The Enclave at Chandler Senior Living

Based on record review and interview, the manager failed to document the suspected exploitation and initiate an investigation. Findings include: 1. A review of R5's medical record revealed no documentation or investigation regarding suspected abuse or exploitation. 2. In an interview, E1 reported that they were made aware of the incident regarding R5 once Adult Protective Services came out to investigate. E1 also reported that the facilities employees were not involved in the incident, no investigation was initiated, and no documentation regarding the incident was completed.

Based on documentation review, record review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. \'a7 36-420.04, for one of one applicable resident sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report dated November 6, 2024. The incident report revealed the facility called emergency medical services due to R2 exhibiting out-of-control behavior and was transported to Chandler Regional Medical Center. 2. A review of R2's medical record revealed no documentation of the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). 3. In an interview, E1, E8, and E9 acknowledged the documentation provided to emergency medical services did not include all the information required in A.R.S. \'a7 36-420.04.

Based on record review and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of one sampled resident who was storing medications in the resident's unit, which posed a health and safety risk. Findings include: 1. In interview, E2 reported that R1 was allowed to manage R1's own medications. 2. R1's current service plan dated July 24, 2023 failed to state how R1's medications would be stored and controlled in R1's unit. 3. In an interview, E2 acknowledged the sampled resident was allowed to self-administer R1's own medications, however, R1's service plan did not include how R1's medications would be stored and controlled.

Based on documentation review and interview, the manager failed to ensure there was the required documentation of the annual disaster plan review. Findings included: 1. At the beginning of the compliance inspection E1 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was provided documentation of the annual disaster plan meeting that was dated July 6, 2023. There was no documentation that included the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an interview, E1 acknowledged the disaster plan meeting was lacking the required documentation. Technical assistance was provided during the compliance inspection conducted on October 26-27, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of the facility's documentation revealed evacuation drills were conducted on July 20, 2023 and October 13, 2023 during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during the past 12 months. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.

Based on observation and interview, the manager failed to ensure that garbage and refuse were stored in covered containers. Findings include: 1. During a facility tour, in the memory care's prep kitchen, E2 and the compliance officer observed a large uncovered gray trash bin half-full of trash sitting next to the prep food counter. This trash container was not in use at the time of the observation. 2. In an interview, E1 and E2 acknowledged the uncovered trash.

Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents. Findings include: 1. During a facility tour of randomly selected residents' areas, E2 and the compliance officer observed in R3's, R4's, and R5's bathrooms the hot water registered on the compliance officer's thermometer from 122.9 to 125.6\'ba F. 2. In an interview, E2 acknowledge the facility's hot water was over 120\'ba F in areas of the facility that were used by residents.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers, which posed a health risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's memory care laundry room there was stored an open uncovered large basket full of soiled linen sitting on the floor of the laundry room. An employee reported the laundry needed washing. 2. In an interview, E2 acknowledged the soiled linen in the memory care laundry room that was not being stored in a closed container as required.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were maintained in a locked area, which posed a health and safety risk. Findings include: 1. During a facility tour of the memory care unit, E2 and the compliance officer observed the unlocked memory care central laundry room there was stored in an unlocked cabinet bathroom cleaner and glass cleaner. 2. In an interview, E2 acknowledged the unlocked poisonous or toxic materials.