Sweetwater Senior Living Home

Based on documentation review and interview, the manager failed to ensure that the facility maintained a standardized form for each resident that included the information prescribed in A.R.S. § 36-420.04.A Findings include: 1. A documentation review of the facility's form titled, "Assisted Living Resident Transfer Checklist" used by the facility, revealed that the only prefilled area was the area titled, "Facility Information." There was no prefilled Emergency Medical Services (EMS) Face Sheet readily available with resident information. 2. In an interview, E2 revealed that the employees filled out the EMS sheet while on the phone with 911. E2 acknowledged that the manager failed to ensure that the facility maintained a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of the medical records for R3, revealed that based on the resident's move in date, the service plan service plan was not completed within 14-days of admission. 2. In an interview, E2 acknowledged that the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance.

Based on record and interview, the manager retained a resident confined to a bed or chair without meeting the requirements in R9-10-814.B.2.a.b.i-iii., including documentation of the resident's or the resident's representative's request the resident remain in the facility; documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility, for two residents sampled who was unable to ambulate and received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. 1. A review of the “Initial Physician Recommendation Form” was completed for R1 on May 23, 2023. A review of R1's most recent service plan dated May 28, 2025 revealed that the resident was in a wheelchair and received directed care services. There was no continuation of care physician statement reviewed every six months for R1. 2. A review of the “Initial Physician Recommendation Form” was completed for R2 on January 9, 2024. A review of R2's most recent service plan dated January 2, 2025 revealed that the resident was in a wheelchair and received Directed or Personal care services. There was no continuation of care physician statement reviewed every six months for R2. 3. In an interview, E2 acknowledged that there was no documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition.

Based on record review, documentation review, and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements of this rule. The deficient practice posed a health and safety risk to residents if an investigation was not completed and documented, as required. Findings include: 1. In documentation review, the Department received notification of an allegation of suspected abuse reported to, and being investigated by O1, which indicated R1 reported being touched by a caregiver, in an inappropriate manner. 2. In documentation review, the facility did not have documentation as required by this rule, and A.R.S. \'a7 46-454. 3. In record review, R1's service plan dated May 22, 2023, indicated R1 received personal care services, was alert, oriented and able to identify an emergency 24/7. 4. In documentation review, a facility policy, titled, "Quality Management Program Including Incident Reports," documented, "...If the manager has reasonable basis to believe abuse, neglect, or exploitation has occurred ... while the resident is receiving services from the assisted living facility's manager, caregiver.., the manager shall: 1. If applicable take immediate action to stop the suspected abuse... 2. Immediately report in person or by telephone the suspected abuse... of the resident to a peace officer or to a protective services worker... 4. Initiate an investigation... and document by filling out "Report of suspected abuse.... form... 5. Document the action taken in the facility specific form to report abuse, neglect or exploitation; 6. Maintain the documentation [copy of this report and investigation] for at least 12 months after the date of the report completion." 5. During an interview, E1 reported R1 reported (E2) touched [R1's] breasts. E1 reported an investigation of the allegation was conducted. E1 discussed the allegation with R1's family, interviewed E2, removed E2 from caring for R1, and put a camera in R1's room. E1 did not report or document the suspected abuse, and the investigation that was conducted. E1 acknowledged the suspected abuse was not reported, and the investigation, and action taken by the facility was not documented, as required by R9-10-803.J.

Based on record review, observation, and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care dated May 29, 2023. The service plan indicated R1 received medication administration. 2. Further review of R1's medical record revealed a signed medication order dated May 16, 2023 for "Gabapentin 300 MG (milligrams) THREE TIMES A DAY, BY MOUTH." 3. Further review of R1's medical record revealed a medication administration record (MAR) dated June 2023. R1's June 2023 MAR indicated "Gabapentin 300 mg" was administered to R1 three times a day from June 1-11, 2023. 4. The Compliance Officer observed a pharmacy prepared multi-dose two packets of "Gabapentin 400 mg" capsules in a basket containing R1's medication. The packets were dispensed on June 1, 2023. One packet initially contained 15 capsules, and the other packet initially contained 30 capsules. The Compliance Officer observed 9 capsules of "Gabapentin 400 mg" were missing from one of the packets. 5. In an interview, E1 reported the dosage for R1's "Gabapentin" was recently changed from 300 mg three times daily, to 400 mg three times daily. E1 reported R1 was now taking 400 mg of "Gabapentin" three times daily. E1 reported a medication order for the increased dosage was not available for review. E1 acknowledged the medication was not administered in compliance with the most recent available medication order.