The Ranch Estates of Tucson

Based on document review and interview, the manager failed to ensure a documented report identifying concerns about the delivery of services, and any changes or actions taken, was submitted to the governing authority. Findings include: 1. A review of facility policy and procedures, last reviewed January 1, 2025, revealed a policy outlining quality management. The policy indicated a report, compliant with the facility’s quality management program, was to be sent to the governing authority on an annual basis. 2. A request was made to review the facility’s most recent quality management report to the governing authority. However, evidence of documentation of such a report was unavailable for review. 3. In an interview, E1 acknowledged the annual quality management report to the governing authority was unavailable for review.

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for one of six sampled caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency. Findings include: 1. A review of E4's personnel record revealed E4 was hired as a caregiver in January 2024. 2. A review of E4's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection. 3. A review of staff schedules revealed R4 was scheduled to work May 5, 6, 7, 12, 13, 14, 15, 19, 20, 21, 26, 27, 28, 29, 2024, at 2:00 pm to 10:00 pm. 4. A review of a policy and procedures revealed a policy titled "CPR and First Aid Training - Arizona" Policy: Before providing assisted living services to a resident, all wellness associates will provide current documentation of certification of First Aid and Cardiopulmonary Resuscitation (CPR) specific to Adults". 5. In an interview, E1, acknowledged E4's personnel records did not include documentation of first aid training.

Based on record review and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of 10 residents sampled. This deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings included: 1. A review of R1's medical records revealed a document titled "Treatment/Services Authorization - Arizona". The document was dated April 4, 2024, five days after R1 moved into the facility and not within 90 calendar days before R1 was accepted by the facility. 2. A review of R2's medical records revealed a document titled "Treatment/Services Authorization - Arizona". The document was dated February 8, 2024, one day after R2 moved into the facility and not within 90 calendar days before R2 was accepted by the facility. 3. In an interview, E1 acknowledged R1 and R2's documentation was not provided before the residents moved into the facility. This is a repeat citation from the compliance inspection conducted on June 12, 2023.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of five residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. A review of R4's medical record revealed a written service plan for directed care services dated November 30, 2023. The Compliance Officer asked E1 if R4 had a current service plan. The Compliance Officer received a service plan dated March 2, 2024, however, the service plan was not signed or dated by the manager, the nurse and the residents representative which is required for a directed care resident. 2. In an interview, E1 acknowledged R4 was receiving directed care services and the service plan was not updated at least once every three months as required.

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. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. A review of the facility's documentation revealed an evacuation drill for employees and residents was conducted on October 31, 2023. There was no additional documentation of evidence to indicate an evacuation drill was conducted at least once every six months. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months. This is a repeat citation from the compliance inspection conducted on June 12, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility's caregiver for three of eleven residents sampled. Findings: 1. A review of department documentation revealed the facility made a self-report regarding missing narcotics. The document revealed on Sunday, November 5, 2023, the assistant wellness director was doing a routine audit of the medication cart and found four carts of the drug Hydrocodone missing. The medications belonged to R9, R10, and R11. 2. E1 started an investigation and reported the following "We reached out to all med aides that had worked the carts. One Med Aide [E2] did not reply to our request to come in on E2's off day as an investigation was started. On November 7, 2023, at 6 am Med Aide [E2] informed our Wellness Director [E7] that [E2] resigned effective immediately 11/7/2023. The Executive Director [E1] reached out to [E2] by phone and text stating that we were performing an investigation and needed E2 to come in so we could ask E2 about the missing narcotics. Tuesday, November 7, 2023. E2 stated E2 would come in but did not show up as agreed upon. We called the Sheriff's Department to inform them that we had missing narcotics. [E1] called [E2] again and texted E2 stating that we were going to escalate the investigation. E2 stated E2 would come in on Thursday, November 9, 2023. We interviewed [E2]. E2 stated that E2 had not seen the missing narcotics. E2 did not give a reason for E2's resignation. .... The Executive Director called the Pima County Sheriff's Department and informed them of missing narcotics. The doctor, and the residents Medical POA have been contacted". 3. A review of a documentation provided by E1 revealed a Medication Cart/Refrigerator Audit for Cart two. The document stated "Log sheets are maintained and count correct? Missing 241 hydro, 232 hydro and 231 hydro reported to wellness director". E1 stated 241, 232, and 231 are residents R9, R10, and R11's room numbers. 4. A review of R9's medical record revealed a medication order for "Hydrocodone 5 MG - Acetaminophen 325 MG tablet, give 1 tablet by mouth every 4 hours as needed for pain". The Compliance Officer observed on the medication record for R9 this medication had not been given from January 1, 2024 until the Compliance Officer was on-site on January 22, 2024. 5. A review of R10's medical record revealed a medication order for "Hydrocodone 5 MG - Acetaminophen 325 MG oral tablet, take 1 orally every 4 hours PRN pain level over 5, NTE 4 doses/day". The Compliance Officer observed on the medication record for R10 this medication had not been given from January 1, 2024 until the Compliance Officer was on-site on January 22, 2024. 6. A review of R11's medical record revealed a medication order for "Hydrocodone 7.5 MG - Acetaminophen 325 MG 1 tablet by mouth every 4 hours as needed/PRN". The Compliance Off

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed no documentation indicating E1 completed fall prevention and fall recovery training. 2. Review of E6's personnel record revealed no documentation indicating E6 completed fall prevention and fall recovery training. 3. Review of E7's personnel record revealed no documentation indicating E7 completed fall prevention and fall recovery training. 4. Review of E8's personnel record revealed no documentation indicating E8 completed fall prevention and fall recovery training 5. In an interview, E1, and O2 reported being unaware that all employees needed fall prevention, and fall recovery training. E1 and O2 acknowledged documentation was not available showing E1, E6, E7, and E8 had completed a training program for fall prevention and fall recovery. This is a repeat citation from the compliance survey conducted on May 26, 2022.

Based on record review and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for four of nine residents sampled. This deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed no documentation dated within 90 calendar days before R1 was accepted by the facility, and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of R2's medical record revealed documentation dated within 90 calendar days before R2 was accepted by the facility, however this document was missing if an individual was requesting or is expected to receive supervisory care services, personal care services, or directed care services, to include whether the individual required "restraints". 3. A review of R6's medical record revealed a document dated ten days after R6 was accepted by the facility. 4. A review of R9's medical record revealed a document dated nine days after R9 was accepted by the facility. 5. In an interview, E1 reported being unaware R1, R2, R6, and R9's medical records did not contain the required documentation. This is a repeat citation from the compliance inspection conducted on May 26, 2022.

Based on medical record review, documentation review, observation, and interview, the manager failed to ensure a resident has a written service plan for a resident who will be storing medication in the resident's bedroom, how the mediation will be stored and controlled for one of nine residents sampled. Findings include: 1. A review of R4's medical record revealed R4 self administers own medication. 2. In an interview, E2 reported R4 self-administered R4's own medication. The Compliance Officer asked E2 how the facility monitors a residents who self administers their own medication. E2 stated every 6 months. 3. A review of R4's service plan dated December 14, 2022, revealed R4 was receiving supervisory care services. However no documentation to indicate where R4's medication will be stored and controlled in R4's bedroom was available for review. 4. During a facility tour the Compliance Officer toured R4's room with E1. When entering the room the Compliance Officer observed the door was unlocked. In an interview The Compliance Officer asked R4 where R4 kept R4's medication's. R4 stated in the bathroom on the counter and in the top drawer. The Compliance officer observed medications sitting on the bathroom counter and in an unlocked vanity drawer the Compliance Officer observed the following medications: - Xarelto 20 MG; - Propafenone 150 MG; and - Metoprolol Succ ER 25 MG (3 bubble packs). 5. In an interview the Compliance Officer asked R4 if R4 locks the door when R4 is not in the room? R4 stated "No only at night when I'm sleeping" 6. A review of policies and procedures titled "Self-Administration Of Medications" revealed .... 2. The Wellness Director or designee will evaluate the assisted Living resident utilizing the Self--Administration Medication Assessment Tool to determine the resident's medication self-administration capabilities. This evaluation shall occur upon admission and a least quarterly thereafter or whenever a change in condition is evident. 3. If the resident is deemed capable of self-administration: All medications will be properly stored in a locked container or drawer in the resident's apartment". 7. In an interview, E2 acknowledged no documentation was available to review to show E2 had been monitoring R4's medications, and the service plan for R4, who stored medication in R4's bathroom, did not include how the medication would be stored.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, reviewed and updated at least once every six months, for one of three residents sampled who received personal care services; and at least once every three months for three of four residents sampled who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. A review of R6's medical record revealed a written service plan for directed care services dated March 1, 2023. A service plan completed no more than three months later was not available for review. 2. A review of R7's medical record revealed a written service plan for directed care services dated February 13, 2023. A service plan completed no more than three months later was not available for review. 3. A review of R8's medical record revealed a written service plan for directed care services dated February 24, 2023. A service plan completed no more than three months later was not available for review. 4. In an interview, E1, and E2 acknowledged services plans were not updated per R9-10-808.A.4.b

Based on record review, observation, and interview, the manager failed to ensure a resident had a written service plan when initially developed and when updated was signed and dated by the resident's representative, the manager and if a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan for five of nine residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R4's medical record revealed a service plan dated December 14, 2022, for personal care services. However, the service plan was not signed and dated by the following individuals: - The resident or resident's representative; - The manager; and - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan. 2. A review of R5's medical record revealed a service plan dated May 29, 2023, for directed care services. However, the service plan was not signed and dated by the following individuals: - The resident or resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 3. A review of R6's medical record revealed a service plan dated March 1, 2023, for directed care services. However, the service plan was not signed and dated by the following individuals: - The resident or resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 4. A review of R7's medical record revealed a service plan dated February 13, 2023, for directed car services. However, the service plan was not signed and dated by the following individuals: - The resident or resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 5. A review of R8's medical record revealed a service plan dated February 24, 2023, for directed care services. However, the service plan was not signed and dated by the following individuals: - The resident or resident's representative; - The manager; - If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and - If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan. 6. In an interview, E1, and E2 acknowledged the serv

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for five of five directed care residents sampled. Findings include: 1. A review of R5's, medical record revealed documentation of service plans indicating all were receiving directed care services dated May 24, 2023. However, the service plans did not contain the following: - Hydration; - Strategies to ensure a resident's personal safety; - Cognitive stimulation and activities to maximize functioning; - Encouragement to eat meals and snacks; and - The resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 2. A review of R6's medical records revealed documentation of service plans indicating all were receiving directed care services dated March 1, 2023. However, the service plans did not contain the following: - Hydration; - Strategies to ensure a resident's personal safety; - Cognitive stimulation and activities to maximize functioning; - Encouragement to eat meals and snacks; and - The resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 3. A review of R7's medical records revealed documentation of service plans indicating all were receiving directed care services dated February 2023. However, the service plans did not contain the following: - Hydration; - Strategies to ensure a resident's personal safety; - Cognitive stimulation and activities to maximize functioning; - Encouragement to eat meals and snacks; and - The resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 4. A review of R8's medical records revealed documentation of service plans indicating all were receiving directed care services dated February 24, 2023. However, the service plans did not contain the following: - Strategies to ensure a resident's personal safety; - Cognitive stimulation and activities to maximize functioning; and - The resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 5. A review of R9's medical records revealed documentation of service plans indicating all were receiving directed care services dated March 15, 2023. However, the service plans did not contain the following: - Strategies to ensure a resident's personal safety; - Cognitive stimulation and activities to maximize functioning; and - The resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 6. In an interview, E1 acknowledged the service plans did not contain all of the requirements for directed care residents. This is a repeat citation from the compliance survey conducted on May 26, 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 no documentation was available to review on evacuation drills for employees and residents conducted at least once every six months as required. 2. In an interview, E1 acknowledged no documentation was available to review on evacuation drills for employees and residents conducted at least once every six months as required. Technical assistance was provided during the on-site compliance inspection conducted on May 26, 2022.