, E4's, E5's and E6'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, E4, E5 and E6 were not qualified to be left alone with the residents based on the lack of caregiver training. 4. In separate interviews, E3, E4, E5 and E6 reported they were assistant caregivers, however, did not want to comment on who was at the facility other than themselves during the overnight hours. 5. In an Interview, E1 and E2 reported that E3, E4, E5 and E6 were live-in assistant caregivers and they were the only personnel at the facility working overnight since December 16, 2024. However, E1 reported E1 lived close by to come over if there were any issues. E1 and E2 acknowledged not having licensed caregivers present on the assisted living facility's premises when the manager was not present during the overnight hours.

Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for eight of eight residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading documentation. Findings include: 1. A review of facility documentation revealed the work schedule for the month January 2025. The work schedule showed E1 worked as a backup (On Call) caregiver. However, this schedule did not show E1 worked during the overnight hours. 2. A review of R1's, R2's, R3's, R4's, R5's, R6's, R7's and R8's medical record revealed activities of daily living (ADL) sheets for January 2025. The ADL sheets stated the following services were provided overnight; - Night Checks 10:00 PM/ Midnight/ 2:00AM/5:00AM - Toileting CG Assist 8:00 PM/ Midnight/ 4:00AM The Compliance Officers observed all services documented as provided to R1, R2, R3, R4, R5, R6, R7 and R8 in January 2025 were documented using the same initials, indicating the same personnel member provided the service. 3. In an interview, E1 reported E1 did supervise the services provided to the residents during the day, however, during the night the assistant caregivers provided the services to the residents and E1 signed the ADL sheets. 4. In an interview, E1 and E2 acknowledged R1, R2, R3, R4, R5, R6, R7 and R8 services documented on the ADL sheets during the overnight hours were not provided by E1 and the Department was provided false or misleading documentation.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering medication, for eight of eight residents sampled. The deficient practice posed a risk as the required information could not be verified and the Department was provided false or misleading information. Findings include: 1. A review of R1's, R2's, R3's, R4's, R5's, R6's, R7's and R8's service plans revealed they received medication administration. 2. A review of R1's, R2's, R3's, R4's, R5's, R6's, R7's and R8's medical records revealed medication administration records (MAR) for the month of January 2025. The Compliance Officers observed all medications documented as administered to R1, R2, R3, R4, R5, R6, R7 and R8 in January 2025 were documented using the same initials, indicating the same personnel member administered all medication. 3. In an interview, E1 reported E1 did provide medication administration during the day, however, during the night E1 set the medication in a med cup and one of the assistant caregivers provided the medications to the residents and E1 signed the MARs. 4. In an interview, E1 and E2 acknowledged R1's, R2's, R3's, R4's, R5's, R6's, R7's and R8's MARs did not contain documentation of medication administered that included the name and signature of the individual who actually administered the medication during the night and the Department was provided false or misleading information.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the environmental tour, the Compliance Officers observed three small oxygen containers in bedroom six, the oxygen containers were upright but not secured. 2 .During the environmental tour, the Compliance Officers observed two large oxygen containers in bedroom seven in the closet, the oxygen containers were upright but not secured. 3. In an interview, E1 and E2 acknowledged that the oxygen containers were not secured.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees reviewed, which required an employee to have a valid fingerprint card or submitted an application for a fingerprint card no more than 20 working days after the date of hire. 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..." 2. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of September 28, 2023. The personnel record revealed no documentation of a fingerprint clearance card. However, an application for a fingerprint card was available dated September 28, 2023. 3. In an telephone interview, O1, a Department of Public Safety (DPS) representative, reported a fingerprint clearance card application was not received for E3. O1 additionally reported DPS was working on applications received November 15, 2023. 4. Review of the November 2023 personnel schedule revealed E3 worked a 24 shift November 1st - 3rd, 6th - 10th, and 13th - 17th. 5. In an interview, E1 and E2 acknowledged documentation was not available that showed E3 had a valid fingerprint clearance card or applied for a fingerprint clearance card within 20 working days of employment.