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Based on record review, documentation review, and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2), and include the dates, times, and description of the suspected abuse, a description of any injury to the resident related to the suspected abuse, and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, and actions taken by the manager to prevent the suspected abuse and maintain a copy of the documentation required in subsection (J)(5) for at least 12 months after the date the investigation was initiated. Findings include: 1. A review of documentation revealed the facility had reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises. The document included all the requirements in R9-10-803.J.1-6 except for "the actions taken by the manager to prevent the suspected abuse from occurring in the future". 2. In an interview, E2 and E3 acknowledged the document did not include "the actions taken by the manager to prevent the suspected abuse from occurring in the future".

Based on record review and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of two residents sampled. The deficient practice posed a direct health or safety risk to residents and if the facility was unable to meet the needs of R2. Findings include: 1. A review of R2's medical record revealed a document titled "Diagnoses and Doctor's Orders," dated July 28, 2022. The document included a section titled, "Diagnoses:," which identified "Schizoaffective d/o Unspecified." Evidence of any other type of medical diagnosis of R2 was not available for review. 2. A review of R2's service plan (dated October 23, 2023) for directed care services revealed a section titled, "Medical Diagnosis/Health Problems:," which indicated "Depression, Schizoaffective Disorder, Bipolar Disorder, Hypothyroidism." The service plan indicated [R2] was "unable to reliably use [R2's] call button if [R2] in need of assistance...due to cognitive deficits." However, the service plan did not indicate if the cognitive deficit was linked to R2's listed diagnoses or another medical condition. Additionally, R2's service plan revealed R2 was largely independent of all activities of daily living, and required only behavioral care, medication administration, and required mainly Monitoring, cues or "Set-up/Standby" assistance with instrumental activities of daily living. The service plan also indicated R2 "requires a caregiver with [R2] while outside due to wandering risk," however the plan does not link the behavior to a medical diagnosis rather than a behavioral diagnosis. 3. In an interview, E1 acknowledged R2's medical record did not contain evidence which indicated the primary condition R2 needed assisted living services was other than a behavioral health issue.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a documented residency agreement, signed by the resident. However, the residency agreement had not been signed or dated by the manager. 2. In an interview, E1, E2, and E3 acknowledged the manager had not signed and dated the residency agreement provided for R1.

Based on record review, observation, and interview, the manager failed to ensure a resident's written service plan included the requirements in R9-10-808(A)(3)(e) for two of two residents sampled who required behavioral care. Findings include: 1. A review of R1's medical record revealed a document titled, "Behavioral Plan of Care," signed and dated by a medical practitioner on March 8, 2023. The document included sections labeled, "Psychosocial interactions / Behaviors requiring assistance, Psychotropic Medications, Frequency of Psychosocial interactions/behaviors," and, "Goals for changes in psychosocial interactions / Behaviors of Frequency," however, the document had not been filled out except for being signed by a medical practitioner and did not include any of the required information. 2. A review of R1's medical record revealed medication administration record (MAR) dated June 2023. The MAR indicated R1 had received the following psychotropic medications: - Risperidone; and - Diphenhydramine. 3. A review of R2's medical record revealed a document titled, "Behavioral Plan of Care," signed and dated by a medical practitioner on January 30, 2023. The document stated, "Behaviors requiring assistance: Physical and Verbal Aggression. Psychotropic Medications: None, Frequency of psychosocial interactions/behaviors: Daily - Physical Aggression." The document included a section to list planned strategies and actions, however, the section had been left blank. The service plan did not include interventions for self-harming behaviors and did not list R2's psychotropic medications. 4. A review of R2's medical record revealed a medication administration record dated May 2023. The MAR indicated R2 had received the following psychotropic medications: - Sertraline; and - Trazodone. 5. A review of R2's medical record revealed a history and physical dated June 5, 2023. The history and physical stated, "staff report mood swings, impatience, and temper tantrums, during which patient bangs on things or knocks on own forehead. Has scabbed wound on forehead." 6. The Compliance officer observed R2 had a scab on R2's forehead. 7. In an interview, E4 reported R2 hits themselves on the forehead and demonstrated this behavior since moving in. E4 reported the wound on R2's forehead has been there for a long time now, possibly since R2 moved in, and does not heal because R2 keeps hitting themselves and picks at the wound. E4 reported there is no planned intervention for R2's self harming behaviors. 8. In an interview E1, E2, and E3 acknowledged the behavioral care service plans for R1 and R2 did not include the required information.

Based on record review, and interview, the manager failed to ensure a behavioral health professional or medical practitioner evaluated a resident within 30 calendar days before acceptance of the resident or before the resident began receiving behavioral care and signed and dated a determination stating that the resident's need for behavioral care could be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, were being met by the assisted living facility, for one of two residents sampled receiving behavioral care. Findings include: 1. A review of R1's medical record revealed a document titled, "Behavioral Plan of Care," signed and dated by a medical practitioner on March 8, 2023. The document included sections labeled, "Psychosocial interactions / Behaviors requiring assistance," "Psychotropic Medications," "Frequency of Psychosocial interactions/behaviors," and, "Goals for changes in psychosocial interactions / Behaviors of Frequency," however, the document had not been filled out except for being signed by a medical practitioner. 2. A review of R1's medical record revealed service plan, dated May 18, 2023, for Directed care services including medication administration. The service plan indicated R1's medical diagnoses were: "high blood pressure, atrial fibrillation, anxiety, psychophysiologic insomnia, bipolar disorder, alcohol induced disorder, edema, urinary incontinence." 3. A review of R1's medical record revealed a court order dated November 2, 2022. The court order stated, "The court finds by clear and convincing evidence that [R1] is, as a result of a mental disorder, persistently or acutely disabled, and is in need of a period of mental health treatment...It is therefore ordered that [R1] receive court-ordered treatment for one year with the ability to be re-hospitalized, should the need arise, in an inpatient psychiatric facility for a time period not to exceed 180 days." 4. A review of R1's medical record revealed a form titled, "Behavioral Health Care Authorization." The form stated, "We provide behavioral care and our staff is able to assist with your patient's psychosocial interactions and medications to manage behavior under the direction of a behavioral health professional and/or a medical practitioner. We do not provide continuous behavioral health services. Attached is a copy of our facility's scope of services for your review. Your authorization is required at the date of acceptance into our facility, and at least once every six months throughout the duration of your patient's need for behavioral care and/or behavioral health services. We will follow all orders provided by you and work with you to address patient needs and concerns and ensure behavioral health services appointments are kept. Please sign and date, and return this form to use as soon as possible." The form had been filled out and stated, "[R1], needs for behavioral care can be met by this fa

Based on observation and interview, the manager failed to ensure potentially hazardous foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen contained food items. The Compliance Officer observed a thermometer on the top shelf of the refrigerator measured the temperature of the refrigerator at 45\'b0F. The Compliance Officer observed the refrigerator contained items requiring refrigeration such as mayonnaise, biscuit dough, salad dressing, guacamole, salsa, and yogurt. 2. Approximately two hours after the start of the inspection, the Compliance Officer checked the refrigerator again and observed a thermometer on the top shelf of the refrigerator measured the temperature of the refrigerator at 48\'b0F. The Compliance Officer observed the refrigerator was set to 7\'b0C (44.6\'b0F). 3. In an interview, E1, E2, and E3 acknowledged the refrigerator's temperature had not been maintained at 41\'b0F or below.

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. Findings include: 1. A review of the facility work schedule revealed the facility worked on two shifts per day. 2. A review of facility disaster drills conducted during the previous twelve months revealed the following drills: - December 20, 2022 during the 7 am to 7 pm shift; - September 12, 2022 for both shifts; and - June 7, 2022 for both shifts. However, disaster drills conducted in December, 2022, on the 7 pm to 7 am shift, and drills conducted in March of 2023 on both shifts were not available for review. 3. In an interview, E1, E2, and E3 acknowledged documentation of disaster drills conducted on each shift at least once every three months was not provided for review.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed documented evacuation drills with the following dates: - December 20, 2022 at 12:35 p.m.; and - December 16, 2021 at 9:30 a.m. However, documentation of an evacuation drill conducted in June of 2022 was not available for review. 2. In an interview, E1, E2, and E3 acknowledged documentation of evacuation drills conducted at least once every six months was not available for review.