Tender Care II

Based on interview and documentation review, the assisted living home failed to maintain a copy of the documentation provided to an emergency responder for two of two residents sampled for whom an emergency responder had been contacted. Findings include: 1. In an interview, E1 reported the facility had contacted emergency medical services on behalf of two residents who were ultimately transported to the hospital. E1 advised R1 had been transported to the hospital on March 3, 2025, and R3 had been transported on June 9, 2025. 2. A request was made to view the documentation provided to the emergency responders as required by ARS 36-420.04.D. However, an exact copy of the documentation provided to emergency responders was unavailable for review. 3. In an interview, E1 advised the required documentation was provided to emergency responders, but agreed, exact copies of the documentation provided to emergency responders as required by ARS 36-420.04.D were not made for each individual incident.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included an accurate description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents sampled. Findings include: 1. A review of R3’s medical record revealed a medical evaluation, dated November 21, 2024, which included a section titled “Diagnoses.” The section included medical and behavioral health conditions, including “Chronic Obstructive Pulmonary Disease, Parkinson’s disease without dyskinesia, major depressive disorder.” Further review of R3’s medical record revealed a current service plan which reflected R3’s medical, behavioral, or health problems. However, the service plan did not list R3’s diagnosed conditions of "Chronic Obstructive Pulmonary Disease, Parkinson’s disease without dyskinesia, major depressive disorder.” 2. In an interview, E1 agreed R3’s service plan did not include all of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review and interview, for one of three residents sampled, the manager failed to ensure an entry in a resident’s medical record was not changed to make the initial entry illegible. Findings include: 1. A review of R2’s medical record revealed a document titled “Routine Medication Administration Record” (MAR) used for documenting the administration of medication for the month of June 2025. The record included a section for documenting the administration of Lorazepam twice daily, at “7 AM” and “7 PM.” The section used for documenting Lorazepam administered at 7 PM had been overwritten, and the time of administration was changed to “5 PM.” Entries documenting the administration of Lorazepam at 5 PM on June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, 2025 had been overwritten to make the original entries illegible. 2. In an interview, E1 advised they had overwritten the original entry documenting the administration of Lorazepam at 5 PM on June 1 through June 14, 2025. E1 agreed the original entry had been changed, making the entry illegible.

Based on interview and documentation review, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency, or injury and needed medical services, as required per R9-10-819.D.2. Findings include: 1. In an interview, E1 advised R3 was the only resident who had an emergency requiring medical services in June 2025. E1 said emergency medical services were called for R3 on June 9, 2025, and R3 was transported to the hospital at approximately 7:30 a.m. 2. A review of facility incident reports for June 2025 revealed evidence of documentation of an incident report involving R3 was unavailable for review. 3. In an interview, E1 advised on the morning of June 9, 2025, R3 was having a panic attack and experiencing shortness of breath. E1 indicated they had notified R3’s emergency contact and R3’s medical provider, but E1 had not documented the incident as required, per R9-10-818.D.2.

Based on record review, documentation review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee 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. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. During the environmental inspection the Compliance Officer observed when exiting from the kitchen a door alarm at the right the top of the door, however, this alarm did not alert employees of a resident's egress. 3. During an interview, E1, acknowledged the kitchen door leading onto the patio did not have any means to alert employees of a resident's egress.

Based on record review, documentation review, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection (J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse, and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. Findings include: 1. A review of documentation provided by Adult Protective Services (APS) revealed an incident occurred involving R1, and E2 on March 26, 2023. The allegation was suspected abuse by E2. 2. A review of R1's medical record revealed R1 was receiving personal care services. 3. The Compliance Officer requested a copy of the facility's investigation on the allegations. E1 gave the Compliance Officer a copy of the APS report dated April 10, 2023. The Compliance Officer asked E1 for the facility's investigation/incident report. E1 reported not doing an investigation and documenting it. 4. In an interview, E1 acknowledged an investigation was not completed or documented as required in R9-10-803.J.

Based on documentation review, and interview the manager failed to ensure a resident is treated with dignity, respect, and consideration. Findings include: 1. A review of documentation provided by Adult Protective Services (APS) revealed the following "AV (alleged victim) has lived in the assisted living home for 8 years. RS (reporting source) states the AP (alleged perpetrator) is getting "rough" with the AV. RS states the AP believes the AV is capable of moving themselves and does not help enough. The AP also pushed the AV's wheelchair into the wall on purpose on March 26, 2023. A few days previously, the AP got upset with AV and the AP kicked the AV's wheelchair. The AV sometimes drops their food and the AP is not allowing the AV to have snacks during the day. RS states the AP and their spouse are the only caregivers in the home. RS is concerned that the AV may need to find somewhere else to live, but they cannot find a place on their own". 2. The Compliance Officer requested a copy of the facility's investigation on the allegations. E1 gave the Compliance Officer a copy of the APS report dated April 10, 2023. The Compliance Officer asked E1 for the facility's investigation/incident report. E1 reported not doing an investigation and documenting it. 3. In an interview, R1 told the Compliance Officer that R1 was unhappy at the facility but could not afford to go anywhere else. R1 reported being there for eight years and feels like R1 is not welcomed anymore. R1 reported getting yelled out for dropping food and crumbs on the floor, and told to go back to the kitchen and brush yourself off. The Compliance Officer asked R1 the following questions "do you feel like you are treated with dignity? R1 reported "no", respect, R1 reported "no", and consideration, and R1 reported "no". R1 reported R1's needs are met however, they are not very pleasant and don't have warm feelings for R1 anymore. The Compliance Officer asked R1 about the roughness of E2, R1 reported when assisting R1, E2 can be a little rough. R1 reported E2 has kicked the wheels on R1's wheelchair. 4. In an interview, E1 reported R1 is not happy at the home and there is conflict between R1 and E2.