Tucson Place, Assisted Living & Memory Care

Based on documentation review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to immediately report the suspected abuse, neglect, or exploitation of the resident, according to A.R.S. § 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. R9-10-101.111 stated "Immediate" means without delay. 2. A review of facility documentation revealed a document dated January 11, 2026, which documented alleged physical abuse of a resident by another resident. Further review revealed documentation of an internal investigation, which included documentation of notification to Adult Protective Services (APS). However, notification to APS was documented as completed on January 12, 2026, at approximately 4:45 p.m. 3. In an interview, E1 advised they became aware of the alleged abuse when E1 arrived to work on the morning of January 12, 2026, but did not make the required report until later in the afternoon. E1 agreed they did not make the report immediately, as required by A.R.S. § 46-454. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from an inspection conducted on November 15, 2023 and May 14, 2025.

Based on documentation review and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of five personnel sampled. Findings include: 1. A review of E7's personnel record revealed a hire date of July 4, 2024. E7's personnel file included documentation of initial fall prevention and fall recovery training. However, E7's personnel file did not include documentation of continued competency training on fall prevention and fall recovery. 2. In an interview, the findings were reviewed with E1. E1 acknowledged the facility required annual fall prevention and fall recovery training. E1 acknowledged E7 had not completed the fall prevention and fall recovery continued competency training for this year. This is a repeat deficiency from the compliance/complaint inspection conducted on April 14, 2025, the complaint inspection conducted on March 10, 2023, and the complaint inspection conducted on January 30, 2023.

Based on documentation review and interview, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider (PCP). Findings include: 1. A review of facility documentation revealed that 5 out of 5 incident reports reviewed by the Compliance Officer included the date when the emergency contact and PCP were contacted; however, the incident reports did not include the times the emergency contact and PCP were contacted. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged that the time the residents' emergency contact or PCP was contacted was not included in the documentation. E1 indicated that staff were advised to include the information in the "notes" section of the incident reports, but failed to do so. This is an uncorrected deficiency from the complaint inspection conducted September 9, 2025.

Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. Findings include: 1. A review of facility documentation revealed an incident report dated August 28, 2025. The report stated “[R4] had an unwitness fall on overnight shift and have no obvious injuries at this time 911 was called to help lift [R4] off the floor…” 2. In an interview, E1 confirmed 911 was called for a lift assist. E1 was informed of the statute, and E1 acknowledged facility personnel failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident, who had fallen, appeared to be uninjured, and was unable to reasonably recover independently.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver assisted with activities of daily living according to the resident’s service plan, and/or documented services provided in the resident's medical record, for two of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include:  1. A review of R4’s medical record revealed a service plan dated May 13, 2025, for directed care services. The service plan included the type, amount, and frequency of a variety of activities of daily living, including medication administration. Further review of R4’s medical record revealed a document titled “Care Services,” used for documenting provided services listed in R4’s service plan, during August 2025. However, the document contained numerous blank spaces, and sections indicating services were undocumented. 2. A review of R5’s medical record revealed a service plan dated July 21, 2025, for directed care services. The service plan included the type, amount, and frequency of a variety of activities of daily living, including medication administration. Further review of R5’s medical record revealed a document titled “Care Services,” used for documenting provided services listed in R5’s service plan, during August 2025. However, the document contained numerous blank spaces, and sections indicating services were undocumented. 3. In an interview, E1 acknowledged R4’s and R5’s medical records did not contain evidence of documentation of services provided. 4. This is a repeat deficiency from the complaint inspection conducted June 24, 2024, and the compliance/complaint inspection conducted April 14-15, 2024.

Based on record review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. A review of facility documentation revealed an incident report dated August 26, 2025. The report stated “[R4] had an unwitness fall on overnight shift and have no obvious injuries at this time 911 was called to help lift [R4] off the floor…” The report included a section titled “Fall Details” which described the “Fall surface” as “Hard.” The report indicated “No Medical Treatment Necessary,” and identified an “Action” as “ Non-Emergency Fire Department.” 2. In an interview, E1 confirmed 911 was called to assist R4 off the ground after they suffered an unwitnessed fall. E1 did not know how long R4 lay on the floor prior to emergency medical services responding and assisting R4 off the floor. E1 acknowledged R4 was not treated with dignity or consideration when the caregiver did not render first aid and left R4 on the floor until emergency medical services responded. 3. This is a repeat deficiency from the complaint inspection conducted May 14, 2025.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's primary care provider or emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a risk as the standards expected of employees were not followed. Findings include: 1. A review of facility incident reports revealed an incident report for R2, dated September 3, 2025, in which emergency services were contacted. The incident report indicated R2 was “found in the bathroom floor” at 6:45 a.m., and emergency medical services were contacted. The report included documentation of the notification of R2’s emergency contact and primary care provider. However, evidence of documentation of the time R2’s emergency contact was immediately notified was unavailable for review. 2. A review of facility incident reports revealed two incident reports in August 2025, in which emergency services were contacted for R4. The first report, dated August 3, 2025, indicated 911 was called and R4 was transported to the hospital after suffering an unwitnessed fall, and complaining of hip pain. The report included documentation of the notification of R4’s emergency contact and primary care provider. However, evidence of documentation of the time R4’s emergency contact and primary care provider were immediately notified was unavailable for review. A review of the second report, dated August 28, 2025, revealed 911 was called after R4 suffered an unwitnessed fall. The report included documentation of notification of R4’s emergency contact, but did not include documentation of notification of R4’s primary care provider. Furthermore, the report did not include documentation of the time R4’s emergency contact was immediately notified. 3. A review of facility incident reports revealed an incident report for R5, dated September 9, 2025, in which emergency services were contacted. The report indicated R5 was found in the dining room with their “head down the table,” and indicated “[R5’s] hands were cold and like fainted for a while.” The report reflected R5 was transported to the hospital, and R5’s emergency contact was notified. However, evidence of documentation of the time R5’s emergency contact was immediately notified was unavailable for review. Furthermore, evidence of documentation R5’s primary care provider was immediately notified was unavailable for review. 4. In an interview, E1 agreed there was no evidence to indicate emergency contacts and/or primary care providers were immediately notified, for incidents in which emergency services were contacted for R2, R4, and R5.

Based on document review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454. The deficient practice posed a risk as there was a delay in reporting, according to A.R.S. § 46-454, and designated standards were not followed. Findings include: 1. A review of facility documentation revealed an incident report, dated April 23, 2025, which documented alleged verbal abuse of a resident by a caregiver. Further review revealed documentation of an internal investigation conducted between April 23 and 26, 2025, compliant with R9-10-803(J)(1-6), including documentation of notification of Adult Protective Services. However, notification of Adult Protective Services (APS) was documented as having been completed on April 29, 2025. 2. In an interview, E1 acknowledged the incident report and internal investigative documents documented an allegation of abuse of a resident by a caregiver. E1 indicated they became aware of the incident on April 28, 2025, and reported APS was notified on April 29, 2025. E1 indicated law enforcement was never notified. E1 agreed APS was not notified immediately, per A.R.S. § 46-454.

Based on record review and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program, as required in R9-10-806(A)(1)(b)(i). The deficient practice posed a risk if the individuals were not qualified to provide the required services. Findings include: 1. A review of E9’s personnel record revealed evidence of documentation of E9’s caregiver certificate was unavailable for review. Research conducted through https://azcg.tmutext.com/search revealed E9 was a certified caregiver. 2. In an interview, E1 agreed E9 had not provided documentation of completion of a caregiver training program as required.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for three of nine employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E7’s personnel record revealed evidence of documentation of baseline screening for signs and symptoms, and an assessment of risk of exposure to active TB was unavailable for review. 2. A review of E8’s personnel record revealed evidence of documentation, dated July 23, 2019, indicating E8 had a history of testing positive for TB. No additional documentation to indicate E8 had been examined by a medical provider and deemed free from symptoms of infectious TB was available for review. 3. A review of E9’s personnel record revealed evidence of documentation of an initial skin test for TB, as well as baseline screening; however, evidence of a second negative TB skin test or a negative blood test conducted within 12 months of E9’s date of hire was unavailable for review. 4. In an interview. E1 acknowledged E4, E7, E8, and E9 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date E4, E7, E8, and E9 began providing services at or on behalf of the assisted living facility.

Based on record review, document review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. A review of facility documentation revealed investigative reports about R1’s allegation of abuse by E3. The reports reflected E2 became aware of the allegation on April 23, 2025, at approximately 5:30 p.m., and outlined E2’s investigation into the allegation. Notes within the documentation reflect E2 confirmed R1’s allegations with R1 at approximately 5:48 p.m., on the same date. Documentation further reflects E2 first informed E1 on April 27, 2025, after E2’s investigation. 2. A review of E3’s personnel record revealed a document titled “Notice of Suspension Without Pay,” dated April 30, 2025. The document indicated E3 was “suspended to ensure the safety and well-being of residents…” Further review revealed a “Time Card,” documenting times and days E3 worked between April 20, 2025, and April 28, 2025. The record reflected E3 worked over seven hours on April 23, 2025 and April 24, 2025 over fourteen hours on April 25, 2025, and over sixteen hours on April 27, 2025. 3. A review of facility staffing schedules for April 2025 revealed E3 was scheduled to work from 2:00 p.m. until 10:00 p.m. on April 23, 24, 25, and 27, 2025. 4. In an interview, R1 appeared confused, and was unable to provide any information relating to resident rights. 5. In an interview, E1 acknowledged they were not informed of R1’s allegations against E3 for four days after the initial report. E1 agreed R1 was not treated with respect or consideration when E3 was allowed to return to work, despite R1 having informed the facility of their complaint against E3 and while E2 was conducting their investigation.

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of four personnel sampled. Findings include: 1. A review of the facility’s fall prevention and fall recovery program revealed documentation of a program. However, the program did not include initial training and continued competency training for employees. 2. A review of E5’s, E6’s, E7’s, E8’s, E9’s, E10’s, E11’s, and E12’s personnel records revealed evidence of documentation each employee had received initial training in fall prevention and fall recovery, as well as continued training in fall prevention and fall recovery, based upon each employees date of hire. 3. In an interview, E1 acknowledged the facility had been carrying out initial training and continued competency in fall prevention and fall recovery. E1 agreed the facility’s fall prevention and fall recovery program did not specifically include initial training or continued competency as required.

Based on observation, documentation review, and interview, the Governing Authority failed to designate, in writing, a manager compliant with R9-10-803.A.3. Findings include: 1. During a facility tour conducted on April 14, 2025, the Compliance Officer observed certificate ALM-013074 prominently displayed near the foyer. The certificate identified O1 as a “Certified Assisted Living Facility Manager” and indicated the certificate expired on April 4, 2025. 2. Online research conducted through the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers, https://aznciab.portalus.thentiacloud.net/webs/portal/register/#/, revealed documentation indicating “License Number ALM-013074,” associated with O1, expired on April 5, 2025, and had not been renewed. 3. The Compliance Officer informed E1 the current manager’s license on display had expired, and requested to review the personnel record of the current manager. E1 advised E1 was not aware O1’s manager’s license had expired. E1 advised the current manager's personnel record was unavailable for review. 4. In an interview, E1 advised O1 had placed O1's license on display as a correction to a previous citation for non-compliance with R9-10-803.A.b. E1 reported O1’s position as a manager was not permanent, and E1 was unaware O1’s license had expired. E1 agreed a licensed assisted living facility manager had not been designated in writing as required per R9-10-803.A.b. This is a repeat citation from a complaint investigation conducted on February 21, 2025.

Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411 by failing to verify each employee was not on the adult protective services registry (APS), pursuant to section 46-459, for eight of eight employees sampled. The deficient practice posed a risk if any employee was a danger to a vulnerable population. Findings include: 1. A review of E5’s, E6’s, E7’s, E8’s, E9’s, E10’s, E11’s, and E12’s personnel records revealed evidence of documentation verifying each employee is not on the APS registry was unavailable for review. 2. In an interview, E1 advised they were unaware of the change in A.R.S. § 36-411 and indicated none of the employees at the facility had been checked through the APS registry. Prior to the conclusion of the survey, E3 produced evidence of documentation indicating E5, E6, E7, E8, E9, E10, E11, and E12 had been verified as not being on the APS registry.

Based on document review, record review, and interview, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of facility documentation revealed an incident report documenting an incident that occurred on March 10, 2025, involving R1. The report indicated R1 “was off, not [R1’s] self,” was “very confused…,” and “kept falling back off the WC every time [R1] tried to stand up.” The report reflected “paramedics suspected that resident maybe has UTI,” and R1 was transported to the hospital. 2. A review of R1’s medical record revealed documentation dated March 12, 2025, titled “After Visit Summary,” which summarized R1’s hospital visit after the aforementioned March 10, 2025 incident. The summary did not include documentation of the reason for R1’s hospital visit. The summary included basic vital sign information, current medications, and lab tests ordered; however, the summary did not include documentation of any current or past medical diagnoses, injuries, or physical conditions, including any documentation referring to a urinary tract infection or other treatable medical condition, which may have contributed to R1’s confusion. 3. A request was made to review R1’s progress notes from January 1, 2025, through April 14, 2025. A review of R1’s medical record revealed progress notes within the requested date range, beginning on January 21, 2025. A note entry on February 20, 2025, documented concerns regarding R1’s “depression” and discussed the possible need for a psychiatric evaluation. Entries on March 11, 2025 and March 12, 2025, were related to R1’s hospitalization and return, after the incident on March 10, 2025. Two entries on March 13, 2025, document observation of R1’s confusion at “3:45 AM” and “2:36 PM.” R1 was observed at 3:45 AM “up all night wandering very confused, locking [R1's self] out of [R1's] room.” At 2:36 PM, R1 was observed “…happily confused,” needing frequent reminders to use R1's walker, socializing with others, and spending “some time in [R1’s] room relaxing.” Entries on March 14, 2025 and March 15, 2025, document observations of R1 having a “fair day,” being “confused,” “argumentative with staff,” “downstairs socializing, and needing frequent reminders." An entry on March 26, 2025, indicated R1 “continues with odd behavior, PCP in today and will make changes to [R1’s] night medications.” Entries on April 1, 2025, reflect R1 was found “by the ditch…asking for help…had bumps on the back of [R1’s] head, bruises on [R1's] knees, elbow and hands…” The entries also reflect R1 was transported to a hospital and returned from a hospital visit the same night. An entry on April 1, 2025 reflects R1 was moved to memory care “due t

Based on record review and interview, the manager failed to ensure, before providing assisted living services to a resident, a caregiver received orientation specific to the duties to be performed for four of seven caregivers sampled. Findings include: 1. A review of E6’s, E7’s, E9’s, and E12’s personnel records revealed each employee was hired as a caregiver or as a medication technician, whose duties included those of a caregiver. Further review revealed evidence of documentation E6, E7, E9, or E12 had received orientation before providing assisted living services to a resident was unavailable for review. 2. In an interview, E1 advised E6, E7 and E12 were hired before E1’s date of employment, and E1 did not know if they had been oriented prior to providing assisted living services. E1 advised E9 was hired after E1’s employment; however, E1 did not know if E9 had received orientation prior to providing assisted living services. E1 agreed E6’s, E7’s, E9’s, and E12’s personnel records did not contain documentation of completed orientation.

Based on document review, record review, and interview, the manager failed to ensure a resident had a written service plan which was reviewed and updated no later than 14 days after a significant change in the resident’s physical, cognitive, or functional condition. The deficient practice posed a risk as the employees were unable to meet a resident’s needs. Findings include: 1. A review of facility documentation revealed an incident report documenting an incident that occurred on March 10, 2025, involving R1. The report indicated R1 “was off, not [R1’s] self,” was “very confused…,” and “kept falling back off the WC every time [R1] tried to stand up.” The report reflected “paramedics suspected that resident maybe has UTI,” and R1 was transported to the hospital. 2. A review of R1’s medical record revealed documentation dated March 12, 2025, titled “After Visit Summary,” which summarized R1’s hospital visit after the aforementioned March 10, 2025 incident. The summary did not include documentation of the reason for R1’s hospital visit. The summary included basic vital sign information, current medications, and lab tests ordered; however, the summary did not include documentation of any current or past medical diagnoses, injuries, or physical conditions, including any documentation referring to a urinary tract infection or other treatable medical condition, which may have contributed to R1’s confusion. 3. A review of R1’s medical record revealed progress notes revealed an entry on February 20, 2025, documenting concerns regarding R1’s “depression” and discussed the possible need for a psychiatric evaluation. Entries on March 11, 2025 and March 12, 2025, were related to R1’s hospitalization and return, after the incident on March 10, 2025. Two entries on March 13, 2025, document observation of R1’s confusion at “3:45 AM” and “2:36 PM.” R1 was observed at 3:45 AM “up all night wandering very confused, locking [R1] out of [R1's] room.” At 2:36 PM, R1 was observed “…happily confused,” needing frequent reminders to use R1's walker, socializing with others, and spending “some time in [R1’s] room relaxing.” Entries on March 14, 2025 and March 15, 2025, document observations of R1 having a “fair day,” "being “confused,” “argumentative with staff,” “downstairs socializing,” and needing frequent reminders. An entry on March 26, 2025, indicated R1 “continues with odd behavior, PCP in today and will make changes to [R1’s] night medications.” Entries on April 1, 2025, reflect R1 was found “by the ditch…asking for help…had bumps on the back of [R1’s] head, bruised on [R1's] knees, elbow and hands…” The entries also reflect R1 was transported to a hospital and returned from a hospital visit the same night. An entry on April 1, 2025 reflects R1 was moved to memory care “due to safety concerns.” 4. A review of facility documentation revealed an incident report documenting a March 31, 2025 incident involving R1. The report indicated “[R1] was in [R1's] room after giv

Based on record review and interview, for one of two residents sampled, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months. Findings include: 1. A review of R2’s medical record revealed a service plan, dated December 8, 2024, for directed care services. However, service plan updates dated on or before March 8, 2025, were unavailable for review. 2. In an interview, E1 acknowledged R1’s record did not include a written service plan update dated at least once every three months.

Based on record review 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 or resident’s representative, the manager, and a nurse or medical practitioner. Findings include: 1. A review of R1’s medical record revealed a service plan dated April 2, 2025, indicating R1 received directed care services, including medication administration. The service plan had a signature page and designated areas for the “Administrator or Designee,” “Community Nurse or Designee,” “Resident,” and “Resident Representative” to sign the service plan. However, each signature line was blank. 2. A review of R4’s medical record revealed a service plan dated February 26, 2025, indicating R4 received personal care services, including medication administration. The service plan was signed by the manager, nurse, and the resident’s representative; however, the signatures were dated March 14, 2025. 3. In an interview, E1 advised when service plans are initially developed or updated, the service plans are not immediately signed by the manager or reviewing nurse. E1 said the service plans are forwarded to the resident’s representative for their signature, before the manager and nurse sign. E1 agreed R1’s service plan had not been signed by the manager, reviewing nurse, or medical provider, or the resident’s representative when initially developed or updated, as required.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of eight residents sampled. Findings include: 1. A review of R1’s, R2’s, R4’s, R7’s, and R8’s medical records revealed each resident had a service plan describing the services which would be provided to each resident. 2. A review of R1’s, R2’s, R4’s, R7’s, and R8’s medical records revealed electronic documentation titled “Resident Monthly Assignment Report” (ADL), which documented the services provided to each resident on each day. However, the ADLs included multiple gaps, for each resident, where required services had not been documented to have been provided. 3. In an interview, E1 acknowledged the services provided to each resident had not been accurately documented on the provided ADL forms. This is a repeat citation from a complaint investigation conducted on June 24, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, 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 authorized to provide directed care services. 2. During a tour of one of the facility's two secure memory care units, the Compliance Officer observed a door leading to an emergency exit out of the unit. The door was equipped with an alarmed push bar which required a key to activate and deactivate the alarm. When the Compliance Officer pressed the push bar the door opened with little effort, and no alarm sounded. The Compliance Officer stepped into a landing at the bottom of a stairwell, which led to the second floor of the facility, where only personal care and supervisory care resident’s resided. Next to the stairwell was a door marked “EMERGENCY EXIT ONLY.” The door was equipped with a push bar, as well as a separate alarm, which could be activated or deactivated with a key. The Compliance Officer pressed the push bar, the door opened with little effort and no alarm sounded. On the other side of the door, was a concrete pathway which led around the facility. Next to the pathway was a steep, rocky hill extending downward, away from the facility, and into open desert. 3. During a tour of the facility’s second memory care unit, the Compliance Officer approached a door marked “EXIT,” which was equipped with an alarmed push bar which required a key to activate and deactivate the alarm. When the Compliance Officer pressed the push bar, the door opened with little effort, and no alarm sounded. The Compliance Officer stepped into a service hallway used for service access to various areas of the facility, including maintenance offices and the facility’s main kitchen. 4. During an interview, E1 agreed there was a means of exiting the facility which allowed residents to be at least 30 feet away from the facility, which did not control or alert employees of the egress of a resident. During the tour, E1 ensured available staff to immediately activated the push bar alarms which had been turned off.

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 a tour of the facility, the Compliance Officer randomly entered R9’s residential unit. The Compliance Officer observed a bowl on a bedside table next to R9, which contained hard candy, and a bottle of over-the-counter “Omeprazole Delayed-Release Capsules, 20mg Acid Reducer.” 2. In an interview, R9 advised the medication was R9's and was administered to R9 by caregivers. 3. In an interview, E1 agreed medication was not stored in a locked cabinet.

Based on observation, record review, document review, and interview, the manager failed to implement established and documented polices and procedures for receiving, storing, inventorying, tracking, dispensing, and discarding medication. The deficient practice posed a risk as the standards expected of employees were not followed. Findings include: 1. During a tour of the facility, the Compliance Officer randomly entered R9’s residential unit. The Compliance Officer observed a bowl on a bedside table next to R9, which contained hard candy, and a bottle of over-the-counter “Omeprazole Delayed-Release Capsules, 20mg Acid Reducer.” 2. In an interview, R9 advised the medication was R9's and was administered to R9 by caregivers. 3. A review of R9’s medical record revealed a service plan that indicated R9 received personal care services and medication administration. 4. In an interview, E1 advised E1 believed R9’s relative had brought the medication to R9 and left it in R9’s room. E1 acknowledged caregivers administered the medication to R9, and caregivers should have taken custody of the medication when they had first observed it. 5. A review of facility documentation of controlled substance logs from September 1, 2024 through April 1, 2025, revealed documentation titled “Removed From Drawer Report.” The reports documented the removal of approximately 1000 individual controlled substances from facility medication carts, for various reasons, including “expired,” and “discontinued.” 6. A review of facility policy and procedures, last reviewed February 21, 2025, revealed a policy titled “Receipt of Medication Policy.” In part, the policy stated, “All medications stored by the Community must be maintained in a clean, neat LOCKED stationary container or area.” 7. A review of facility policy and procedures revealed a policy titled “Drug Disposal Process.” In part, the policy stated as follows: “5. Controlled Medications. Controlled Medications should be disposed of in accordance with one of the following procedures: · Call the Community pharmacy to see if they will pick up the controlled medications and dispose of them… · If the pharmacy will not permit the return of the controlled medication, ask the consulting pharmacist if he/she will dispose of the medication when he/she is next at the Community… · Document on the Narcotic Inventory Sheet how the medications were disposed of… · Record the disposal of the controlled medications on a Drug Disposal form…” The policy continued as follows: “7. Unused medications should not be flushed down the toilet or poured down the sink…To return medications to the pharmacy: · Complete the applicable information on a Drug Disposal form… · Place the medications to be returned, along with the original Drug Disposal form, in the pharmacy pick-up box. Keep a copy of the form…” 8. A request was made to review documentation confirming the removed medications were returned to the pharmacy or destroyed. However, evidence of docume

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift, at least once every three months, and documented. Findings include: 1. A review of facility staffing schedules revealed the facility operated three shifts: days, 6:00 AM – 2:00 PM, swing shift, 2:00 PM – 10:00 PM, and nights, 10:00 PM – 6:00 AM. 2. A review of facility documentation revealed evidence of documentation of an employee disaster drill conducted during the day shift on April 18, 2024. In addition, there was evidence of documentation of a disaster drill conducted during the swing shift on January 16, 2025, and during the night shift on September 19, 2024. However, evidence of documentation of any additional employee disaster drills conducted was unavailable for review. 3. In an interview, E1 agreed disaster drills were not being conducted on each shift, at least once every three months, and documented.

Based on document review and interview, the manager failed to ensure an evacuation drill was conducted at least every six months. Findings include: 1. A review of facility documentation revealed evidence of documentation of an evacuation drill conducted in 2024 or 2025 was unavailable for review. 2. In an interview, E1 advised they were unable to locate documentation of an evacuation drill conducted in 2024, or in January 2025 before E1’s date of hire. E1 reported the facility had not conducted an evacuation drill since E1's hire date. E1 acknowledged the facility had not conducted an evacuation drill every six months as required.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, emergency or injury and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of eight sampled facility incident reports from January 1, 2025, through April 13, 2025, revealed five incident reports documenting accidents, emergencies, or injuries where medical services were needed. Of those five reports, two involved falls. Those reports contained documentation of the date and time of the incident, a description of the incident name(s) of those who observed the incident, actions taken and appropriate persons notified. However, the reports did not include documentation of any action taken by the caregiver to prevent the incident from occurring in the future. 2. In an interview, E1 acknowledged the incident reports did not contain all documentation as required per R9-10-818.D.2. This is a repeat citation from a complaint investigation conducted on September 17, 2024.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation which may cause a resident or other individual to suffer physical injury. The deficient practice posed a threat to the physical health and safety of a resident prone to wander. Findings include: 1. During a tour of one the facility’s two memory care units, the Compliance Officer approached a door leading to the unit's courtyard. The door was equipped with an alarmed push bar which required a key to activate and deactivate the alarm. When the Compliance Officer pressed the push bar, the door alarm sounded for approximately fifteen seconds, and then opened. The Compliance Officer went into the courtyard, which was enclosed by a wrought iron fence. The courtyard fence had an exit door equipped with an alarmed push bar which required a key to activate and deactivate the alarm, as well as a key pad, apparently to deactivate the doors locking mechanism. A cover on the hinge side of the push bar was missing, and electric wiring inside the push bar was exposed. A sign on the door read “When resetting the doors-Turn the key twice And make sure the light is GREEN that means the door is locked Thanks!” The Compliance Officer observed no green light on the push bar. When the Compliance Officer pressed the push bar, the door opened with little effort, granting access to the front parking lot of the facility. 2. In an interview, E1 agreed the courtyard door had not been maintained in working order. E1 also agreed the door was not able to be secured and presented a condition or situation which may cause a resident to suffer physical injury. E1 secured the door with a cable and padlock until the door’s push bar could be repaired.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility’s memory care unit, the Compliance Officer observed a closed door equipped with a locking handle that required a key to engage or disengage the lock. The Compliance Officer checked the door handle, found it was unlocked, and opened the door with little effort. The Compliance Officer went through the door and into a shower room which was being used for storage. In the shower room, the Compliance Officer observed two one-gallon jugs of “Spectracide Home Defense” insecticide, as well as various cleaning agents, such as toilet bowl cleaner, marked “KEEP OUT OF REACH OF CHILDREN DANGER.” In the kitchen area of the memory care unit, the Compliance Officer opened an unsecured cabinet door. Inside, the Compliance Officer observed various items used for crafting, hair and nail care, including fingernail polish and a bottle of nail polish remover with a label reading “WARNING: EXTREMELY FLAMMABLE. KEEP AWAY FROM FLAME.” The Compliance Officer observed a sink cabinet equipped with locking mechanisms that required a key to lock and unlock the doors. The Compliance Officer was able to open one of the doors with little effort, even though the locking mechanism was engaged. Inside, the Compliance Officer observed numerous cleaning chemicals with labels reading “KEEP OUT OF REACH OF CHILDREN.” The Compliance Officer also observed a can of “DROP DEAD FLYING AND CRAWLING INSECT KILLER,” as well as a one-gallon jug of “Spectracide” Home Defense, insect killer. 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not in a locked area separate from food preparation and storage, dining areas, or were inaccessible to residents. E1 ensured the unlocked door to the shower room was locked and had the chemicals under the sink cabinet removed until the locking mechanism could be replaced. This is a repeat citation from a complaint investigation conducted on September 17, 2024.

Based on observation and interview, the manager failed to ensure equipment at the facility was maintained in working order. The deficient practice posed a risk to the health and safety of residents. Findings include: 1. During a tour of the facility, the Compliance Officer entered the courtyard connected to one of two memory care units at the facility. The courtyard was enclosed by a wrought iron fence, and had an exit door equipped with an alarmed push bar which required a key to activate and deactivate the alarm. A key pad, apparently to deactivate the door's locking mechanism, was mounted to the door frame, above the door latch. A cover on the hinge side of the push bar was missing, and the electric wiring inside the push bar was exposed. A sign on the door read “When resetting the doors-Turn the key twice And make sure the light is GREEN that means the door is locked Thanks!” The Compliance Officer observed no green light on the push bar. When the Compliance Officer pressed the push bar, the door opened with little effort, granting access to the front parking lot of the facility. The Compliance Officer also observed a sink cabinet which was equipped with locking mechanisms requiring a key to lock and unlock the doors. The Compliance Officer was able to open one of the doors with little effort. While the locking mechanism was engaged, the metal tab on the back side of the lock had been bent to the point it no longer prevented the door from opening. Inside, the Compliance Officer observed numerous cleaning chemicals with labels reading “KEEP OUT OF REACH OF CHILDREN.” The Compliance Officer also observed a can of “DROP DEAD FLYING AND CRAWLING INSECT KILLER,” as well as a one-gallon jug of “Spectracide” Home Defense insect killer. Lastly, during a tour of the facility, the Compliance Officer entered a random residential suite and observed venetian blinds covering one of the windows had numerous slats which were missing and had obviously broken. 2. In an interview, E1 agreed the equipment at the facility had not been maintained in working order. E1 took action to secure the broken courtyard door and remove the toxic substance below the sink cabinet until the lock could be replaced. E1 also advised they would put in a work order to have the resident’s window blinds replaced.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, injury or emergency and needed medical services, as required per R9-10-818.D.2. Findings include: 1. A review of facility documentation from June 2024 through August 2024 revealed three incident reports documenting accidents, injuries or emergencies where 911 was contacted. A review of the incident report dated June 24, 2024, revealed R9 had fallen and received a head injury. The report contained most documentation required required per R9-10-818.D.2. However, the report failed to identify three care staff who witnessed the incident and did not indicate what action was taken to prevent the accident, injury or emergency from occurring in the future. A review of the incident report dated August 16, 2024 revealed R5 had fallen and received a head injury. The report failed to document what action was taken to prevent the accident, emergency or injury from occurring in the future. A review of the incident report dated August 28, 2024 revealed R10 had a leg injury which required emergency medical attention. The report failed to document notification of R10's medical provider and failed to document what action was taken to prevent the emergency from occurring in the future. 2. In an interview, E1 agreed the incident reports did not contain all documented required per R9-10-818.D.2.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials 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. Findings include: 1. During a tour of the facility, the Compliance Officer observed a high security janitor cart in a hallway of residential units, which was left unattended. The cart contained a roll top section for storing chemicals which was securable with a locking mechanism which required a key. However the lock was not engaged and the Compliance Officer was able to open the roll top section. Inside the storage section, the Compliance Officer observed numerous containers of detergents and cleaners to include bottles of commercial toilet bowl cleaner, disinfectants, alkaline cream cleanser and a bottle of "Goof Off Marks, Messes & Stains Remover." Each bottle was labeled "KEEP OUT OF REACH OF CHILDREN." 2. In an interview, E1 acknowledged the toxic chemicals were not kept in a locked area, inaccessible to residents.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of four residents sampled. Findings include: 1. A review of R2's medical record revealed a current personal care service plan indicating R2 "requires caregiver to put [R2's] TED hose on in the morning" and removing them in the evening. 2. A review of R2's medical record revealed a document dated June 2023, used for documenting services provided and activities of daily living. However, the document did not contain evidence demonstrating R2 received assistance putting on or removing R2's TED hose. 3. In an interview, E1 acknowledged evidence of documentation R2 was receiving assistance putting on or removing R2's TED hose was unavailable for review.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of four residents sampled. 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 current service plan which indicated R2 received medication administration. Further review revealed a medication administration record (MAR) dated June 2024, which indicated R2 was being administered "SENNA 8.6MG Tablet" twice per day. The MAR also indicated R2 was being administered "MILK of Magnesia w/Cascara Oral Susp, Give 30ML," one time per day and "Hydrocodone-Acet 5 MG-325MG Tablet," every four hours. 2. A review of R2's medical record revealed evidence of an order, signed by a medical provider, for SENNA 8.6MG Table, twice per day, MILK of Magnesia w/Cascara Oral Susp, Give 30ML" or "Hydrocodone-Acet 5 MG-325MG Tablet," every four hours was unavailable for review. 3. In an interview, E1 acknowledged an order for SENNA 8.6MG Table, twice per day, MILK of Magnesia w/Cascara Oral Susp, Give 30ML" or "Hydrocodone-Acet 5 MG-325MG Tablet," every four hours was unavailable for review.