The Bluffs of Flagstaff

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for seven of seven residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's medical record revealed evidence of freedom from TB; however, there was no documentation of a completed TB Screening and Risk Assessment. Based on R1's date of admission, this documentation was required. 2. A review of R2's medical record revealed documentation that stated R2 had a negative TB test; however, there was no documentation of the test itself, nor was there documentation of a completed TB Screening and Risk Assessment. Based on R2's date of admission, this documentation was required. 3. A review of R3's medical record revealed evidence of freedom from TB; however, there was no documentation of a completed TB Screening and Risk Assessment. Based on R3's date of admission, this documentation was required. 4. A review of R5's medical record revealed evidence of freedom from TB; however, there was no documentation of a completed TB Screening and Risk Assessment. Based on R5's date of admission, this documentation was required. 5. A review of R6's medical record revealed evidence of freedom from TB; however, there was no documentation of a completed TB Screening and Risk Assessment. Based on R6's date of admission, this documentation was required. 6. A review of R7's medical record revealed documentation that stated R7 had a negative TB test; however, there was no documentation of the test itself, nor was there documentation of a completed TB Screening and Risk Assessment. Based on R7's date of admission, this documentation was required. 7. A review of R8's medical record revealed there was no evidence of freedom from TB available for review at the time of the inspection, nor was there documentation of a completed TB Screening and Risk Assessment. Based on R8's date of admission, this documentation was required. 8. In an interview, E2 expressed understanding that the facility had been using the wrong form for the TB Screening and Risk Assessment. 9. In an interview, E1 and E2 acknowledged that the aforementioned medical records did not provide evidence of freedom from TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that a resident had a service plan, for two of seven residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of R5's and R8's medical records revealed that R5's and R8's current service plans were not available for review. 2. In an interview, E2 explained that there was a recent glitch in the system when the service plans were uploaded into the electronic medical records, but the originals had been shredded before they knew that some of the service plans didn't upload due to the volume of the scan. E2 reported E2 was in the process of creating new service plans. E2 ensured that R5 and R8 were receiving all of the necessary services. 3. Further review of R5's and R8's medical records revealed Activities of Daily Living (ADL) sheets for both R5 and R8. The ADL's indicated the appropriate and/or necessary services were being provided to the residents. 4. In an interview, E1 and E2 acknowledged that R5's and R8's current service plans were not in the medical records at the time of the inspection.

Based on the documentation review and interview, the manager failed to ensure that a resident was not subjected to misappropriation of personal and private property by the assisted living facility's manager, caregivers, assistant caregivers, employees, or volunteers. Findings include: 1. A review of facility documentation revealed evidence that E3 was terminated due to misappropriation of residents’ and the facility’s property, in addition to exploitation. 2. A documentation review revealed a document titled “Termination notice” dated June 10, 2025. The document reported that E3 admitted to the following: · Removing food from residents’ apartments without consent, · Taking food from the facility’s main kitchen after hours, without proper authorization, and · Placed a food order under a resident’s name and consumed food 3. In an interview, E1 reported that once the incidents were reported to E1 and E2, an investigation was conducted. E1 and E2 had a meeting with E3 regarding the incidents. E3 admitted to each incident and was terminated. E1 acknowledged that residents had been subjected to misappropriation of personal or private property and exploitation by an employee at the assisted living facility.

Based on record review and interview, the manager failed to ensure a written service plan included the level of service the resident received, for four of four residents sampled. 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 review of R1's medical record revealed a written service plan dated January 03, 2025. The service plans did not include the level of service R1 received. 2. A review of R2's medical record revealed a written service plan dated April 24, 2025. The service plans did not include the level of service R2 received. 3. A review of R3's medical record revealed a written service plan dated October 18, 2024. The service plans did not include the level of service R3. received. 4. A review of R4's medical record revealed a written service plan dated April 24, 2025. The service plans did not include the level of service R4 received. 5. In an interview, E1 and E2 acknowledged R1's, R2's, R3's, and R4's service plans did not include the level of service the resident received.

Based on record review and interview, the manager failed to ensure a written service plan included the level of medication assistance, for four of four residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. This service plan did not include the level of medication assistance R1 received. 2. In an interview, E2 reported that R1 received directed care services and medication administration. 3. A review of R2's medical record revealed a written service plan dated April 24, 2025. This service plan did not include the level of medication assistance R2 received. 4. In an interview, E2 reported that R2 received personal care services and medication administration. 5. A review of R3's medical record revealed a written service plan dated October 18, 2024. This service plan did not include the level of medication assistance R3 received. 6. In an interview, E2 reported that R3 received personal care services and self-administration of medication. 7. A review of R4's medical record revealed a written service plan dated April 24, 2025. This service plan did not include the level of medication assistance R4 received. 8. In an interview, E2 reported that R4 received personal care services and medication administration. 9. In an interview, E1 and E2 acknowledged R1's, R2's, R3's and R4's service plans did not include the level of medication assistance.

Based on interview and record review, the manager failed to ensure the service plans for one of one residents sampled, who stored medication in the resident's residential unit, included how the medication was stored and controlled. Findings include: 1. In an interview, E2 reported that R3 received personal care services and self-administered medication. 2. A review of R3's medical record revealed a written service plan dated October 18, 2024. This service plan did not include how the medication would be stored and controlled in R3's room. 3. In an interview, E1 and E2 acknowledged the service plan did not indicate how the medications would be stored and controlled.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning, for one of one resident sampled receiving directed care services. 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 review of R1's medical record revealed a written service plan dated January 03, 2025. This service plan revealed no documentation of cognitive stimulation and activities to maximize functioning. 2. In an interview, E2 reported that R1 received directed care services. 3. In an interview, E1 and E2 acknowledged R1's service plan did not include cognitive stimulation and activities to maximize functioning.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident sampled receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a written service plan dated January 03, 2025. The service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. In an interview, E2 reported that R1 received directed care services. 3. In an interview, E1 and E2 acknowledged R1's service plan did not include documentation of R1's weight and documentation was not available in R1's record from a medical practitioner stating weighing R1 was contraindicated.

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 caregiver provided physical health services on behalf of the facility, for one of one sampled caregiver. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed E2 worked on January 25, 2025. 2. A review of E2's personnel record revealed E2 was hired in April 2023, as a caregiver . Review of E2's personnel record revealed no documented verification of E2's skills and knowledge. 3. In an interview, E1 acknowledged E2's personnel record did not contain documentation of verification of skills and knowledge.

Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of physical and/or psychosocial harm. Findings include: 1. The Compliance Officer reviewed and listened to a video provided by the facility and observed E2 not treating R1 with dignity, respect, or consideration. E2 was belittling R1 for wetting self and having to be changed. E2 was speaking harshly to R2 while aggressively changing R2’s brief. 2. During an interview, E1 reported that E1 also reviewed the video with upper management. E1 acknowledged that E2 did not treat R1 with dignity, respect, or consideration. This is a repeat deficiency from the inspection conducted on November 3, 2023.

Based on record review and interview, the manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order. Findings include: 1. The record for R9 contained a physician's order for Sodium Chloride tab, take 1 tab by mouth, daily. 2. Record review further indicated that the medication was not given from June 10-16, 2024. 3. The medication administration record (MAR) for R9 indicated that the medication had not been given due to pharmacy not delivered. 4. During an interview, E1 stated, "The medication was not given because pharmacy did not deliver. The facility contacted family due to resident had not received medication". E1 acknowledge that the medication was not given to resident as directed.

Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for nine of nine residents sampled. Findings include: 1. A record review of R1's, R2's, R3's, R4's, R5's, R6's, R7's, R8's, and R9's medical records revealed a lack of documentation indicating the residents received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility. 2. In an interview, E1 reported all new residents received orientation to the exits from the assisted living facility as part of their move-in process. E1 reported the orientation was conducted but was unaware that separate documentation was needed. E1 acknowledged the residents' orientation to the assisted living facility's evacuation route was not documented.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. Review of the record for E4 (hired April 27, 2023), failed to reveal documentation of fall prevention and fall recovery training. 2. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. Findings include: 1. Review of the facility delegation of authority statement revealed that E6, E7, and E8 were delegated the authority to act as the manager in the absence of E1. 2. Upon entry into the facility E1 and E6 were not present. 3. During an interview, E1 indicated that E7 and E8 were not caregivers. 4. During an interview, E1 acknowledged that documentation failed to indicate that a caregiver, who was present on the facility premises had been designated to act as manager designee when the manager is not present.

Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years. Findings include: 1. Review of the facility policy and procedure manual revealed no documentation indicating that the manual had been reviewed. No additional documentation indicating that the policies and procedures had been reviewed once every three years was available. 2. During an interview, E1 acknowledged the documentation failed to indicate that the policies and procedures were reviewed at least once every three years and updated as needed.

Based on documentation review and interview, the manager failed to ensure that a quality management plan was established, documented, and implemented for an ongoing quality management program that includes subsections a. - e. of this rule. Findings include: 1. Review of the facility quality management plan revealed documentation that directly reflected the information found in R9-10-804.1.a.-e. The documentation failed to reveal a quality management plan that was established and documented for the facility. 2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management plan.

Based on record review and interview, the manager failed to ensure for two of four records that before providing personal care services or directed care services to a resident, a manager or caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. The record for E4 (hired April 27, 2023), failed to reveal documentation of CPR and First aid certifications. 2. The record for E1 (hired October 2, 2023), contained documentation of CPR and First Aid training that expired on July 22, 2023. 3. During an interview, E1 acknowledged that the caregiver and manager provided services to residents without current documentation of first aid and CPR training certification.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113. Findings include: 1. The record for R2 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required. 2. The record for R3 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required. 3. During an interview, E1 acknowledged that the records did not contain evidence of freedom from TB as required.

Based on record review and interview, the manager failed to ensure that one of one sample resident records, had a service plan that was reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1. The record for R5 contained a service plan that was last updated on May 2, 2023. 2. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.

Based on record review and interview, the Manager failed to ensure that a resident was treated with dignity, respect and consideration. Findings include: 1. Review of the record for R1 revealed an incident report dated July 11, 2023 that indicated E4 reacted to R1's attempt to bite them by "..hitting (R1) on the back of the head and restraining (R1) around the wrists." 2. During an interview, E1 acknowledged that striking a resident was not treating a resident with dignity, respect and consideration.

Based on record review and interview for one of one personal care resident record, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services. Findings include: 1. During an interview, E5 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Based on documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. The facility medication administration policies and procedures failed to reveal evidence that the policies had been reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. During an interview, E1 acknowledged that facility residents receive medication administration services. 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility documentation failed to reflect that disaster drills had been conducted. 2. During an interview, E1 acknowledged that no documentation of employee disaster drills was available for review.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months. Findings include: 1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided failed to reveal that resident evacuation drills had been conducted. The only evacuation drill documentation available for review was for employees only, and these drills did not involve residents. 2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and maintained for 12 months after the date of the evacuation drill that included the amount of time taken for employees to evacuate the assisted living facility. Findings include: 1. Facility evacuation drill documentation for the past 12 months was reviewed. The documentation failed to reveal the amount of time taken for employees to evacuate the facility for the following dates in 2023: March 16, May 30, June 30, July 20, August 25 and September 28. 2. During an interview, E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal. Findings include: 1. Facility documentation indicated the last fire inspection was conducted by the local fire department on April 27, 2022. 2. During an interview with a representative from the local Fire Department it was determined that fire inspections are required on an annual basis. 3. During an interview, E1 acknowledged that the facility did not have documentation indicating that a fire inspection had been conducted as required by the fire authority.