The Terraces Assisted Living

Based on interview and record review, for one resident confined to a bed or chair and unable to ambulate, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a signed and dated determination from a primary care provider (PCP) or medical practitioner (MP), at the onset of the condition, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident if a facility retained a resident without the required authorization. Findings include: 1. In record review, R7's service plan (received directed care services), dated February 2025, included documentation that R7 was "bedbound." R7's record did not include documentation of a signed and dated determination from a primary care provider (PCP) or medical practitioner (MP), at the onset of the condition, that stated the resident's needs could be met by the facility 2. During an interview, E1 and E3 reported R7 was unable to walk, even with assistance, for approximately three months. E1 acknowledged the facility did not have a signed and written determination from the resident's PCP or MP at the onset of the condition, which stated that the facility could meet the resident's needs.

Based on observation, documentation review, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was licensed for 98 beds at the directed care level. 2. The Compliance Officer observed the facility had a secured memory care unit, with "23 residents," and an "assisted living" area with "45 residents." The facility had residents on two floors of the facility. The area outside of the secured memory care unit did not have exits that controlled or alerted staff of the egress of a resident from the facility, including but not limited to: the front entrance, doors on the second floor that exited to the stairwells, and doors that exited to the outside common area. 3. During an interview, E1 and O1 reported the facility was licensed for Directed Care services, and acknowledged the doors exiting the "Assisted Living" section of the facility provided access to outside areas, which were not controlled and/or did not alert employees of the egress of a resident from the facility.

Based on observation, record review, and interview, the manager failed to ensure medications stored by a resident in the resident's residential unit, were stored according to the resident's service plan. The deficient practice posed a health and safety risk to residents if medications were not stored in a locked manner and were accessible to residents. Findings Include: 1. A review of Department records revealed the facility was licensed for 98 beds at the Directed Care Level. 2. During an environmental inspection with E1, the Compliance Officer observed R4's residential unit door was unlocked and R4 had medications stored in an unlocked kitchen drawer. Medications observed were Altenolol, Imodium, Aspirin, Odansetron, Docusate, Senna, and Cephalaxin. 3. In record review, R4's service plan, dated March 14, 2025 (received personal care services) indicated R4 self-administered medications and stored the medications in [R4's] locked unit. The service plan documented, "Resident demonstrated correct ability to store medications in room, educated to lock apartment door when out of the apartment. 4. During an interview, E1 acknowledged R4's residential unit door was unlocked, and R4's medications were not stored according to the service plan.

Based on documentation review and interview, for two of two evacuation drills conducted, the manager failed to ensure that documentation of each evacuation drill included an identification of residents needing assistance for evacuation, and an identification of residents who were not evacuated. The deficient practice posed a health and safety risk if the staff were unaware of the needs of a resident during an evacuation. Findings include: 1. In documentation review, the facility had documentation evacuation drills conducted on November 26, 2024, and May 2024. The documentation did not include an identification of residents who needed assistance for evacuation, and an identification of residents who were not evacuated. 2. During an interview, E1 and E5 reported the facility documented the residents who were evacuated during the evacuation drills; however, the documentation of the residents who were evacuated was unable to be located.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident if toxic materials were accessible. Findings include: 1. The faciilty was licensed at the Directed Care level of services. 2. During an environmental inspection with E1, the Compliance Officer observed housekeeping carts in two separate residential areas were unattended, unlocked, and contained cleaning supplies. The toxic materials included bottles of Spar Creme Cleanser, Spic and Span, Comet liquid, and AirLift deodorizer. 3. During an interview, E1 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.

Based on documentation review, record review, and interview, for three of eight employees reviewed, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented for all staff. Findings include: 1. In documentation review, the facility had a fall prevention and fall recovery training program in place. 2. In record review, the personnel records for E5 (server hired on December 30, 2019), E6 (maintenance director hired on November 4, 2019), and E8 (housekeeper, hired on February 2, 2008) did not include documentation the employees received training on fall recovery. 3. During an interview, E1 acknowledged the employees did not receive training on fall recovery, as required.

Based on documentation review, record review, and interview, for one of four 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 able 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 documentation review, O1 reported: "Staff failed to recover patient per ARS 36-420... had a call ... for a fall injury... staff ... said patient hit their head... Patient was alert and oriented and said... just slowly slipped out of bed, never hit head. Staff on scene ... unable to lift patient and made no attempt to gather staff to help..." 2. During an interview, R2 reported a fall where paramedics arrived. "It wasn't a big deal...such a minor thing..." R2 reported [R2] did not hit head, and paramedics assisted R2 from the floor. 3. In record review, R2's medical record included an Incident Report (IR), which documented R2 had a fall in resident's room, ambulance was called, "but not used." 4. During an interview, E1 reported the facility's caregivers were trained to assist non-injured residents after a fall; however, it depended on the situation whether 911 would be called. E1 acknowledged the aforementioned incident report did not indicate the resident had an injury or hit head, and the resident was alert and oriented, and reported [R2] did not hit...head during the fall.

Based on record review, documentation review, and interview, for three of five caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. In record review, the personnel records for E4 (hired as a caregiver on March 21, 2023), E5 (hired as a caregiver on August 2, 2023), and E6 (hired as a caregiver on November 24, 2023), did not include documentation the caregivers' skills and knowledge were verified. 2. In documentation review, the staffing schedule for April 2024, included documentation the caregivers worked shifts at the facility. 3. In documentation review, a facility policy titled, "Orientation," page 2, documented "9. Competency evaluation form process: a. Each new employee is responsible for keeping track of ... competency evaluation form throughout the orientation process. b. The preceptor, or designee, shall verify competency in each skill or content area at the time competency is demonstrated. The preceptor's initials/signature indicate competency. c. The competency review form is reviewed no less than weekly to keep track of the new employee's status. Actions will be taken to assist a new employee as needed to facilitate success in the new position. d. The completed form is forwarded to the Staff Development Coordinator, or designee, the form is forwarded to the Human Resources Director to place in the employee's personnel file. f. The completed form represents initial competency in the skills needed to care for residents and perform job functions." 4. During an interview, E1 acknowledged the personnel records for the caregivers did not include documentation of the verification of the caregivers' skills and knowledge, and the verification was required before the caregiver or assistant caregiver provided services.

Based on record review, and interview, for two of five caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid training (FA) and cardiopulmonary resuscitation training (CPR) certification specific to adults which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have the required FA and CPR training. Findings include: 1. In record review, E5's personnel record (hired as a caregiver on March 21, 2023), did not include documentation of FA training. 2. In record review, E7's personnel record (hired as a caregiver on November 24, 2023, included documentation of CPR training provided by the "NationalCPRFoundation," which is an online training program, and did not include a demonstration. 3. During an interview, E1 acknowledged the caregivers did not provide the required documentation of current FA and CPR training, and reported the facility had facilitated providing CPR and FA training for employees on site.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures for medication services included procedures for assisting a resident in procuring medication. The deficient practice posed a health and safety risk if the facility did not implement procedures to ensure a resident's prescribed medications were available for administration, and a resident did not receive medication as ordered. Findings include: 1. In record review, R3's medical record (received directed care services) included an order for Mirtazapine 7.5 mg, take one tablet by mouth at hour of sleep. The medication administration record (MAR) indicated R3 did not receive the medication on November 4, 2023, through November 9, 2023. The MAR included "Notes" which documented on November 5 through November 8, 2023, "not on cart..." The MAR did not include a note for November 4 and November 9, 2023, which indicated why the medication was not administered to R3. 2. During an interview, E2 reported the resident refused the medication on November 4, 2023, and the facility did not have the medication available for administration on the other days. 3. In documentation review, the compliance officer requested to review the facility's medication policies and procedures for procuring medication for residents. The facility provided a policy, which documented on page 86, "6. Procuring Medication A. The resident or resident's representative must arrange for timely delivery of medications to the facility. The facility may assist the resident or resident's representative in making those arrangements..." On page 87, the medication policies documented, "E. Refilling Medications a. To refill a medical practitioner's order the manage/caregiver will contact the resident or resident's representative to report the need for additional medications. As a courtesy to the resident and representative the facility may upon resident or representative authorization contact the pharmacy to refill needed medications..." 4. During an interview, E1 and E2 reported the facility assisted R3 in procuring R3's medications from the pharmacy. E1 and E2 acknowledged the resident's medication was unavailable for administration during the week of November 5 through 9, 2023.

Based on record review and interview, for one of four residents reviewed, the manager failed to ensure medications were administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medications in compliance with a medication order, and a resident did not receive medication as ordered. Findings include: 1. In record review, R3's medical record (received directed care services) included an order for Mirtazapine 7.5 mg, take one tablet by mouth at hour of sleep. The medication administration record (MAR) indicated R3 did not receive the medication on November 4, 2023, through November 9, 2023. The MAR included "Notes" which documented on November 5 through November 8, 2023, "not on cart..." The MAR did not include a note for November 4 and November 9, 2023, which indicated why the medication was not administered to R3. 2. During an interview, E2 reported the resident refused the medication on November 4, 2023, and the facility did not have the medication available for administration on the other days. 3. During an interview, E1 and E2 reported the facility assisted R3 in procuring R3's medications from the pharmacy. E1 and E2 acknowledged the resident's Mirtazapine medication was not available for administration during the week of November 5 through 9, 2023.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C), for four of four personnel members sampled. Findings include: 1. A review of E1's, E3's, E4's, and E5's personnel records revealed no documentation to indicate previous employers were contacted to obtain information or recommendations that may be relevant to E1's, E3's, E4's, and E5's fitness to work in a residential care institution. 2. In a joint interview, E1 and E2 reported E1, E3, E4, and E5 had documentation of reference checks done prior to their hire dates, but the documentation was unable to be provided within two hours after the Department's request.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation training (CPR) for applicable employees and volunteers, including the method and content of CPR, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation, for one of four personnel members sampled. Findings include: 1. A review of E3's personnel record revealed documentation of CPR training dated September, 13, 2022. The documentation indicated the CPR training did not include a demonstration of E3's ability to perform CPR. The documentation stated the CPR training was an "E-Learning" course. 2. In a joint interview, E1 and E2 acknowledged policies and procedures for CPR training did not include the method and content of CPR training to include a demonstration of the employee's or volunteer's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of four personnel members sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of E3's personnel record revealed no documentation of evidence of freedom from infectious TB. 2. In a joint interview, E1 and E2 acknowledged E3's personnel record did not contain documentation of evidence of freedom from infectious TB.

Based on documentation review, record review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with Arizona Administrative Code (A.A.C.) R9-10-807(G), for one of six residents sampled. Findings include: 1. A.A.C. R9-10-807(C) states: "C. A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails." 2. A review of R3's medical record revealed a residency agreement dated March 21, 2023. The residency agreement stated: "Upon fourteen (14) days prior written notice provided to the Resident, The Terraces may terminate this agreement for the following non-medical reasons: a. If Resident fails to comply with Resident Rules and Regulations...or b. If Resident fails to pay the Monthly Service Fee or any other charges and amounts when due..." The residency agreement did not include terminology in compliance with A.A.C. R9-10-807(G)(2)(b). 3. In a joint interview, E1 and E2 reported R3 may have been provided with an outdated residency agreement. E1 and E2 acknowledged R3's residency agreement did not contain provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G).

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement and any amendments, for two of six residents sampled. Findings include: 1. A review of R1's and R6's medical records revealed no documentation of R1's or R6's residency agreement. 2. In a joint interview, E1 and E2 reported R1 and R6 did have residency agreements, but the agreements were not maintained in R1's or R6's medical records.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for two of six residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R1's and R6's medical records revealed no documentation of notification of R1 or R6 of the availability of vaccination for influenza and pneumonia. 2. In an interview, E1 acknowledged R1's and R6's medical records did not contain documentation of notification of R1 or R6 of the availability of vaccination for influenza and pneumonia.

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 four of six residents sampled. Findings include: 1. A review of R1's, R3's, R5's, and R6's medical records revealed no documentation of orientation to exits from the assisted living facility. 2. In a joint interview, E1 and E2 reported R1, R3, R5, and R6 had completed the orientation but the documentation was not on file. E1 and E2 acknowledged R1's, R3's, R5's, and R6's medical records did not contain documentation of orientation to exits from the assisted living facility.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked room, closet, cabinet, or self-contained unit. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bottle of "CVS Health Ibuprofen 200 mg (milligrams)" and a bottle of "Similasan Ear Wax Removal Kit 33 oz (ounces)" in R2's bedroom. The medications were not stored in a locked area and were accessible to residents. 2. A review of R2's medical record revealed a service plan dated August 11, 2023. The service plan indicated R2 received assistance with self-administration of medication. 3. In an interview, E1 acknowledged the aforementioned medications for R2 were not stored in a separate locked room, closet, cabinet, or self-contained unit.