The Manor Village at Desert Ridge

Based on record review and interview, the manager failed to ensure a resident’s written notice of termination of residency in subsection (G) included the date of notice; the reason for termination; the policy for refunding fees, charges, or deposits; the deposition of a resident’s fees, charges, and deposits; and contact information for the State Long-Term Care Ombudsman. Findings include: 1. In an interview, E1 reported that R2 was given a termination of residency due to the facility no longer being able to meet the needs of the resident after R2’s hospital stays. E1 reported R1 initiated termination of residency after being told R2 could no longer return and verbally gave R1 a 14-day notice. 2. A review of R2’s medical record revealed there was no written documentation of a notice of termination issued to R1 on behalf of R2.  3. In an interview, E1 acknowledged the manager failed to ensure R2’s written notice of termination of residency included the date of notice; The reason for termination; the policy for refunding fees, charges, or deposits; the deposition of a resident’s fees, charges, and deposits; and contact information for the State Long-Term Care Ombudsman. There was no documentation available for review at the time of the survey to reflect that the above requirement was met.

Based on record review and interview, the manager failed to provide a copy of the resident’s current service plan and documentation of the resident’s freedom from infectious tuberculosis when the manager provided the written notice of termination of residency. Findings include: 1. In an interview, E1 reported that R2 was given a termination of residency due to the facility no longer being able to meet the needs of the resident after R2’s hospital stays. E1 reported R1 initiated termination of residency after being told R2 could no longer return and verbally gave R1 a 14-day notice. 2. A review of R2’s medical record revealed there was no documentation that the manager provided a copy of the resident’s current service plan and documentation of the resident’s freedom from infectious tuberculosis when termination of residency was initiated. 3. In an interview, E1 acknowledged that E1 failed to ensure a copy of the resident’s current service plan and documentation of the resident’s freedom from infectious tuberculosis was provided when R1 was provided the termination of residency on R2’s behalf.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the assisted living facility accepted the individual, that included if the individual required continuous medical services; continuous or intermittent nursing services; or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant; for two out of seven sampled residents. Findings include: 1. A review of R6’s medical record contained a blank document titled “Determination for Admission", which did not include if R6 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of R7’s medical record contained a document titled “Determination for Admission” dated July 25, 2024, which reflected that R7 required continuous nursing services. 3. In an interview, E1 reviewed R6’s and R7’s medical records and acknowledged that there was no documentation available to reflect that the above requirement had been met.

Based on record review and interview, before or within five working days after a resident's acceptance by an assisted living facility, the manager failed to obtain on the residency agreement, the signature of the resident, the resident's representative, the resident's legal guardian, or another individual who has been designated by the individual under A.R.S § 36-3221 to make health care decisions on the individual's behalf for one of seven residents sampled. Findings include: 1. A review of R3's medical record revealed a residency agreement; however, the residency agreement was not signed by R3 or R3's representative. Based on R3's date of acceptance, this documentation was required. 2. In an interview, E1 reviewed R3's medical record. E1 acknowledged that R3's documented residency agreement did not include the signature of the identified resident or their representative.

Based on record review and interview, the manager failed to ensure that a caregiver or assistant caregiver provided a resident with assistance with activities of daily living according to the resident's service plan for two of seven sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated June 2, 2025, for directed care. The service plan indicated R1 required the following assistance: - grooming personal hygiene twice daily; - dressing twice daily; - toileting assistance three times daily; - bathing twice weekly. 2. A review of R1’s medical record contained a document titled “Monthly task log” dated September 2025, which reflected “INF (information only)” and did not reflect that R1 was provided assistance with activities of daily living according to R1’s service plan. 3. A review of R6's medical record revealed a service plan dated September 3, 2025, for directed care. The service plan indicated R6 required the following assistance: - transfer and escort assistance; - grooming twice daily; - dressing twice daily; - toileting three times daily; - bathing one time per day every week on Wednesday and Saturday. 4. A review of R6’s medical record contained a document titled “Monthly task log” dated September 2025, which reflected the above services were not provided for various days, and did not reflect that R6 was provided assistance with activities of daily living according to R6’s service plan. 5. In an interview, E1 reviewed R1’s and R6’s medical records and acknowledged that the medical records did not reflect that the residents were provided assistance with activities of daily living according to the residents’ service plans.

Based on record review and interview, the manager failed to ensure that a resident or the resident’s representative received a written copy of the resident rights. Findings include: 1. A review of R3's medical record revealed no documentation to indicate R3 was given a written copy of the resident rights in subsection (C). 2. In an interview, E13 acknowledged there was no documentation to indicate R3 was given a written copy of the resident rights on R3's date of acceptance.

Based on record review, observation, documentation review, and interview, the manager failed to ensure that a caregiver documented assistance with activities of daily living according to the service plans for two of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a service plan dated June 3, 2025, that reflected R1 required the following assistance: dressing twice daily and escorts twice daily. A review of R1’s June 2025 “Monthly task log did not reflect that R1 was assisted with escorts twice daily on June 1, 2025, and dressing assistance twice daily from June 1, 2025, through June 10, 2025. 2. A review of R2’s medical record revealed a service plan dated June 3, 2025, that reflected R2 required the following assistance: ambulation assistance three times daily, transferring assistance three times daily, grooming twice daily, dressing twice daily, and toileting three times daily. A review of R2’s June 2025 “Monthly Task Log” did not reflect that R2 was assisted with ambulation twice daily on June 1, 2025, June 3, 2025 through June 8, 2025, and June 10, 2025, assisted with grooming/personal hygiene, dressing, and toileting on June 1, 2025, June 3, 2025 through June 8, 2025, and June 10, 2025. 3. In an interview, E1 and E2 reviewed R1’s and R2’s service plans and documentation of services provided and acknowledged at the time of the survey, R1’s and R2’s documentation did not reflect that R1 and R2 were provided the above services. This is a repeat deficiency from the complaint investigation conducted on September 30, 2024.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of five sampled personnel. The deficient practice posed a risk if the individuals were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411.A. states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E4's personnel record revealed an invalid fingerprint clearance card that expired September 19, 2024, and no documentation that E4 applied for a new fingerprint clearance card. 3. A review of R2's and R3's medical record revealed medication administration records dated August 2024 and September 2024 which reflected E4 provided medication administration services on various times and dates. 4. In an interview, E1 acknowledged E4's fingerprint clearance card was expired and reported being unaware of E4's fingerprint status.

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 provided physical health services, for one of three caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E3's personnel records revealed no documented verification of E3's skills and knowledge. 2. A review of R2's and R3's medical record revealed a medication administration record dated August 2024 and September 2024, reflected E3 provided medication administration services on various dates. 3. In an interview, E1 reviewed and acknowledged E3's personnel file did not contain documented verification of E3's skills and knowledge. This is a repeat deficiency from the complaint investigation conducted on February 1, 2024.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of four sampled caregivers and assistant caregivers. Findings include: 1. A review of E1's personnel record revealed no documentation of completed orientation, based on E1's hire date orientation was required. 2. In an interview, E1 acknowledged E1's personnel record did not include documentation of orientation. This is a repeat deficiency from the complaint investigation conducted on February 1, 2024.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for three of three sampled residents reviewed. Findings include: 1. A review of R1's medical record revealed a service plan August 23, 2024. R1's service plan reflected R1 would be provided assistance with bathing every Sunday, Wednesday and Saturday, grooming once daily, dressing two times daily, toileting every four hours daily. There was no documentation to show the above services were provided to R1. 2. A review of R2's medical record revealed a service plan dated December 14, 2023. R2's service plan reflected R2 would be provided assistance with bathing, grooming/personal hygiene three times daily, dressing three time daily, and toileting five times daily. A document titled "Monthly Task Log" dated August 2024 and September 2024 reflected "documented by exception". There was no documentation to show the above services were provided to R2. 3. A review of R3's medical record revealed a service plan dated August 23, 2024. R3's service plan reflected R3 would be provided assistance with bathing every Wednesday and Saturday, grooming/personal hygiene four times daily, dressing twice daily, toileting assistance every two hours daily. There was no documentation to show the above services were provided to R3. 4. In an interview, E1 reviewed R1's, R2's, and R3's medical records and reported the facility documents on exception and does not document the services provided to the residents.

Based on record review and interview, the manager failed to ensure the service plan for a resident who received directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for three of three residents. Findings include: 1. A review of R1's medical record revealed a service plan August 23, 2024. R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. A review of R2's medical record revealed a service plan dated April 26, 2024. R2's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 3. A review of R3's medical record revealed a service plan dated August 23, 2024. R3's service plan R3's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 4. In an interview, E1 reviewed and acknowledged R1's, R2's, and R3's service plans did not include skin maintenance to prevent and treat bruises, injuries, pressure sores and infections.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: R9-10-101.110. "Immediate" means without delay. 1. A review of R2's medical record revealed an incident report dated August 6, 2024 in which 911 was contacted due to R2 feeling like lava was in R2's stomach and R2 was taken to the hospital by emergency medical services. However, R2's primary care physician (PCP) was not notified of the incident immediately. 2. In an interview, E1 acknowledged there was no documentation to reflected R2's physician was notified.

Based on documentation review, record review, and interview, for two of six residents reviewed, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. In record review, the personnel records reviewed for E3, E4, E5, E6, E7, and E8, and E9 included documention the personnel received training on fall prevention and fall recovery. 2. In documentation review, the Department received a report from O1, which documented, "4/2/2024... 1:52 am...Staff failed to recover patient [R1] per ARS 36-420... Patient found supine on floor in bathroom in no distress... states... slipped of the toilet and needs help up... denies injury, 3 staff members on scene state they cannot lift [R1] up... they have no hoyer or other lift device. Patient lifted to wheelchair and transferred to recliner by LT52 without incident... has no additional needs." 3. In documentation review, the Department received a report from O1, which documented, "4/4/2024... 1:18 am... Staff failed to recover patient [R2] ... found patient laying in the prone position next to ... bed... Staff... states patient rolled out of bed... they need help lifting patient back into bed. Staff states patient is a hospice patient and hospice states they are on their way and will take care of the patient. Hospice nurse says they do not need patient transported... Pt is alert and oriented times three. Staff states this is a normal baseline for patient... facility had four staff members present... states that they need help lifting the patient into bed... did not assist the fire department in lifting the patient in the bed...". 4. During an interview, the findings were reviewed with E1, and E2, who reported all employees received fall prevention and fall recovery training, which included a video on fall recovery. E1 and E2 acknowledged, however, the night shift employees called for emergency services for R1 and R2 and reported they were unable to lift the residents from the floor.

Based on record review, documentation review, and interview, for one of seven caregivers reviewed, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers (NCIA Board). The deficient practice posed a risk if a caregiver was not qualified to provide the required services, and the Department was provided false and misleading information. Findings include: 1. In record review, E6 was hired as a caregiver on November 23, 2022, and worked night shifts at the facility. E6's personnel record included a caregiver certificate from GSDM Healthcare Academy ALTP #0102, dated November 19, 2012. 2. In documentation review, a review of the website for caregiver certification verification, revealed the GSDM Healthcare Academy operated as an approved training program from September 13, 2004, through September 30, 2012, and was not in operation on November 19, 2012, (the date of E6's caregiver certificate). 3. During an interview, the findings were reviewed with E1 and E2, who acknowledged E6 did not provide documentation of completion of a caregiver training program approved by the Department or the NCIA Board as required.