Suncreek Surprise LLC

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “ANNUAL STAFF TRAINING/CONTINUING EDUCATION.” The P&P stated, “All employees will have an initial fall prevention training during their orientation and will have a continuous training on a yearly basis by a school approved and regulated by [the] NCIA board.” 2. A review of E2's personnel record revealed E2 was hired as a caregiver more than one year before the date of the inspection. The review revealed an “EMPLOYEE ORIENTATION FORM.” However, the form revealed E2 did not receive training regarding fall prevention and fall recovery during orientation as stated in the P&P. The review further revealed E2 did not receive training regarding fall prevention and fall recovery until July 7, 2025. 3. In an interview, E1 reported E1 believed E2 received the training upon hire in 2024. E1 reported E1 would look for the training certificate. 4. A review of E2’s personnel record revealed the training certificate provided by E1. However, the certificate revealed E2 received training regarding fall prevention and fall recovery on June 8, 2023, before hire and not during orientation or annually thereafter as stated in the P&P.

Based on documentation review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9), for eight of eight total residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A review of facility documentation revealed standardized forms for R1, R2, R3, R4, R5, R6, R7, and R8. However, the forms were left blank and did not contain any of the items required by this statute. 2. In an interview, E1 reported the forms were left blank until facility personnel needed to contact an emergency responder on behalf of a resident, at which time facility personnel would fill out the forms.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees, and annually assessing the health care institution’s risk of exposure to infectious tuberculosis. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.” The webpage stated: “The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting…Initial TB training should be provided before the HCW starts working.” 2. A review of E1’s personnel record revealed E1 was hired as the manager. The review revealed E1 received training and education related to recognizing the signs and symptoms of TB on June 2, 2023, and June 21, 2025, more than two years apart. 3. A review of E2’s personnel record revealed E2 was hired as a caregiver in 2024. However, the review revealed E2 did not receive training and education related to recognizing the signs and symptoms of TB until July 8, 2025, after E2 began providing services at the facility. 4. A review of facility documentation revealed a personnel schedule which indicated E1 was on call or worked on a regular basis in August-October and December 2024 and January and March-September 2025, and E2 worked on a regular basis between August 2024 and July 2025. 5. In the exit interview, the Compliance Officer reviewed the findings regarding the training with E1 and E1 offered no comment. When the Compliance Officer asked if facility personnel had assessed the health care institution’s risk of exposure to infectious TB, E1 stated, “No.” Technical assistance was provided on this rule during the compliance inspection conducted on June 30, 2023.

Based on documentation review, observation, interview, and record review, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as residents were alone with an individual who was not a certified caregiver. Findings include: 1. Arizona Revised Statutes § 36-401(A)(49) states, "'Supervision' means directly overseeing and inspecting the act of accomplishing a function or activity." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “JOB DESCRIPTION FOR ASSISTANT CAREGIVER/VOLUNTEER.” The P&P stated, “The assistant caregiver or volunteer performs duties and can only interact with the residents under the supervision of a manager or caregiver.” 3. Upon entering the facility at approximately 9:30 AM, the Compliance Officer observed E2 and E3 were the only personnel present. 4. In an interview, E2 reported E2 was a caregiver and E3 was an assistant caregiver. 5. A review of E3’s personnel records revealed E3 was hired as an assistant caregiver. The review further revealed no documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). 6 A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate under E3's name. 7. The Compliance Officer observed E2 in the kitchen but did not observe E3. 8. In an interview, E2 reported E3 was assisting a resident. 9. The Compliance Officer observed E3 interacting with R6 and another resident in R6’s bedroom without being under the supervision of a manager or caregiver. 10. At approximately 10:30 AM, the Compliance Officer observed E1 arrive at the facility. 11. In an interview shortly after E1 arrived, the Compliance Officer informed E1 that E3 could only interact with residents under the supervision of a manager or caregiver. E1 reported assistant caregivers were not to interact with residents without being with the manager or a caregiver. 12. After the interview, the Compliance Officer observed E3 interacting with R4 in a hallway, E3 interacting with R5 in the living room, and E3 interacting with R1, all three times without being under the supervision of a manager or caregiver. 13. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no further comment.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver’s skills and knowledge were verified and documented before the assistant caregiver provided physical health services, for one of one sampled assistant caregiver. The deficient practice posed a risk if an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “PERSONNEL RECORD.” The P&P stated: “1. A personnel record for each employee or volunteer shall be maintained at the facility… 3. The record shall include: c. Documentation of the individual’s qualifications, including skills and knowledge applicable to the person’s job duties.” The review further revealed a personnel schedule which indicated E3 worked on September 10-18, 2025. 2. A review of E3's personnel record revealed E3 was hired as an assistant caregiver. The review revealed a “CAREGIVER SKILLS” form signed and dated as complete by E1 and E3 on August 1, 2025. 3. In an interview, E1 reported E1 was still in the process of hiring E3 and verifying E3’s skills and knowledge. E1 and E4 reported E1 had not officially been hired as of the date of the inspection. When the Compliance Officer asked if E3 had completed all items on the skills and knowledge verification form, E1 stated, “I didn’t just show [E3] that one yet]” referring to the skill of “Assisting with Tub Bath and Shower.” However, E1 acknowledged all items on the form had been signed off by E1 as completed on August 1, 2025. When the Compliance Officer asked if E1 had completed verifying E3’s skills and knowledge, E1 stated, ”No.”

Based on documentation review, observation, interview, and record review, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING POLICY.” The P&P stated: “Employees are required to accurately record all time worked, including the time they begin and end each shift. Staff should also record the beginning and ending time of any split shift or departure from work for personal reasons. Employees are responsible for completing their own name records on a daily basis. Altering, falsifying, tampering with time records, and/or recording time on another employee's time record will result in disciplinary action, up to and including termination.” 2. When the Compliance Officer arrived at the facility at approximately 9:30 AM, the Compliance Officer observed E2 and E3 working at the facility and no other personnel present. At approximately 10:30 AM, the Compliance Officer observed E1 arrive at the facility. 3. A review of facility documentation revealed a series of personnel schedules dated between August 2025 and September 2025. The schedules revealed the following: - E1 and E2 worked from 7:00 AM to 7:00 PM on August 5, 2025; - E1 worked from 7:00 AM on September 6, 2025, through 7:00 PM on September 8, 2025; - E1 worked from 7:00 AM on September 13, 2025, through 7:00 PM on September 15, 2025; - E1 was scheduled to work from 7:00 Am to 7:00 PM on the date of the inspection; and - E3 was not scheduled to work in September. 4. In an interview, E1 reported the schedule was not accurate. E1 reported E3 recently began working at the facility and had not been added to the schedule yet. 5. A review of E1’s personnel record revealed a first aid and cardiopulmonary resuscitation training certificate dated as issued on August 5, 2025, when E1 was scheduled to work from 7:00 AM to 7:00 PM. 6. In an interview, E1 reported E1 took the class during the day. E1 reported E1 left the facility for approximately four hours during E1’s scheduled work hours to attend the training. E1 reported E1 did not update the schedule to show E1 was not at the facility during the training. 7. A review of R1's, R2’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) dated September 2025. The MARs revealed documentation demonstrating E1 administered medications to R2 at 7:00 PM on September 13-14, 2025, and to R1, R4, R5, R6, R7, and R8 at 7:00 PM on September 6-7 and 13-14, 2025, even though E1 was not at the facility on those dates at that time. 8. In an interview, E1 reported E1 worked the night shift from 6:30 PM to 7:00 AM on Fridays, Saturdays, and Sundays at another

Based on documentation review, record review, interview, and observation, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(iii) states: "A. 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…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: iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC).” 3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 4. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (TB) TESTING.” The P&P stated: “1. For each individual required to be screened for infectious tuberculosis, the manager or manager's designee shall obtain from the individual: a. On or before the date the individual begins providing services at the facility (employee)...one of the following as evidence of freedom from infectious tuberculosis: i. Documentation of a negative Mantoux skin test administered within six months before the date the employee begins providing services…that includes the date and type of the TB screening test.” 5. A review of E2’s personnel record revealed E2 was hired as a caregiver. The review revealed a negative TST dated as read more than one year before E2’s date of hire. The review revealed a second negative TST, d

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the assistant caregiver before providing assisted living services to a resident, for one of one sampled assistant caregiver. The deficient practice posed a risk if an assistant caregiver was unable to meet a resident's needs and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “ORIENTATION, IN-SERVICE TRAININGS FOR EMPLOYEES.” The P&P stated: “3. Review each item listed on the orientation form…Prior to providing services, orientation will be performed. 4. After reviewing all items with the employee, both the individual providing the training and the new employee should sign the bottom of the form. 5. No individual should work unsupervised or alone in the facility until thoroughly familiar with all items listed on the New Employee Orientation form.” The review further revealed a personnel schedule which indicated E3 worked on September 10-18, 2025. 2. A review of E3's personnel record revealed E3 was hired as an assistant caregiver. The review revealed an “EMPLOYEE ORIENTATION FORM” signed and dated as complete by E1 and E3 on August 1, 2025. 3. In an interview, E1 reported E1 was still in the process of hiring E3 and completing E3’s orientation. E1 and E4 reported E1 had not officially been hired as of the date of the inspection. When the Compliance Officer asked if E3 had completed all items on the orientation form, E1 stated, “Not all of them.” However, E1 acknowledged all items on the form had been signed off by E1 as completed on August 1, 2025. When the Compliance Officer informed E1 the form could not be fully signed off on until after orientation was complete, E1 stated, “I know.”

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis.” 2. A review of R1's medical record revealed R1 was admitted to the facility more than seven days before the date of the inspection. However, the review revealed no documentation assessing risks of prior exposure to infectious tuberculosis and determining if R1 had signs or symptoms of TB. 3. In the exit interview, the Compliance Officer reviewed the findings with E1 and E1 offered no comment. Technical assistance was provided on this rule during the compliance inspection conducted on June 30, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLAN.” The P&P stated: “A. The manager or manager’s designee shall ensure that a resident has a written service plan that: 3. Includes the following: c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication.” 2. A review of R1's medical record revealed a service plan dated June 20, 2025. The service plan indicated R1 was to receive medication administration. However, the service plan did not include the frequency of medication administration. The service plan indicated R1 did not require assistance with incontinence care/toileting and showering and did not indicate whether R1 required assistance with dressing, grooming, oral care, skin care, and night time monitoring. The review further revealed documentation of assisted living service provided to R1 (ADLs) dated September 2025. The ADLs indicated R1 received assistance with dressing, grooming, oral care, showering, skin care, incontinence care/toileting, and night time monitoring, in opposition to R1’s service plan. 3. A review of R2's medical record revealed a service plan dated August 1, 2025. The service plan indicated R2 was to receive medication administration and one person assists with mobility. However, the service plan did not include the frequency of medication administration or assistance with mobility. The service plan indicated R2 was to receive assistance with showers both daily and only once per week, and did not indicate whether R2 required assistance with dressing, grooming, and night time monitoring. The review further revealed ADLs dated September 2025. The ADLs indicated R2 did not receive assistance with showers and did receive assistance with dressing, grooming, and night time monitoring, in opposition to R2’s service plan. 4. In an interview, E1 reported hospice had been providing R2’s showers since R2 returned from the hospital on September 10, 2025. When the Compliance Officer asked if R2’s service plan included dressing and grooming, E1 stated, “No.” E1 acknowledged R1’s and R2’s service plans did not include the correct amount, type, and frequency of assisted living services being provided to R1 and R2. This is a repeat citation from the compliance inspection conducted on June 30, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLAN.” The P&P stated: “C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident’s service plan.” 2. A review of R2's medical record revealed a service plan dated August 1, 2025. The service plan indicated R2 was to receive assistance with showers. The review further revealed documentation of assisted living services provided to R2 (ADLs) dated September 2025. The ADLs indicated R2 did not receive assistance with showers after September 1, 2025. 3. In an interview, E1 reported R2 went to the hospital in early September 2025 and hospice had been providing R2’s showers since R2 returned from the hospital on September 10, 2025. E1 confirmed hospice provided R2’s showers and facility personnel did not.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. 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 information. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SERVICE PLAN.” The P&P stated: “C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident’s medical record.” 2. A review of R1's medical record revealed a service plan dated June 20, 2025. The service plan indicated facility personnel were to offer R1 sufficient fluids to maintain hydration. The review further revealed documentation of assisted living service provided to R1 (ADLs) dated September 2025. However, the ADLs did not include documentation demonstrating facility personnel offered R1 sufficient fluids to maintain hydration. 3. In an interview regarding the ADLs not including offering sufficient fluids to maintain hydration, E1 stated, “I don’t have that on there.” 4. A review of R2's medical record revealed a service plan dated August 1, 2025. The service plan indicated facility personnel were to offer R2 sufficient fluids to maintain hydration. The review further revealed ADLs dated September 2025. However, the ADLs did not include documentation demonstrating facility personnel offered R2 sufficient fluids to maintain hydration. 5. In an interview, E1 reported R2 went to the hospital in early September 2025 and hospice had been providing R2’s showers since R2 returned from the hospital on September 10, 2025. E1 reported facility personnel had been providing daily bed baths since hospice was providing the showers. When the Compliance Officer asked whether R2’s bed baths had been documented on the ADLs, E1 stated, “It’s not here” while looking at the ADLs. E1 stated R2 returned to the facility “On the tenth in the evening time.” E4 reported E4 had camera footage of R2 returning. 6. A review of the camera footage provided by E4 revealed R2 returned to the facility on September 10, 2025, at approximately 6:10 PM. 7. A review of R2’s medical record revealed ADLs dated September 2025. However, the ADLs indicated R2 received breakfast, lunch, assistance toileting at 6:00 AM, and night time monitoring at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM even though R2 was not at the facility at those times. Technical assistance was provided on this rule during the compliance inspection conducted on June 30, 2023.

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 date and time of administration or assistance, for seven of eight total residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's, R2’s, R4’s, R5’s, R6’s, R7’s, and R8’s medical records revealed medication administration records (MARs) dated September 2025. The MARs revealed documentation demonstrating E1 administered medications to R2 at 7:00 PM on September 13-14, 2025, and to R1, R4, R5, R6, R7, and R8 at 7:00 PM on September 6-7 and 13-14, 2025. 2. In an interview, E1 reported E1 worked the night shift from 6:30 PM to 7:00 AM on Fridays, Saturdays, and Sundays at another business. E1 reported E1 usually left the facility at approximately 6:00 PM on Saturdays and Sundays to get to work at the other business on time. E1 stated E1 typically administered the 7:00 PM medications at 5:00 PM “before I leave.” When the Compliance Officer asked if E1 documented the administration on another form that included the accurate time of administration, E1 stated, “This is the only place.” E1 acknowledged the MARs did not include the accurate time of administration.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of two sampled residents receiving personal care services. Findings include: 1. A review of R1's medical record revealed a service plan dated June 20, 2025. The service plan revealed R1 was to receive personal care services. However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The review further revealed documentation of assisted living service provided to R1 (ADLs) dated September 2025. The ADLs indicated R1 received assistance with skin care on a daily basis. 2. In an interview, E1 acknowledged R1’s service plan did not include skin maintenance.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. After arriving at the facility at approximately 9:30 AM and entering the facility, the Compliance Officer observed E2 lock the door. 3. At approximately 2:20 PM, the Compliance Officer observed an unidentified visitor leave through the front door with no personnel in sight. The Compliance Officer did not hear an alert and did not observe any sort of monitoring system. Less than five minutes later, the Compliance Officer heard the doorbell ring and observed E3 open the door for E4. However, after E4 entered, the Compliance Officer observed E3 and E4 did not lock the door. The Compliance Officer approached the door and observed the door was unlocked but had an alert installed. However, upon opening the door, the Compliance Officer heard no alert and did not observe any sort of monitoring system. The Compliance Officer further observed the key to the front door sitting in an open container on the medication cart in the open office area, accessible to residents and visitors. 4. In an interview, when the Compliance Officer informed E1 the unidentified visitor had left the facility without anyone knowing, E1 confirmed E1 did not know the individual had left.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “SAFE STORAGE OF MEDICATION.” The P&P stated, “All medications centrally stored by the facility must be maintained in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.” 2. At approximately 9:50 AM, the Compliance Officer observed a medication cart in an open office area. The Compliance Officer observed the cart was unlocked and had a lanyard hanging from the lock with the key in the lock. The Compliance Officer observed no personnel within sight of the cart. Inside the cart, the Compliance Officer observed a variety of resident medications. After opening the cart, the Compliance Officer observed E2 approach the open office area, see the Compliance Officer looking in the cart, and make no comment. Using one of the keys on the lanyard, the Compliance Officer unlocked a section of the cart used to store controlled medications. Upon opening said section, the Compliance Officer observed several controlled medications. 3. In an interview conducted at approximately 11:00 AM, the Compliance Officer informed E1 the medication cart was unlocked. 4. After inspecting other rooms and returning to the open office area, the Compliance Officer observed the medication cart was locked. However, at approximately 11:40 AM, the Compliance Officer observed E3 unlock the medication cart, leave the key in the lock, and walk out of sight of the cart. 5. At approximately 2:10 PM, upon returning from lunch and reentering the facility, the Compliance Officer observed the medication cart was unlocked and unattended for a third time. 6. In an interview, the Compliance Officer informed E1 the medication cart was unlocked again. 7. At approximately 5:50 PM, the Compliance Officer observed the medication cart was unlocked and unattended for a fourth time. 8. At approximately 6:10 PM, the Compliance Officer observed E2 unlock the medication cart in E1’s presence before both E1 and E2 walked away from the cart to unlock the front door. The Compliance Officer observed E2 return to the cart, open a drawer, remove an item, close the drawer, and walk away with the key without locking the cart. 9. During the exit interview, the Compliance Officer informed E1 the medication cart was unlocked again. E1 reported facility staff should not be leaving the medication cart unlocked.

Based on interview, documentation review, and record review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the date and time of the accident, emergency, or injury. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. In an interview, E1 reported R2 had an accident, emergency, or injury that resulted in R2 needing medical services on September 4, 2025. 2. A review of facility documentation revealed an “INCIDENT REPORT FORM” dated September 4, 2025. The report revealed R2 had an accident, emergency, or injury at 11: 00 AM that resulted in R2 needing medical services. 3. A review of R2’s medical record revealed a handwritten note which indicated facility personnel planned to call a wound care company on September 3, 2025, for R2. The note further indicated facility personnel called 911 for R2 on September 4, 2025, and R2 was taken to the hospital at 11:30 AM. The review further revealed documentation of assisted living services provided to R2 (ADLs) and a medication administration record (MAR), both dated September 2025. The ADLs revealed R2 was in the hospital before lunch time on September 2, 2025, as opposed to the incident report and note which stated September 4, 2025. The MARs confirmed R2 was in the hospital on September 2, 2025. 4. In an interview, E1 reported E1 did not know for sure when R2 went to the hospital. E1 reported E1 would need to ask E2. E2 then reported R2 went to the hospital on September 2, 2025. 5. A review of facility documentation revealed a calendar provided by E2 which indicated R2 was sent to the hospital on September 2, 2025, at 9:40 AM, and not on September 4, 2025, at 11:00 AM or 11:30 AM as stated on the incident report and note. 6. In an interview, E1 confirmed the incident report did not include the correct date and time of the incident.

Based on documentation review, record review, and interview, the manager failed to ensure a written service plan include the correct level of service the resident received for one of two residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. 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. 2. Review of R2's medical record revealed a written service plan for personal care services dated March 16, 2023. 3. During an interview, E1 reported R2 was incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. E1 acknowledged R2 received directed care services and the service plan did not include the correct level of service.

Based on record review and interview, the manager failed to ensure a written service plan included the amount, type, and frequency of assisted living services provided for one of two residents reviewed. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. Review of R2's medical record revealed a written service plan dated March 16, 2023. This service plan indicated R2 was incontinent of bladder and bowel, however did not indicate the amount, type, and frequency of incontinence care provided to R2. 2. During an interview, E1 reported R2 was provided with incontinence care multiple times a day and acknowledged R2's service plan did not include the amount, type, and frequency of incontinence care provided to R2. 3. Technical assistance was provided on this Rule during the compliance inspection conducted June 20, 2022.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan dated March 16, 2023. This service plan stated "Wound: both heels acquired @ Banner on 3/6/23. Healed 4/20/2023". This service plan revealed no documentation of skin maintenance to prevent skin issues. 2. During an interview, E1 reported R2's wounds had healed, however acknowledged R2's service plan did not include skin maintenance to prevent skin issues. 3. Technical assistance was provided on this Rule during the compliance inspection conducted June 20, 2022.