The Retreat at Alameda

Based on record review, documentation review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide the emergency responders with a written document that included all information required in A.R.S. § 36-420.04, for one of four residents 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 R3's medical record revealed an incident that occurred on March 01, 2025. The Incident/ Accident Report stated, “At 2:28 pm on 3/1/2025, a server delivered lunch meal to resident [R3]. At that time [Staff] saw something wrong due to [R3] not responding to basic commands. … went into [R3] room and [R3] was unresponsive… while on phone with 911, performed CPR until fire dept. & paramedics arrived…” However, R3 was pronounced dead later that day. 2. A review of facilities policy and procedures revealed a policy titled "Advanced Directive." The policy stated, "It is the policy of The Retreat at Alameda that each Resident must provide information addressing an advanced directive, prior to becoming a Resident in our Community..." 3. A review of Department documentation revealed that on March 1, 2025, EMS was requested for R3; however, the facility did not provide the required documentation of a copy of the resident’s advance directives, if any, on file at the facility. O1 stated that ‘There was no DNR in that paperwork either. Later to find out at the hospital that the [O2] called the pt’s [O3] and [O2] found out the pt does in fact have a DNR and the facility failed to produce one to ems at the time arrival to pt’s bed side.’ 4. In an interview, E3 acknowledged that the documentation provided to the emergency responder did not include a copy of the resident’s advance directives, if any, on file at the facility. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the complaint investigation conducted on July 23, 2024, and the complaint investigation and compliance inspection conducted on January 30, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that an assisted living center maintained a copy of the document provided to the emergency responders and documentation of the actions required for a period of two years after the date of the emergency. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).” 2. A review of R3's medical record revealed an incident that occurred on March 01, 2025. The Incident/ Accident Report stated “At 2:28 pm on 3/1/2025, a server delivered lunch meal to resident [R3]. At that time [Staff] saw something wrong due to [R3] not responding to basic commands. … went into [R3] room and [R3] was unresponsive… while on phone with 911, performed CPR until fire dept. & paramedics arrived…” However, R3 was pronounced dead later that day. 3. In an interview, E3 reported that the facility had completed an EMS packet for the emergency responders on March 01, 2025; however, the facility did not retain a copy of the document provided to the emergency responders or maintain documentation of the required actions for a period of two years after the date of the emergency. 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 provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. The deficient practice posed a risk, if the Department was not informed of a resident's death, and was unable to assess a potential danger to other residents at the facility. Findings include: 1. A.R.S. § 11-593 states, "B. Reporting is required in the following circumstances: ... 3. Unexpected or unexplained death." 2. A review of R3's medical record revealed an incident that occurred on March 01, 2025. The Incident/ Accident Report stated “At 2:28 pm on 3/1/2025, a server delivered lunch meal to resident [R3]. At that time [Staff] saw something wrong due to [R3] not responding to basic commands. … went into [R3] room and [R3] was unresponsive… while on phone with 911, performed CPR until fire dept. & paramedics arrived…” However, R3 was pronounced dead later that day. 3. A review of R3's medical record revealed a document titled. “MARICOPA COUNTY Office of the Medical Examiner” dated March 03, 2025. The document stated, “You are commanded pursuant to the Medical Examiner’s subpoena powers to produce the following specimens, documents, reports and papers designated below. See Federal Title 45 CFR 164.512(g) & A.R.S. § 11-594(A)(4). This request is made because the decedent’s death falls under one of the circumstances enumerated under A.R.S. § 11-593. The county medical examiner is required by law to direct a death investigation in this instance to determine the circumstances of this death and to fulfill the requirements as mandated by A.R.S. § 11-594…” 4. A review of Department documentation received from the facility revealed no documentation of notification of R3's death according to A.R.S. § 11-593. 5. In an interview, acknowledged written notification to the Department of R3's death was required according to A.R.S. § 11-593, and was not provided within one working day after the resident's death. 6. 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 a documented residency agreement was available for one of four residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R3's medical record revealed no residency agreement. Based on R3's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged that R3's medical record did not have a documented residency agreement. 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 one of four residents sampled received a copy of the policy and procedure on health care directives at the time of acceptance. Findings include: 1. A review of facilities policy and procedures revealed a policy titled "Advanced Directive." The policy stated, "It is the policy of The Retreat at Alameda that each Resident must provide information addressing an advanced directive, prior to becoming a Resident in our Community..." 2. A review of R3's medical records revealed no documentation indicating the residents received a copy of the facility's policy and procedure on health care directives. 3. In an interview, E1 acknowledged that no documentation was provided to the Department to demonstrate that R3 or R3’s representative received a copy of the facility’s policy and procedure on health care directives before or at the time of the individual’s acceptance into the assisted living facility. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure safeguards exist to prevent unauthorized access if an assisted living facility maintains residents' medical records electronically. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a laptop on a medication cart. The laptop was on and open. Upon further review, the Compliance Officer was able to access resident file information including diagnosis and face sheet. A staff member closed the website used. After walking around the memory care unit of the facility, the Compliance Officer observed the laptop on the medication cart on and open again, with the Compliance Officer able to access resident information. 2 . In an interview, E1 acknowledged E1 failed to ensure safeguards exist to prevent unauthorized access if an assisted living facility maintains residents' medical records electronically.

Violation cited

Violation cited

Based on documentation review and interview, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. 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 on July 15, 2024 which resulted in the need for emergency medical services (EMS). A statement of the incident included "Medtech started on paperwork but the computer was down." 2. In an interview, E1 reported E1 was unsure if the documentation required was given the emergency responder, and went to double check. Upon return, E1 confirmed the documentation had not been supplied to the emergency responder. 3. In an interview, E1 acknowledged written documentation with all required information was not given to the emergency responder when EMS services were called.

Based on documentation review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were documented and verified before the caregiver or assistant caregiver provided services and according to policies and procedures, for one of two sampled caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility policy and procedures revealed a policy detailing how skills and knowledge for a caregiver were verified and documented was not available for review at the time of inspection. 2. A review of E2's personnel record revealed documentation of skills and knowledge being verified was not available for review at the time of inspection. 2. In an interview, E1 acknowledged E2's documentation of skills and knowledge being verified and documented and a policy and procedure on how skills and knowledge would be verified and documented was not available for review at the time of inspection.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility the Compliance Officer observed a bench blocking a hallway to an exit from the memory care section of the facility. 2. In an interview, E1 reported unsure why the bench was located in the hallway as they have had multiple corrective actions to stop this type of incident. 3. In an interview, E1 acknowledged the bench blocking access to an exit was a condition were a resident or other individual could suffer physical injury.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if facility staff were unable to implement the disaster plan. Findings include: 1. A review of facility documentation revealed no documentation to indicate the facility's disaster plan was reviewed at least once every 12 months. 2. In an interview, E1 acknowledged there was no documentation to indicate the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of facility documentation revealed no documentation to indicate a fire inspection was conducted by the local fire department or the State Fire Marshal. 2. In an interview, E1 acknowledged a fire inspection was not conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal.