Visions Senior Living at Apache Junction 1

Based on documentation review, record review, and interview, for one of six employees reviewed, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a safety risk to residents. Findings include: 1. A.R.S. § 36-411(C)(1) states, "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. A review of E4's personnel record did not include documentation of the facility's good-faith effort to contact E4's previous employers. 3. In an interview, the finding was reviewed with E2 and no additional information was provided.

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk to the health and safety of residents as there was not a qualified manager to implement policies and procedures or provide direction to personnel. Findings include: 1. A review of Department documentation revealed the previous manager resigned from the facility effective July 15, 2025. 2. During the environmental inspection of the facility, the Compliance Officer did not observe a manager's certificate posted at the facility. 3. In an interview, E2 reported E2 was issued a temporary Certified Assisted Living Facility Manager (ALM-T-004049) effective July 25, 2025. E2 reported the facility had gaps with no manager from July 16, 2025, to July 24, 2025. 4. A review of the Nursing Care Institution Administrators and Assisted Living Facility Managers website revealed E2's temporary manager's certificate was revoked as of August 7, 2025. 5. In an interview, E2 reported the facility had a gap with no manager from August 8, 2025, to August 14, 2025. E2 reported the facility hired a new manager effective August 15. 6. In an exit interview, the findings were reviewed with E2 and no additional information was provided. This is a repeat deficiency from the inspection conducted on July 16, 2025.

Based on documentation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I), when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A review of Department documentation revealed O1 was no longer the manager of the facility effective July 15, 2025. 2. While on-site for compliance inspection, the Compliance Officer observed a conspicuously posted notice from the Board of Arizona Nursing Care Institution Administrators documenting R2 as a "Certified Assisted Living Facility Manager-Temporary" issued on July 25, 2025, and expired on December 22, 2025. 3. In an interview, E2 reported the facility hired E1 as the new manager effective August 15, 2025. However, E2 was unaware if the governing authority notified the Department of the change in manager. 4. A review of Department documentation revealed the facility did not notify the Department of the change in the manager according to A.R.S. § 36-425(I). 5. In an interview, E2 acknowledged the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager; 6. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, 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 one of six employees reviewed. The deficient practice posed a potential TB exposure 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 "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E5's personnel record revealed no evidence of freedom from infectious tuberculosis on or before the date of hire. 4. A review of E5's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E5 had signs or symptoms of TB on or before the date of hire. 5. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a personnel record was available for one of six employees reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. The deficient practice posed a risk as required information could not be verified for E1. Findings include: 1. The Compliance Officer requested E1's personnel record. However, it was not available for review. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided. This is a repeat deficiency from the on-site inspection completed September 4, 2024.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for two of five residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services dated March 6, 2025. However, a service plan dated after March 6, 2025 was not available for review. 2. A review of R3's medical record revealed a written service plan for directed care services dated March 6, 2025. However, a service plan dated after March 6, 2025 was not available for review. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for two of five sampled residents' records that were reviewed who had resided at the assisted living facility for more than 12 months. 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 R2's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2023. 3. A review of R4's medical record did not include current documentation of notification of the resident or representative of the availability of the flu and pneumonia vaccines since 2022. 4. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the disaster plan review included the time of the disaster plan review, a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan review dated February 28, 2025. However, the disaster plan review did not include documentation of the time of the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement. 2. In an exit interview, the findings were reviewed with E2 and no additional infomration was provided.

Based on documentation review, observation, and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk if the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of Department documentation revealed O1 was no longer the manager of the facility effective July 15, 2025. 2. While on-site for the complaint investigation, the Compliance Officer observed there was no acting manager's license conspicuously posted. 3. In an interview, E1 reported O1 had been the facility manager until July 15, 2025. 4. In an interview, E1 acknowledged the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. 5. 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 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 four of four personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated February 20, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 2. A review of E2's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated February 20, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 3. A review of E3's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated March 8, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 4. A review of E4's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated March 6, 2023. However, no documentation of further fall prevention and fall recovery training was available for Compliance Officer review. 5. In an interview, E1 reported the facility administered fall prevention and fall recovery training on an annual basis. E1 acknowledged the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training for E1, E2, E3, and E4.

Based on documentation review, observation, and interview, the governing authority failed to designate a manager who had a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C) or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of the Department documentation revealed O1 was no longer the facility's manager effective September 20, 2024. No information was received from the governing authority to indicate a new manager had been appointed. 2. While on-site for the compliance inspection, the Compliance Officers did not observe a manager's certificate posted at the facility. 3. In an interview, E1 reported O1's last day as manager was September 20, 2024; however, no manager has been appointed in O1's place. E1 acknowledged the governing authority failed to designate a manager who had a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C) or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06.

Based on observation, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults for one of four personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers observed E4 on-site and providing services to residents. 2. A review of E4's personnel record revealed a CPR and First Aid certification with an expiration date of August 4, 2023. 3. In an interview, E1 acknowledged E4's personnel record did not contain documentation of current CPR and first aid training certification.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for three of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated September 8, 2024) that indicated, R1 would receive the following services: - Staff will remind / cue the resident to perform grooming and personal hygiene; and - Safety Check 24-hour: Staff will check on the resident's whereabouts and safety regularly throughout the day, around the clock. 2. A review of R1's activities of daily living (ADL) documentation, for October 10, 2024, revealed prefilled documentation documentation of the following services: - Oral Care, PM; and - Night Checks. 3. A review of R2's medical record revealed a service plan (dated September 4, 2024) that indicated R2 received the following services: - Medication Administration; - Moderate assistance with bathing, twice a week; - Assistance with dressing, twice a day; - Assistance with transfers, as needed (PRN); - Safety Check 24-hour: Staff will check on the resident's whereabouts and safety regularly throughout the day, around the clock; - Offer a regular set of activities that will be available to the resident, twice a day; - Provide all meals and regular snacks, three times a day; - Regular housekeeping services, weekly; and - Laundry services, weekly. 4. A review of R2's ADL documentation, for the months of October 2024, revealed missing documentation of all services provided October 7, 2024 - October 8, 2024. 5. A review of R3's medical record revealed a service plan (dated August 1, 2024) that indicated R3 received the following services: - Skin Monitor/Care for bruising; - Monthly weight checks; - Medication administration; - Care staff to remind and escort R3 to all mealtimes and encourage eating to promote proper nutrition; - Offer and encourage drinking fluids at all mealtimes and in between meals with snack to support adequate hydration; - Moderate assistance with bathing, twice a week; - Assistance with transfers, PRN; - Safety Check 24-hour: Staff will check on the resident's whereabouts and safety regularly throughout the day, around the clock; - Offer a regular set of activities that will be available to the resident, twice a day; - Provide all meals and regular snacks, three times a day; - Regular housekeeping services, weekly; and - Laundry services, weekly. 6. A review of R3's ADL documentation, for the months of October 2024, revealed missing documentation of all services provided on October 3, 2024. 7. A review of R3's ADL documentation, for the months of October 2024, revealed missing documentation of lunch and dinner meals provided on October 8, 2024. 8. In an interview, E1 reported R1, R2, and R3 received all aforementioned services in the month of October 2024. However, documentati

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established and documented. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards, and the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. The facility's policies and procedures were not available for review. 2. In an interview, E2 reported the policies and procedures were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged policy and procedures were not available for review.

Based on documentation review and interview, the manager failed to ensure a plan was established, documented, and implemented for an ongoing quality management program. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. The facility's quality management documentation was not available for review. 2. In an interview, E2 reported the quality management documents were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged the quality management program was not available for review.

Based on record review and interview, the manager failed to ensure a personnel record was available for each employee that was requested. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. The Compliance Officer requested E1's and E2's personnel records. However, they were not available for review. 2. In an interview, E2 reported the personnel records were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged E1's and E2's personnel records were not available for review.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for two of seven residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. A review of R1's medical record revealed no documentation of a residency agreement. 2. A review of R2's medical record revealed no documentation of a residency agreement. 3. In an interview, E2 reported R1's and R2's residency agreements were locked in an office where E2 did not have access to retrieve the documents. E1 acknowledged R1's and R2's residency agreements were not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider. 2. The Compliance Officer requested to review R1's medical record; however, no medical record was provided for review. 3. In an interview, E2 reported R1's medical record was locked in an office where E2 did not have access to retrieve R1's documents. E2 acknowledged R1's medical record was not available 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. The deficient practice posed a risk to the health and safety of R2 as medications were not administered as ordered. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a medication administration record (MAR) for August 2024. The MAR indicated Albuterol Sulfate 90 MCG was "awaiting Medication" for August 3rd, 4th, 5th, and 6th. 3. A review of R2's MAR notes for August revealed a medication for Fluticasone Prop (120 sprays) "N/A" on August 11, 20024. Then on August 12, 2024 it stated "medication unavailable". Then on August 13 to August 29 it stated "awaiting medication" with the exception of August 25th which stated "unavailable" 4. A review of R2's medication orders revealed Albuterol Sulfate 90MCG was originally ordered by the doctor on July 9, 2023 and it was to be administered three times a day. 5. A review of R2's medication orders revealed Flutocasone Prop (120 sprays) was originally ordered by the doctor on June 28, 2023 and it was to be administered once a day 6. In an interview, E2 confirmed when the MAR notes stated "awaiting Medication" R2 did not receive the medication as the facility was waiting for a refill for the medication. 7. In an interview, E3 acknowledged medications were not administered as ordered.

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. The deficient practice posed a risk as required the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. Disaster drills were not available for review. 2. In an interview, E2 reported the disaster drills were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged disaster drills were not available for review.

Based on documentation review and interview, the manager failed to ensure an evacuation drills for employees and residents was conducted at least once every six months. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. Evacuation drills were not available for review. 2. In an interview, E2 reported the evacuation drills were locked in an office where E2 did not have access to retrieve the documents. E2 acknowledged evacuation drills were not available for review.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed an education program for fall prevention and fall recovery. The program included the initial training and continued competency components. 2. A review of E4's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 3. In an interview, E1 acknowledged E4's personnel record did not include documentation of fall prevention and fall recovery training. E1 was unaware E4's job position required the training.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two caregivers sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: 1. A review of E3's personnel record revealed E3 was hired as a caregiver in September 2023. The record included a copy of a fingerprint clearance card, which was issued in August 2016 and expired in August 2022. In addition, the record included verification of E3's submission of a fingerprint clearance card application in February 2023. The verification indicated E3's fingerprint clearance card was issued in March 2023 and would expire in March 2029. 2. A review of the Department of Public Safety's fingerprint clearance card verification website, on September 20, 2023, revealed E3's fingerprint clearance card was not valid. 3. In an interview, E1 reported E3 never submitted a copy of E3's current fingerprint clearance card. E1 reported being unaware E3's fingerprint clearance card was invalid. E1 reported E3 was removed from the facility's work schedule until the issue was resolved.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of five residents admitted in 2023. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R4's medical record revealed a document titled "Physician Plan of Care" (dated January 14, 2023). However, the document indicated R4 required continuous medical services. 2. In an interview, E1 reported R4 was expected to receive directed care services. 3. In an interview, E1 acknowledged R4's medical record indicated R4 required continuous medical services. E1 indicated someone should have caught the error. E1 was aware individuals requiring continuous medical services require services beyond the scope of services the facility is licensed to provide.

Based on record review, interview, and documentation review, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of eight sampled residents with a service plan. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R3's medical record revealed a service plan dated August 1, 2022. The plan stated R3 was to receive the following services at the indicated frequencies: -Apply lotion daily -Weekly skin check -Care staff to remind/escort R3 to all mealtimes and to encourage eating to promote proper nutrition; -Will encourage resident to eat and offer fluids every two hours; -Care staff to encourage drinking fluids at mealtimes and in between meals with snack to support adequate hydration -Care staff to assist R3 with dressing/undressing twice per day; -Assist with dental devices twice per day; -Care staff will check R3's whereabouts and safety regularly, throughout the day, around the clock (six times per day); and -Care staff to do safety checks approximately every two hours to ensure resident safety. 2. A review of R3's medical record revealed a sample of documents (June-August 2023) titled, "Visions Assisted Living [Activities of Daily Living] Sheet." However, the document indicated R3 received assistance with safety checks once per day, rather than every two hours as indicated in the service plan. R3 was offered and encouraged to drink fluids, once per day rather than every two hours according to the service plan. 3. A review of R4's medical record revealed a service plan dated January 20, 2023. The plan stated R4 was to receive the following services at the indicated frequencies: -Facility to provide assistance with toileting and monitor skin for breakdown/significant changes five times per day; -Care staff will check R4's whereabouts and safety regularly, throughout the day, around the clock (six times per day); and -Care staff to offer and encourage activities to promote socialization and cognitive stimulation two times per day. 4. A review of R4's medical record revealed a document (dated February 2023) titled, "Visions Assisted Living [Activities of Daily Living] Sheet." Under the heading, "Assist [with] Toileting," the documentation indicated R4 received assistance with toileting once per day from February 1-February 28, 2023 and not five times per day as indicated in the service plan. The document indicated R4 received assistance with safety checks once per day; although, R4's service plan indicated six safety checks per day. R4 was offered and encouraged to engage in activities once per day on February 1-6, 2023 and February 10-28, 2023. However, R6's service plan indicated this service would be provided twice per day. 5. A review of R6's medical record revealed a service plan dated January 29, 2023. The plan stated R6 was to receive the following services at the indicated frequencies: -Care s

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact or primary care provider, for one of one resident sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: R9-10-101.110. "Immediate" means without delay. 1. A review of Department documentation revealed R5 sustained an injury at the assisted living facility and was transported by emergency medical services to [hospital] on January 21, 2023. 2. A review of R5's medical record revealed documentation the resident's primary care provider or emergency contact was immediately notified was not available for review. 3. In an interview, E1 reported R5 was a resident for less than 24 hours. R5 was admitted without medications and as a result R5 became combative with staff. Emergency Medical Services were called and R5 was transferred to a geriatric psychiatric unit. E1 believed R5's primary care provider or emergency contact was notified. However, E1 acknowledged documentation was not available for review.

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: 1. A review of Department documentation revealed R5 sustained an injury at the assisted living facility and was transported by emergency medical services to [hospital] on January 21, 2023. 2. A review of R5's medical record revealed documentation include the date and time of the emergency; a description of the emergency; the names of individuals who observed the emergency; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; or any action taken to prevent the emergency from occurring in the future was not available for review. 3. In an interview, E1 reported R5 was a resident for less than 24 hours. R5 was admitted without medications and as a result R5 became combative with staff. Emergency Medical Services were called and R5 was transferred to a geriatric psychiatric unit. However, E1 acknowledged documentation with the criteria required by the Rule was not available for review.

Based on observation, documentation review, and interview, the manager failed to ensure the premises was cleaned and disinfected to prevent, minimize, and control illness or infection. Findings include: 1. The Compliance Officer observed debris and dirt on the floor in R1's, R2's, and R3's bedrooms. 2. The Compliance Officer observed the sink in R2's bathroom was sticky and covered with dirt. 3. The Compliance Officer observed brown smears, resembling feces, on the walls of R1's and R3's bedroom. The base of R3's toilet also had several brown smears, resembling feces. 4. A documentation review revealed policy and procedures reviewed on January 9, 2023. A policy titled "Environmental" stated "Facility premises and equipment used there in are in working order, used and cleaned according to the manufacturer's recommendations and, if applicable, disinfected as needed to prevent, minimize, and control illness or infection." 5. In an interview, E1 acknowledged R1's, R2's, and R3's bedrooms and bathrooms were not cleaned and disinfected to prevent, minimize, and control illness or infection. E1 reported it was embarrassing to see the state of the residents' rooms and bathrooms.