VI at Grayhawk, a VI and Plaza Companies Community

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated and signed on October 18, 2025 that stated R1 received personal care services. 2. A review of R1's medical record revealed no documentation that stated whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a Physician, Registered nurse practitioner, Registered nurse, or Physician assistant. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the assisted living center failed to maintain a standardized form for each resident that includes the information prescribed in A.R.S. § 36-420.04.A.1-9 for three out of five residents sampled. The deficient practice posed a risk if the facility was not prepared in case of an emergency. Findings include: 1. A review of R1's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The name, address and telephone number of the resident's current pharmacy; and A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 2. A review of R2's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: The name, address and telephone number of the resident's current pharmacy. 3. A review of R3's medical record revealed a standardized form to be used if an emergency responder was contacted, however, the form was missing the following information: Basic information about the resident's physical and mental conditions and basic medical history. 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 ensure that a resident’s medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia for one of five residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed no documentation of notification of the availability of a vaccination for influenza and pneumonia. Based on R1's date of residency, this document was required. 3. 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 ensure compliance with A.R.S. § 36-411, for one of seven employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "...C. Owners 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...3. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 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." 2. A review of E1's personnel record revealed no documentation of contacting E1's previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution. Based on E1's hire date, this information was required. 3. A review of E4's personnel record revealed documentation of an adult protective services registry check conducted by the facility on December 31, 2024. However, annual documentation was not available. 4. 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 that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for one of seven employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents.  Findings Include: 1. A review of E5’s personnel record revealed a hire date of November 12, 2025. E5's personnel record did not include documentation of fall prevention and recovery training. 2. In an exit interview, the findings were reviewed with E1, no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of five personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a hire date of August 2023. E1's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review. 4. A review of E2's personnel record revealed a hire date of January 2024. E2's personnel record included a negative TST within 12 months prior to E2's hire date. However, no second TST, assessment of risks of prior exposure to infectious TB, or determination of signs or symptoms of TB was available for review. 5. A review of E3's personnel record revealed a hire date of May 2022. E3's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review. 6. A review of E4's personnel record revealed a hire date of August 2022. E4's personnel record included a negative TST within 12 months prior to E4's hire date. However, no second TST, assessment of risks of prior exposure to infectious TB, or determination of signs or symptoms of TB

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of five residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's, R3's, R4's, and R5's medical record revealed documentation of R2's, R3's, R4's, and R5's freedom from infectious tuberculosis. However, assessment of risks of prior exposure to infectious TB or determination of signs or symptoms of TB was not available for review. 3. In an interview, E1 and E6 acknowledged R2's, R3's, R4's, and R5's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.