Vista Pointe at Sierra Vista

Based on document 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. Findings include: 1. A review of R1’s records revealed two incident reports, one dated December 26, 2025, involving R1 and R3, and one dated January 4, 2026, involving R1 and R2. The incident report dated January 4, 2026, had the proper documentation and notification to APS and law enforcement; however, the incident report dated December 26, 2025, which was a physical altercation between the residents, did not include documentation of the incident being reported to law enforcement or APS. 2. In an interview, E1 stated they did not believe the incident report dated December 26, 2025, needed to be reported to APS or law enforcement because the resident did not sustain any injuries.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included compliance with the requirements in A.R.S. § 36-411(A) and (C) for one of four personnel records reviewed. Findings include: 1. A.R.S. § 36-411(A) and (C) states: “A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.” and; “C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card…” 2. A review of E5's personnel record revealed E5’s fingerprint clearance card expired on June 11, 2025. Further review revealed an application for a fingerprint clearance card with a check dated June 27, 2025. 3. A review of resident medical records revealed a Medication Administration Record (MAR) for each resident. A review of the MAR for R1, R2, and R3, dated June 2025, revealed E5 provided medication administration to R1, R2, and R3 on June 15 and 24, 2025. A review of R4’s MAR dated June 2025 revealed E5 provided medication administration to R4 on June 11, 15, 16, 17, 18, 24, and 25, 2025. 4. In an interview, E1 acknowledged the fingerprint clearance card for E5 was expired and not in compliance with A.R.S. § 36-411(A) and (C).

Based on record review and interview, the manager accepted an individual who required continuous medical services, nursing services, or behavioral health services for two of four resident records reviewed. The deficient practice posed a risk as an assisted living facility cannot provide continuous medical, nursing, or behavioral services. Findings include: 1. A review of R3's medical record revealed a document titled "Medical Examination / Move In Orders - Arizona". The document included several questions with boxes next to the questions to indicate yes or no. "Does resident require continuous medical services?”, “Does resident require continuous nursing services?” and “Does resident require continuous behavioral health services?” were all marked yes to indicate R3 required continuous medical, nursing, and behavioral health services. The document was signed by a medical practitioner. 2. Further review of R3’s medical record revealed R3 “had a mental health crisis and was combative with staff and other residents, taken to ER for eval and treatment”. 3. A review of R4's medical record revealed a document titled "Medical Examination / Move In Orders - Arizona". The document included several questions with boxes next to the questions to indicate yes or no. "Does resident require continuous medical services?” and “Does resident require continuous nursing services?” were both marked yes to indicate R4 required continuous medical and nursing services. The document was signed by a medical practitioner. 4. In an interview, E1 neither confirmed nor denied that the manager accepted an individual who required continuous medical, nursing, or behavioral health services. E1 reported R3 would not be returning to the facility.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, when initially developed and when updated, for three of four resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 17, 2025. However, the service plan was not signed and dated by R1 or R1's representative. Further review of R1’s medical record revealed a service plan dated April 13, 2025, for directed care level services and medication administration, which was not signed by the resident’s representative, the manager, or the nurse or medical practitioner who reviewed the service plan. 2. A review of R2's medical record revealed a service plan update dated April 13, 2025, for directed care level services and medication administration, which was not signed by the resident’s representative or the manager. 3. A review of R3's medical record revealed a service plan update dated June 12, 2025, for directed care level services and medication administration, which was not signed by the resident’s representative or the manager. 4. In an interview, E1 acknowledged the service plans provided for R1, R2, and R3 had not been signed and dated by each resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plans.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of four resident records reviewed. Findings include: 1. A review of R1’s medical record revealed medication orders signed on August 24, 2024, for Donepezil 10mg, take one tablet daily; Megestrol 20mg, two times per day; and Mirtazapine 15mg, one tablet per day at bedtime. 2. A review of R1’s medication administration record (MAR) for June 2025 revealed R1 was scheduled to receive Donepezil, Megestrol, and Mirtazapine daily at 8pm. On June 15, 2025, the medications were not administered. The exception note states the medication was attempted to be administered late at 9:35pm; however, was unable to administer because the resident was already asleep. 3. In an interview, E1 acknowledged that medication administered to R1 was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury, that resulted in the resident needing medical services, a caregiver documented a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; actions taken by the caregiver or assistant caregiver; and any action taken to prevent the incident from occurring in the future, for one of four resident records reviewed who had an incident that resulted in the resident needing medical services. Findings include: 1. A review of R3's medical record a note indicating R3 was at the hospital on June 11, 2025, due to “severe behaviors”, from 11:30am to 9:55pm. 2. A review of R2's medical record revealed no documentation or incident report regarding behaviors or a behavioral episode, on June 11, 2025. 3. In an interview, E1 reported that R3 was sent out to the hospital and acknowledged that R3's medical record did not include documentation of the incident or emergency, which resulted in R3 needing medical services.