The Lodge at 14th Street

Based on record review and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for three of three employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1 and E3's personnel records revealed no continued competency in fall prevention and fall recovery training. The latest training was conducted on November 30, 2023 for both staff. No further trainings were available for review. 2. A review of E2's personnel record revealed no initial training in fall prevention and fall recovery. Based on E2's hire date, this information was required. 3. In an exit interview, the findings were reviewed with E1, no additional information was provided.

Based on record review and interview, the assisted living center failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for two out of two residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1's medical record revealed documentation of a standardized form to be used if an emergency responder was contacted; however, the form was missing the following information: The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge; and Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 2. A review of R2's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The point-of-contact information for the assisted living center or assisted living home, as well as the telephone number, if available, cell phone number and email address; A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge; and Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the health care institution failed to ensure that the health care institution implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution for two of three employees sampled and annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1 and E3's personnel records revealed that the latest training was conducted on November 30, 2023, for both staff. No further trainings were available for review. 2. A review of the facility's documentation records revealed no facility risk assessment for infectious TB was documented and available during the inspection. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. Technical assistance was provided on this Rule during the inspection conducted on February 26, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a Medication Administration Record (MAR) for the month of March 2026. This MAR included the documentation for the opioid Oxycodone 10/325 mg, 1 tablet every six hours as needed. According to this MAR, R1 received this opioid twice on March 5-8 and three times on March 9 and 10. However, there was no documentation of the patient's response and the effect of the opioid administered for each administration during the month of March 2026. R1 also did not have an end of life condition or an active malignancy. 2. The facility's opioid policy was not available for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility’s documentation revealed that there was no quality management plan available for review. 2. 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 that a caregiver who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility for one of three employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed documentation of TB skin test that was completed after E2's date of hire, and a second TB skin test was unavailable. Additionally, there was no documentation of assessing risks of prior exposure to infectious TB or documentation of determining if E2 had signs or symptoms of TB. Based on E2's date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 5. Technical assistance was provided on this Rule during the inspection conducted on February 26, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy and as specified in R9-10-113 for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113: "A health care institution’s chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. b. c. 2. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. iii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and Includes the date and the type of tuberculosis screening test;" 2. Review of R1's medical record revealed a chest x-ray indicating no evidence of active TB. However, documentation was not available indicating R1 had a previous positive TB skin test or blood test, and without such documentation, a chest x-ray is not acceptable as documentation of freedom from TB. No additional documentation of freedom from infectious TB was available for review. Based on R1's acceptance date, this documentation was required. 3. A review of R2's medical record revealed no documentation of assessing risks of prior exposure to infectious TB or a determination of whether R2 had signs or symptoms of TB. Based on R2's date of occupancy, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 5. Technical assistance was provided on this Rule during the inspection conducted on February 26, 2025.

Based on documentation review and interview, the manager failed to ensure that an assisted living facility authorized to provide directed care services had policies and procedures for memory care services that were established, documented, and implemented that covered the requirements in R9-10-816.A.1. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility’s documentation revealed no policies and procedures that covered the requirements in R9-10-816.A.1. 2. A review of the facility's license revealed the facility was licensed at the directed care level. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. Technical assistance was provided on this rule during the inspection conducted on September 2, 2025, and December 18, 2025.

Based on record review and interview, the manager failed to ensure that staff obtain a certificate of completion, as specified in R9-10-126, including the minimum eight hours of initial memory care services training within the first 30 days of hire or provided a copy of a certificate of completion, as specified in R9-10-126, obtained within the preceding 12 months from the date of hire. Findings include: 1. A review of E1, E2, and E3’s personnel records revealed no documentation of a certificate of completion for memory care services training. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 3. Technical assistance was provided on this rule during the inspection conducted on September 2, 2025, and December 18, 2025.

Based on observation and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed there was no current drug reference guide available when requested. 2. In an exit interview, the findings were reviewed with E1 and E1 stated "I haven't seen one" and no additional information was provided.

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. During an environmental inspection of the facility, the Compliance Officer observed that there was no current toxicology reference guide when requested. 2. In an exit interview, the findings were reviewed with E1 and E1 stated "I haven't seen one" and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that if the assisted living facility was authorized to provide directed care services, an elopement drill for employees was conducted every six months on each shift and documented the date, time, and description of each drill. The deficient practice posed a risk if employees were unable to implement the elopement plan. Findings include: 1. A review of the facility's license revealed the facility was licensed at the directed care level. 2. A review of the facility's documentation records revealed that elopement drills were unavailable for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 4. Technical assistance was provided on this rule during the inspection conducted on September 2, 2025, and December 18, 2025.

Based on observation and interview, the manager failed to ensure that a first-aid kit was maintained in the assisted living facility in a location accessible to caregivers and assistant caregivers. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed that there was no first aid kit available when requested. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that the premises at the assisted living facility were cleaned. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed soiled laundry in uncovered baskets and all over the floor in the bedroom of R1. 2. "A review of R1's medical record revealed a residency agreement that contained the following verbiage, "Cleaning schedules are as follows: a. Bedrooms and Linens-DAILY, b. Laundry - BI-WEEKLY, c. All residents are expected to be cooperative in allowing staff to complete the cleaning process, and to avoid unnecessary littering and or clutter. All soiled laundry must be kept in a closed or covered receptacle until staff removes it for cleaning." 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. A review of R1's medical record revealed a service plan for personal care. 2. A review of R1's medical record revealed a document titled "Incident Report" dated August 18, 2024. This document stated, " R1 pushed an air conditioner out of a window and left the facility. A follow up with R1's PCP and psych provider will be scheduled upon return to stop future incidents. Primary care providers and case managers were notified." 3. A review of facility policies and procedures revealed a policy titled "Resident Whereabouts," the policy stated "If a resident's whereabouts cannot be verified the staff will follow the wandering policy and procedure." 4. A review of facility policies and procedures revealed a policy titled "Wandering Policy," the policy stated "In the event that a resident has wandered from the facility and is not in view, the caregiver shall call 911." 5. A review of facility documentation revealed no documentation that the facility contacted 911. 6. In an interview, E1 acknowledged that the facility did not contact 911 and was unaware of the general or specific whereabouts of R1.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the unsecured medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an caregivers office / Laundry room with the door unlocked and open wide open accessible to residents. The Compliance Officer observed a medication cup with "Nine unknown unlabeled pills" in the caregivers office in an unlocked file cabinet. The medications were not stored in a self-contained unit used only for medication storage. The caregivers office was not locked at the time of the observation. 2. In an interview, E1 acknowledged the aforementioned medications were not stored in a unit used only for medication storage at the time of observation.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed "Bleach", "Lysol Bathroom Foamer", "Spray Wash Stain Removal", "Cloralen with Bleach", "Fabuloso Multi Purpose Cleaner", "Fabuloso" and "Multi-purpose Cleaner" stored in the unlocked caregiver office / laundry room cabinet which was accessible to residents. The caregiver office / laundry room door had a locking device installed, but the door was left unlocked at the time of the observation. 2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for one of two sampled caregivers. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy titled "Caregiver Skill Verification Policy and Procedure." The policy stated "Caregiver will complete orientation checklist prior to starting duties." 2. A review of E2's personnel record revealed a document titled "Orientation Checklist" used to verify a caregiver's skills and knowledge. However, the document was not initialed to indicate topics were completed or signed and dated by E2 at the time of inspection. 3. In an interview, E1 acknowledged E2's "Orientation Checklist" was not completed at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures, for one of three sampled personnel members. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of facility documentation revealed a policy titled "Job Description and Duties." The policy stated "Caregivers must have a current state of Arizona caregiver certificate and complete an employee orientation checklist." 2. A review of E2's personnel record revealed a document titled "Orientation Checklist." However, the document was not initialed to indicate topics were completed or signed and dated by E2 at the time of inspection. 3. In an interview, E1 acknowledged E2's "Orientation Checklist" was not completed at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement, for one of three sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R2's medical record revealed documentation of a signed residency agreement was not available at the time of inspection. 2. In an interview, E1 reported E1 was sure R2 had a signed residency agreement, but was not sure where it was located. E1 acknowledged R2's medical record did not contain R2's signed residency agreement at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of three sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection. 2. In an interview, E1 reported E1 was sure R2 had documentation of a completed orientation, but was not sure where it was located. E1 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility at the time of the inspection.

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures for all required procedures in R9-10-816(F)(3). Findings include: 1. Documentation review revealed that a policy for inventorying medications was not available for review. 2. Documentation review revealed that a policy regarding storing, inventorying, and dispensing controlled substances was not available for review. 3. In an interview, E1 acknowledged that the manager failed to establish, document, and implement policies and procedures for all required procedures in R9-10-816(F)(3).

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for three of four residents sampled. Findings include: 1. A review of facility documentation revealed AL0021 was not authorized to provide behavioral health services. 2. A review of R1's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "APPROACHES AND ACTIONS 1:1 counseling daily." 3. A review of R2's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "APPROACHES AND ACTIONS 1:1 counseling daily." 4. A review of R3's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "APPROACHES AND ACTIONS 1:1 counseling daily." 5. A review of R1's medical record revealed an activities of daily living (ADL) log for September 2023. The ADL log revealed "1:1 counseling daily" as indicated in R1's service plan was not documented as provided. 6. A review of R2's medical record revealed an ADL log for September 2023. The ADL log revealed "1:1 counseling daily" as indicated in R2's service plan was not documented as provided. 7. A review of R3's medical record revealed an ADL log for September 2023. The ADL log revealed "1:1 counseling daily" as indicated in R3's service plan was not documented as provided. 8. In an interview, E1 reported the facility does "daily checks" with the residents and does not provide counseling, including one on one counseling. E1 reported counseling was documented in the service plans for R1, R2, and R3 by mistake. E1 acknowledged R1, R2, and R3 was not provided assisted living services according to R1's, R2's, and R3's service plans.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for three of four residents sampled. The deficient practice posed a risk as services provided were unable to be verified and the required documentation was not provided during the inspection. Findings include: 1. A review of R1's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily." 2. A review of R2's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily." 3. A review of R3's medical record revealed a current written service plan dated May 1, 2023 for personal care services. The service plan stated "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily." 4. A review of R1's medical record revealed an activities of daily living (ADL) log for September 2023. The ADL log did not include documentation to indicate caregivers provided "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily" assistance to R1. 5. A review of R2's medical record revealed an ADL log for September 2023. The ADL log did not include documentation to indicate caregivers provided "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily" assistance to R2. 6. A review of R3's medical record revealed an ADL log for September 2023. The ADL log did not include documentation of the caregivers providing "Dressing: Requires verbal queuing and set up with clothing selection and dressing daily" assistance to R3. 7. In an interview, E1 acknowledged the aforementioned services were not documented on R1's, R2's and R3's ADL logs as provided.