Woodland Palms

Based on record review and interview, for one of four sampled caregivers, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, to include initial training in fall prevention and fall recovery. Findings include: 1. During the on-site complaint inspection, the Compliance Officer requested documentation of fall prevention and fall recovery training for E4; however, documentation of initial fall prevention and fall recovery training was not available for review. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the complaint inspection conducted on October 17, 2025, and the complaint/compliance inspection conducted on January 18, 2024.

Based on document 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 E3 and E4’s personnel files revealed no documentation that verified E3 and E4's skills and knowledge. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged E3 and E4 did not have the documented skills and knowledge in their files.

Based on documentation review, record review, and interview, for two of four personnel sampled, the manager failed to ensure a caregiver or an assisted caregiver was only assigned to provide the assisted living services the caregiver had the documented skills and knowledge to perform. Findings Include: 1. A review of E3 and E4’s personnel files revealed no documentation of E3 and E4's verified skills and knowledge. 2. A review of four residents' Activities of Daily Living documentation revealed E3 and E4 were providing services to residents. 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged E3 and E4 did not have the documented skills and knowledge in E3 and E4's personnel records as required.

Based on record review and interview, for three of eight sampled caregivers, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, to include initial training in fall prevention and fall recovery. Findings include: 1. During the on-site complaint inspection, the Compliance Officer requested documentation of fall prevention and fall recovery training for E8, E9, and E10. However, documentation of initial fall prevention and fall recovery training was not available for review. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, when a resident had an emergency resulting in the resident needing medical services, the manager failed to ensure a caregiver immediately notified the resident's emergency contact and primary care provider. Findings include: 1. A review of facility incident reports revealed an incident report for R1, dated October 2, 2025 at 1:15 PM. The incident report indicated 911 was called for R1 and R1 was transported to a hospital. The incident report documented contact with R1's emergency contact and primary care provider, however, both required contacts were dated October 2, 2025 at 3:17 PM. 2. In an interview, E2 reported E2 had contacted R1's primary care provider prior to R1 being sent to the hospital, however, E2 acknowledged documentation of this contact had not been provided for review. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established to protect the health and safety of a resident which covered methods by which the assisted living facility is aware of the general or specific hereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. Findings include: 1. A documentation review of facility incident reports revealed an incident report, dated July 10, 2025 at 5:58 PM. The incident report stated, "at 1:50 PM, [a staff member] received phone call from [R1's representative] informing that [R1] was observed walking along Speedway Blvd, and will be retrieving [R1] and returning to facility. 2. A documentation review of facility internal investigations reported an investigation report, dated July 12, 2025, regarding the July 10, 2025 incident. The report stated, "Interviewee Notes: [E2] reports that [E2] had mistaken the resident for a family visitor and accidentally let [E2] out the west gate." 3. A documentation review of the internal investigation revealed a statement by E2, which stated, "This afternoon, I arrived at work and met with my supervisor to talk about various updated of the last 3 days I was off. I learned that several brothers of a resident were here to see her. [My supervisor] pointed out the men so I would be aware who they were. At around 1:05-1:10 p.m. myself and another staff were at the tables facing the window into the courtyard. We saw [R1] at the gate appearing to ring the gate [buzzer] to leave. We were talking about the style of [R1's] shirt, which [R1] was wearing that was in a similar design to the men who were visiting their family member. I mentioned to my coworker that no one was responding to the [buzzer] and that I would go to assist [R1] at the gate and my coworker said, "ok" and thanked me for going to do so. I went into the courtyard and approached [R1] and apologized for no one responding to the [buzzer] at the gate but that I could assist [R1] by letting [R1] out the side gate. I proceeded to escort [R1] to the gate and let [R1] out. [R1] stopped and asked how [R1] would be able to get back in. I replied [R1] would either come back through the front office or [R1] could call the number posted on the gate and someone would come out and let [R1] in. [R1] thanked me and I returned to the community dining area." 4. A review of R1's medical record revealed a service plan, dated July 16, 2025 for personal care services. However, despite stating personal care, the service plan included the following service indicating R1 was directed care, "Wandering/Elopement - Supervision (Behavior Patterns/Wandering Risk)...Put eyes on resident and document location. Provide supervision and redirection to avoid and prevent wandering episodes. If wandering occurs, determine follow up plan. Schedule: Daily @ 9:00 AM, 10:30 AM, 12:30

Based on documentation review, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. Findings include: 1. A documentation review of facility incident reports revealed an incident report, dated July 10, 2025 at 5:58 PM. The incident report stated, "at 1:50 PM, [a staff member] received phone call from [R1's representative] informing that [R1] was observed walking along Speedway Blvd, and will be retrieving [R1] and returning to facility. 2. A documentation review of facility internal investigations reported an investigation report, dated July 12, 2025, regarding the July 10, 2025 incident. The report stated, "Interviewee Notes: [E2] reports that [E2] had mistaken the resident for a family visitor and accidentally let [E2] out the west gate." 3. A documentation review of the internal investigation revealed a statement by E2, which stated, "This afternoon, I arrived at work and met with my supervisor to talk about various updated of the last 3 days I was off. I learned that several brothers of a resident were here to see her. [My supervisor] pointed out the men so I would be aware who they were. At around 1:05-1:10 p.m. myself and another staff were at the tables facing the window into the courtyard. We saw [R1] at the gate appearing to ring the gate [buzzer] to leave. We were talking about the style of [R1's] shirt, which [R1] was wearing that was in a similar design to the men who were visiting their family member. I mentioned to my coworker that no one was responding to the [buzzer] and that I would go to assist [R1] at the gate and my coworker said, "ok" and thanked me for going to do so. I went into the courtyard and approached [R1] and apologized for no one responding to the [buzzer] at the gate but that I could assist [R1] by letting [R1] out the side gate. I proceeded to escort [R1] to the gate and let [R1] out. [R1] stopped and asked how [R1] would be able to get back in. I replied [R1] would either come back through the front office or [R1] could call the number posted on the gate and someone would come out and let [R1] in. [R1] thanked me and I returned to the community dining area." 4. A review of R1's medical record revealed a service plan, dated July 16, 2025 for personal care services. However, despite stating personal care, the service plan included the following service indicating R1 was directed care, "Wandering/Elopement - Supervision (Behavior Patterns/Wandering Risk)...Put eyes on resident and document location. Provide supervision and redirection to avoid and prevent wandering episodes. If wandering occurs, determine follow up plan. Schedule: Daily @ 9:00 AM, 10:30 AM, 12:30 PM, 2:15 PM, 4:30 PM, 6:30 PM, as needed." 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, when the manager had a reasonable basis 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 potential safety risk for residents and a potential rights violation if alleged abuse, neglect, or exploitation was not documented as required. Findings include: 1. A review of facility incident reports revealed an incident report for R1 and R4, dated December 15, 2024 at 8:00 AM. The incident report stated, "[R1] was very mad and agitated with [R4]'s continuous questions/pestering, and [R1] was yelling at screaming at [R4], then [R1] got up and slap [R4's] face. I then redirected [R1] to [R1's] room to cool off." However, the incident report did not document notification of the required report according to A.R.S. § 46-454. 2. A review of facility incident reports revealed an incident report for R1 and R4, dated February 11, 2025 at 4:25 PM. The incident report stated, "[R1] was standing at a dining room table while two others were seated at it. [R1] was talking to one of the seated residents for a minute or so and then took a few steps to [R4's] chair and slapped [R4] across the face with the back of [R1]'s hand. [R4] yelled out but did not hit [R1] back. A caregiver immediately approached the table and escorted [R1] to a different table in the dining room, explaining that it is never okay to hit another resident for any reason. Manager was called to review the camera footage of the dining room and it was confirmed that [R1] did in fact strike [R4], unprovoked. [R1] was talked to by management to discuss how this is not allowed and [R1] denied hitting anyone. When asked why [R1] did it, [R1] stated that [they] never hit anyone. [R1] was in tears explaining that [they] did not hit anyone. All points of contact were notified of situation, and staff will be keeping [R1 and R4] separated for the evening and [R1] will be monitored." However, the incident report did not document notification of the required report according to A.R.S. § 46-454. 3. A review of facility incident reports revealed an incident report for R7 and R5, dated January 22, 2025 at 1:45 PM. The incident report stated, "Employee states that both residents were seated in the dining room. [R7] said nothing, got up and walked over to [R5] sitting and punched [R5] in the back. It didn't appear to be very hard but when caregiver intervened, [R7] said [R7] hit [R5] because [R5] went in [R7's] room earlier in the day and was messing with [R7's] stuff. Caregiver explained that hitting is never allowed, asking [R7] to leave the dining room and stay away from [R5]." However, the incident report did not document notification of the required report according to A.R.S. § 46-454. 4. A review of facility incident reports revealed an incident report for R6 and R5, dated February 22, 2025 at 1:28

Based on documentation review and interview, the manager failed to maintain a separate record for each resident's personal funds account, including receipts. Findings include: A review of R1's personal funds account revealed a document titled, "Petty Cash Report." This report included the following expenditures logged by E2: 05/14/2024, 11:21 AM, $40, "[E6] took [E6] out to the barber shop and then bought a soda and chips for [R1]"; 11/22/2024, 12:01 PM, $15, "Haircut"; 03/14/2025, 12:18 PM, $40, "[E6] took [R1] out for a haircut. [E6] took $40 to pay for the haircut and to tip the barber, and possibly for a snack after the haircut"; and 03/14/2025, 3:47 PM, $808, "[O1] took 808.00 with [O1] to [O1's] office." A review of receipts revealed receipts for the above expenditures were not available for review. For the two $40 haircuts, hand written notes initialed by E2 were available which stated: "[R1] 05/14/24, No Receipt, haircut & drink & chips, $40 total. [R1] 'Put in ECP'"; and "03/14/2025, [E6] took $40 for haircut & snacks." In an interview E2 reported E6 had not returned any change or receipts from the haircuts and snacks and reported E6 had spent more than $40 on the outing. E2 reported O1 had come to retrieve excess money from the personal funds accounts and E2 had logged the transaction but had not asked O1 to sign anything. In an interview, E1 acknowledged R1's personal funds account had not included receipts for all expenditures. Technical Assistance for this rule was provided during the on-site compliance and complaint inspection conducted on January 18, 2024.

Based on record review, and interview, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for one of one resident reviewed who required behavioral care. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. Findings include: 1. A review of R1’s medical record revealed a history and physical dated November 22, 2021, which stated the following: a. “Problem list: Diabetes mellitus, Essential Hypertension, Hypertensive disorder, Tobacco User”; b. “History of present illness, “[R1] is…enrolled with La Frontera BIB LE on RCOT signed in October for evidence of self-harm with superficial cuts to forearms noted by group home. LE reported that patient was found wandering near [R1’s] group home and was confused. At the CRC patient noted to be decompensated, disorganized, although cooperative with assessment and a poor historian. [R1] was disheveled and malodorous. [R1] was oriented to self, disoriented to time and current situation. [R1] was noted to need significant prompting for ADLs, and to be unsafe to make decisions for self. UDS negative, BAL 0.000 [1].” c. “Medications, Home: Risperdal Consta 25mg/ 2 weeks intramuscular injection, extended release, 25 mg, intramuscular, Q2weeks” d. “Assessment/Plan…Psychiatric Inpatient: Continue plan of care per psychiatry…” 2. A review of R1’s medical record revealed a medication order dated December 30, 2024, which included an order for, “Invega Sustenna 156 MG Pref SY, Inject 1 prefilled syringe intramuscularly once a month.” 3. During the on-site inspection, the Compliance Officer requested to review documentation of the behavioral health services being provided to R1, however, E1 reported these records were not available for review. 4. In an interview, E1 reported R1’s behavioral health provider prescribes the Invega injection. E1 reported staff from the behavioral health provider come to the faci

Based on record review and interview, the manager failed to ensure that a behavioral health professional or medical practitioner completed and signed a written determination, 30 days prior to acceptance or before the resident begins receiving behavioral care and at least once every six months thereafter, stating that the resident’s behavioral health needs could be met by the facility and were within the facility’s scope of services, for one of one resident sampled who was receiving behavioral care. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. Findings include: 1. A review of R1’s medical record revealed a history and physical dated November 22, 2021, which stated the following: a. “Problem list: Diabetes mellitus, Essential Hypertension, Hypertensive disorder, Tobacco User”; b. “History of present illness, “[R1] is…enrolled with La Frontera BIB LE on RCOT signed in October for evidence of self-harm with superficial cuts to forearms noted by group home. LE reported that patient was found wandering near [R1’s] group home and was confused. At the CRC patient noted to be decompensated, disorganized, although cooperative with assessment and a poor historian. [R1] was disheveled and malodorous. [R1] was oriented to self, disoriented to time and current situation. [R1] was noted to need significant prompting for ADLs, and to be unsafe to make decisions for self. UDS negative, BAL 0.000 [1].” c. “Medications, Home: Risperdal Consta 25mg/ 2 weeks intramuscular injection, extended release, 25 mg, intramuscular, Q2weeks” d. “Assessment/Plan…Psychiatric Inpatient: Continue plan of care per psychiatry…” 2. A review of R1’s medical record revealed a medication order dated December 30, 2024, which included an order for, “Invega Sustenna 156 MG Pref SY, Inject 1 prefilled syringe intramuscularly once a month.” 3. A review of R1’s medical record revealed a service plan, updated April 7, 2025, for personal care services. a. The service plan included the following diagnoses: i. “Type 2 Diabetes mellitus without complications”; ii. “Unspecified dementia without behavioral disturbance”; iii. “Schizophrenia, unspecified”; iv. “Essential (primary) hypertension”; and v. “Unspecified urinary

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, for two of five residents sampled who received medication administration. 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 R3's medical record revealed a service plan, dated February 5, 2025, for personal care services including medication administration. 2. A review of R3’s medical record revealed a list of medication orders, dated December 6, 2024, which included an order for: - “Metoprolol Succ ER 25 MG Tab, Take 1 tablet by mouth daily **Hold if BP less than or equal to 110/60 or pulse less than or equal to 60**” 3. A review of R3’s medical record revealed a Medication Administration Record (MAR) dated March 2025. For the medication, “Metoprolol Succ ER 25 MG tab, take 1 tablet by mouth daily ** Hold if BP less than or equal to 110/60 or pulse less than or equal to 60**,” the MAR documented the following: - On March 1, at 8:58 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 112/63, Pulse: 60”; - On March 12, at 9:19 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 128/70, Pulse: 56”; - On March 14, at 10:20 AM, the MAR was initialed indicating the medication had been administered late, and additionally, R3’s blood pressure and pulse were documented as, “Blood Pressure: 109/70, Pulse: 72”; - On March 16, at 9:01 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 018/67, Pulse: 68”; - On March 22, at 8:28 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 112/63, Pulse: 60”; - On March 29, at 09:10 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 116/68, Pulse: 60”; - On March 30, at 9:25 AM, the MAR was initialed indicating the medication had been administered, however, R3’s blood pressure and pulse were documented as, “Blood Pressure: 93/61, Pulse: 63.” 4. A review of R4's medical record revealed a service plan, dated February 26, 2025, for directed care services including medication administration. 5. A review of R4’s medical record revealed a list of medication orders, dated December 5, 2024, which included orders for: - “Digoxin 125 MCG Tablet, Take 1 tablet by mouth daily, hold for heart rate <60”; - “Lisinopril 20 MG Tablet, Take 1 tablet by mouth daily for hypertension, hold for spb less than 100”; and - “Metoprolol Tartrate 100 MG tab, Take 1 tablet by mouth twice