The Villas at Wilmot, Villa a

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel records reviewed. The deficient practice posed a risk if E5 was a danger to a vulnerable population. A.R.S. § 36-411 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459. D. An empl

Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's service plan for one of two residents sampled. Findings include: 1. A review of facility staff schedules revealed the facility operated two shifts per day, 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m. 2. A review of R1’s medical record revealed a service plan, dated January 5, 2025, for directed care services. The service plan included the provision of showering twice per week to include, "Set-up, Lower body, hair, and back," and stated, "See shower schedule for current days. Document when showers are given." 3. A review of R1’s medical record revealed a document, titled, "Caregiver ADL Checklist" used for tracking activities of daily living (ADLs), Dated March, 2025. The document included sections for documenting the service “Bathing” The ADL documented the following showering services were provided during March, 2025: On March 1, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 4, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 7, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 14, 2025, on the "7a-7p" shift, "Bathing" was marked with an "R" to indicated R1 refused the shower; On March 19 , 2025, on the "7a-7p" shift, "Bathing" was marked with an "R" to indicated R1 refused the shower; and On March 27, 2025, on the "7a-7p" shift, "Bathing" was marked, "cue." 4. In an interview, E1 acknowledged the ADL documentation provided for R1 did not document R1 had been provided with two showers per week as required by R1's service plan.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. Findings include: A review of R1's medical record revealed R1 received directed care services and medication administration. A review of R1's medical record revealed a signed but undated medication order, for "Valproic Acid, 250 MG/5ML, Take 5ML by mouth twice daily at 8:00 AM, 5:00 PM." A review of R1's February 2025 medication administration record (MAR) revealed R1 had received 5 milliliters of Valproic Acid at 8:00 AM and 5:00 PM on each day except as follows: On February 13, 2025 at 5:00 PM, reason, "Refused;" On February 16, 2025 at 8:00 AM, reason, "Refused;" On February 20, 2025 at 8:00 AM, reason, "Refused;" On February 23, 2025 at 8:00 AM, reason, "Not in med cart;" and On February 24, 2025 at 8:00 AM, reason, "Not in med cart." A review of R1's medical record revealed documentation of progress notes as follows: On February 17, 2025 at 6:01 PM, "Resident remained in [their] room throughout the day, refused to get up from bed, also refused medication until RCC talked to [them] then [they] took meds. On February 22, 2025 at 9:16 AM, "Staff went to give resident her medication while resident was laying down on her, resident turned over and just grabbed onto staff hair and started pulling it, staff asked resident multiple times for resident to let go of staff's hair, staff had to manually remove residents' hands off of her. Resident did not take her meds. A review of an incident report involving R1 revealed a statement signed by E4 on March 27 2025. The statement included the following: "...went to give [R1] her AM meds. The resident was already upset and sitting on the edge of the bed. [E4] went to hand her the liquid med, [R1] slapped it out of her hand it landed all over the resident.... The resident would not take any meds for that day, we tried for a week to give her her meds but she would not take them, other staff members tried. A review of R1's February 2025 and March 2025 MAR's revealed the only liquid medication was Valproic Acid. However, E4 had not marked Valproic acid as refused at any time in the two months reviewed, and the medication had never been marked refused for more than a single dose. In an interview, E1 acknowledged medication administered to R1 had not been accurately documented in R1's medical record.

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. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed, in the kitchen, a cabinet above the kitchen counter, without a lock, contained an unlabeled prescription bottle with a single tablet inside. 2. In an interview, E1 acknowledged a medication was not stored in a separate locked cabinet.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two 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 R3's medical record revealed a service plan dated March 2, 2024, for directed care services. However, the service plan was not signed and dated by R3 or R3's representative, and documentation of attempts to contact R3's representative to obtain a signature was not available for review. 2. In an interview, E1 acknowledged the service plan provided for R3 had not been signed and dated by R3 or their representative when the plan was developed or updated. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on May 18, 2023.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan, dated March 2, 2024, for directed care services, including medication administration. 2. A review of R2's medical record revealed a list of medication orders from R2's primary care physician, dated February 29, 2024, which included: - "Doxepin HCI 10 MG Oral Capsule, 1 capsule (10mg) orally daily at bedtime (start date: 12/19/2023)." 3. A review of R2's medical record revealed a list of medication orders from R2's psychiatric provider, dated January 16, 2024, which included: - "Continue Doxepin 10 mg PO QHS # PMHNP (insomnia)." 4. A review of R2's medical record revealed a medication administration record (MAR) dated May 2024. However, the MAR did not include documentation of administration of Doxepin 10 milligram capsules to R2. 5. The Compliance Officer observed multi-dose packages of medications for R2 did not include 10 milligram Doxepin capsules. 6. In an interview, E1 acknowledged R2 had not been provided 10 milligram Doxepin as ordered. E1 contacted R2's doctor during the on-site inspection and obtained an order to discontinue the medication. This is a repeat deficiency from the the on-site complaint inspection conducted on November 20, 2023 and the on-site compliance and complaint inspection conducted on May 18, 2023.

Based on record review, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk as administered medication could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan, updated August 10, 2023, for directed care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders, dated November 7, 2023, which included the following order: - "Glucose 4GM Chew Tab, Chew 4 tablets by mouth as needed for low blood sugar - chew tablets." 3. A review of R1's medical record revealed a signed list of medication orders, dated November 3, 2023, which included the following order: - "Check fingerstick blood sugar before meal and document result every day. If blood sugars are below 70 mg/dl: Call [medical provider]." 4. A review of R1's medical record revealed a form titled, "Resident Blood Sugar Tracking Form," dated November 2023. The form documented R1's blood sugar at "am," "noon," and, "pm," on each day between November 1, 2023 and November 16, 2023. The blood sugar chart documented the following: - On November 4, 2023 at, "am," R1's blood sugar had not been documented; - On November 5, 2023 at, "am," R1's blood sugar was documented to have been 55; - On November 5, 2023 at, "noon," R1's blood sugar had not been documented; - On November 5, 2023 at, "pm," R1's blood sugar had not been documented; - On November 6, 2023 at, "am," R1's blood sugar had not been documented; - On November 6, 2023 at, "noon," R1's blood sugar had not been documented; - On November 6, 2023 at, "pm," R1's blood sugar had not been documented; - On November 7, 2023 at, "noon," R1's blood sugar had not been documented; - On November 7, 2023 at, "pm," R1's blood sugar had not been documented; - On November 9, 2023 at, "noon," R1's blood sugar had not been documented; - On November 10, 2023 at, "noon," R1's blood sugar had not been documented; - On November 10, 2023 at, "pm," R1's blood sugar was documented to have been 65; - On November 12, 2023 at, "noon," R1's blood sugar was scribbled out and had been rendered illegible; - On November 12, 2023 at, "pm," R1's blood sugar was scribbled out and had been rendered illegible; and - On November 13, 2023 at, "noon," R1's blood sugar had not been documented. 5. A review of R1's medical record revealed an electronic medication administration record (eMAR) dated November 2023. The eMAR included, "Check Blood Sugars" at 7:00 AM, 11:00 AM, and 4:00 PM, starting November 15, 2023 at 4:00 PM through November 20, 2023 at 7:00 AM. The blood sugar chart documented the following: - On November 17, 2023 at 6:20 AM, R1's blood sugar was documented to have been 55; and - On November 17, 2023 at 4:01 PM, R1's blood sugar was documented to have been 67. 6. A review of R1's medical record revealed documentati

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. The Compliance Officer requested incident reports as required by R9-10-818.D.1-2 for R1. The Compliance Officer was provided with one report dated November 17, 2023 at 4:30 pm. However, no other documentation was provided regarding R1 having an emergency, injury, or accident requiring medical services. 2. A review of R1's medical record revealed a discharge summary from a hospital dated August 29, 2023. The discharge summary stated the reason for admission was, "syncope, found slumped in chair by facility staff." However, a facility generated document regarding this emergency medical service was not available for review. 3. In an interview, E1 reported R1 was also hospitalized on September 29, 2023, when R1's medical provider was at the facility and called paramedics due to concerns of a bowel obstruction. E1 reported R1 went to the same hospital as on the August 29, 2023 incident. However, a facility generated document regarding this emergency medical service was not available for review. 4. A review of R1's medical record revealed a blood sugar log dated November 2023, which indicated R1's blood sugar had not been checked before any meal on November 14, 2023. The log included the comment, "hospital." However, a facility generated document regarding this medical service was not available for review. 5. In an interview, E1 and E2 acknowledged documented incident reports for R1 detailing each accident, emergency, or injury requiring medical services had not been provided for review.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an incident resulting in the resident needing medical services. Findings include: 1. The Compliance Officer requested incident reports as required by R9-10-818.D.1-2 for R1. The Compliance Officer was provided with one report dated November 17, 2023 at 4:30 pm. However, no other documentation was provided regarding R1 having had an emergency, injury, or accident requiring medical services. 2. A review of R1's medical record revealed a discharge summary from a hospital dated August 29, 2023. The discharge summary stated the reason for admission was, "syncope, found slumped in chair by facility staff." However, a facility generated document regarding this emergency medical service was not available for review. 3. In an interview, E1 reported R1 was also hospitalized on September 29, 2023, when R1's medical provider was at the facility and called paramedics due to concerns of a possible bowel obstruction. E1 reported R1 went to the same hospital as on the August 29, 2023 incident and was discharged a few days later. However, a facility generated document regarding this emergency medical service was not available for review. 4. A review of R1's medical record revealed a blood sugar log dated November 2023, which indicated R1's blood sugar had not been checked before any meal on November 14, 2023. The log included the comment, "hospital." However, a facility generated document regarding this medical service was not available for review. 5. In an interview, E1 and E2 acknowledged documented incident reports for R1 detailing each accident, emergency, or injury requiring medical services had not been provided for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated May 8, 2023, for directed care services. However, the service plan was not signed and dated by R1 or R1's representative. 2. In an interview, E1 acknowledged the service plan provided for R1 had not been signed and dated by R1 or their representative when the plan was developed or updated. Technical assistance for this rule was provided during the on-site compliance inspection conducted on May 25, 2022.

Based on documentation review, record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated March 26, 2023, for directed care services including medication administration. 2. A review of R2's medical record revealed an order, dated March 24, 2023, for "Midodrine HCI 5 MG Oral Tablet, Give 1 tab PO TID hold for systolic pressure > 120." 3. A review of R2's medical record revealed a deprecated order, dated February 28, 2023, for "Midodrine HCI 10 MG, PO 1 tab TID." 4. The Compliance Officer observed a multi-dose package of R2's medications included a package of, "Midodrine HDL 10 MG tablets, Take 1 tablet by mouth three times daily, hold for SBP > 120." 5. A review of R2's medical record revealed documentation of R2's blood pressure three times per day was not available for review. 6. A review of R2's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR indicated R2 had received, "Midodrine, 8am, 12pm, 5pm, 10mg, PO, 1 Tablet TID," on each day between May 1, 2023, and May 18, 2023. 7. In an interview, E1 acknowledged medication had not been administered to R2 in compliance with a medication order.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a paper cup of loose medications in a drawer above the kitchen counter. The drawer did not have a lock. 2. During an environmental inspection of the facility, the Compliance Officer observed two packages of Albuterol Sulfate in a drawer above the kitchen counter. The drawer did not have a lock. 3. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.