The Landings of Prescott Valley

Based on record review and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety as the resident's whereabouts were unknown. Findings include: 1. A review of R3's medical record revealed a service plan dated February 16, 2026, that indicated R3 had a diagnosis of advanced dementia and was receiving directed care services. The service plan also revealed that R3 was ambulatory, disoriented to person/place/time, was unable to recognize danger, and was prone to getting into dangerous situations. 2. A review of R3's medical record revealed a document dated February 22, 2026, detailing an incident when R3 eloped from the facility. According to this document, R3 was observed in the dining room taking lunch to another part of the facility. Around 3pm, staff became unaware of R3's whereabouts in the community. The facility did a search of the entire building. When R3 could not be located, the facility called the power of attorney and the police around 3:50pm. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed R2’s current service plan dated February 9, 2026. The service plan revealed R2 required medication administration. 2. A review of R2's February 2026 medication administration record (MAR) revealed R2 was administered the following medication: Olanzapine 5mg 1 tab by mouth once a day at 1pm on February 15-25; Lorazepam oral pill, 1mg by mouth every 4 hours, at 8am, 12pm, 4pm, and 8pm on February 6-8 and at 8am on February 9; and Seroquel oral pill, 50 mg tab, 0.5 by mouth two times a week, at bedtime on February 7, 11, and 14. 3. A review of R2's medical record revealed no signed or verbal orders for Olanzapine, Lorazepam, and Seroquel. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure before providing assisted living services to a resident, a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults for one of three personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E5's personnel record revealed that E5 was hired as a caregiver in October 2023. The record included a first aid and CPR card issued on November 2, 2024, with a renewal date of November 2, 2026. However, the certification was from ‘NationalCPRFoundation,’ which provides online-only training and does not include a hands-on demonstration of CPR skills. Therefore, a valid CPR certification for E5 could not be verified from November 2024 to the present. 2. A review of the website "nationalcprfoundation.com" revealed the following, "National CPR Foundation... We're a Premium Online Certification Provider for Healthcare Providers, Workplace Individuals and the Community. We offer a 100% risk-free, money-back guarantee on all Courses! Made Quick, Easy & Simple!" 3. A review of the facility’s work schedule revealed that E5 provided assisted living services to residents during the NOC shift (10:00 p.m. to 6:00 a.m.) on September 29, 30, and October 1, 2025. 4. In an interview, E2 and E3 acknowledged that E5 did not have valid current documentation of CPR training.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated August 08, 2025, for personal care services. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2's medical record revealed a service plan dated August 05, 2025, for directed care services. However, the service plan did not include a description of R2's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. In an interview, E1 reported that the facility provides a link to the resident’s family, granting access to the resident’s chart, which includes all resident information that families can review daily. However, the electronically signed service plans did not include the resident’s medical or health problems. E1 acknowledged that R1’s and R2’s service plans did not include a description of the residents’ medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current service plan dated August 2025. The service plan stated the following; "Assistance with laundry; Assistance with housekeeping - Frequency: As scheduled - Responsible: Caregivers, Med Tech." However, this service plan did not include the amount, type, or frequency of laundry and housekeeping services provided. 2. A review of R2's medical record revealed a current service plan dated August 2025. The service plan stated the following; "Assistance with laundry; Assistance with housekeeping - Frequency: As scheduled - Responsible: Caregivers, Med Tech." However, this service plan did not include the amount, type, or frequency of laundry and housekeeping services provided. 3. In an interview, E1 reported that staff go into residents' rooms daily to clean rooms, check if the bedsheets need to be changed. E1 acknowledged that R1's and R2's service plans did not include the amount, type, and frequency of assisted living services provided to R1 and R2.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning; documentation of the resident's weight, or documentation from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for one of one resident reviewed receiving directed care services. The deficient practice posed a health risk to the resident. 1. A review of R2's medical record revealed a written service plan dated August 2025. However, this service plan did not include cognitive stimulation and activities to maximize functioning; documentation of the resident's weight, or documentation from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident's representative and/or family members. 2. In an interview, E2 and E4 reported R2 received directed care services and acknowledged that the service plans did not include the above-mentioned requirements.

Based on record review and interview the health care institution failed to administer a training program for staff regarding fall prevention and fall recovery, including initial training and continued competency training. Findings include: 1. Review of the record for E1 (hired April 11, 2022), failed to reveal that fall prevention and fall recovery continued competency training had been conducted at the frequency identified in the facility policy. Documentation indicated that the last training had been conducted on February 27, 2023. 2. Review of the record for E3 (hired March 11, 2022), failed to reveal that fall prevention and fall recovery continued competency training had been conducted at the frequency identified in the facility policy. Documentation indicated that the last training had been conducted on February 5, 2023. 3. Review of the facility policy and procedure for fall prevention and fall recovery training indicated that continued competency training would be conducted "..on an annual basis.". 4. During an interview, E1 acknowledged that continued competency training for fall prevention and fall recovery had not been conducted as specified in policy and procedure.

Based on record review and interview, the manager failed to ensure that one of one sample resident records contained documentation of medication administered to the resident that includes all areas identified in subsections a. through d. of this rule. Findings include: 1. The record for R1 contained no record of the medications administered to the resident from the date of admission until one month prior to the residents discharge. 2. During an interview, E4 stated, "She got medications daily since admission. Our MAR software program only stores 14 days of information. I was able to retrieve 30 days for your review. 3. During an interview, E1 acknowledged the resident record did not contain documentation of the medication administered to the resident.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the Lang Poisoning and Drug Overdose manual, 7th edition. 2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution. 3. During an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure that one of one pet that was allowed in the facility, was licensed consistent with local ordinances. Findings include: 1. Documentation for O1, a dog allowed in the facility reflected that the dog's license expired on February 25, 2024. 2. During a telephone interview with the local authority it was determined that the dog required a license. 3. During an interview, E1 acknowledged that facility documentation failed to indicate the dog had a current license.

Based on record review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. During an interview, E1 acknowledge that the required documentation was not available.

Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.