Yuma Senior Living

Based on documentation 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. 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 R1's records revealed there was no incident report available for review regarding the APS visit that was conducted on September 25, 2025. 2. In an interview, E1 acknowledged the facility failed to document an incident report following the APS visit to the facility. E1 provided the Compliance Officer with text messages verifying the facility was aware there was alleged abuse that had been reported to APS. E1 stated employees were notified of the alleged abuse and they conducted an investigation; however, they failed to document it.

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order and documented in the medical record. Findings include: 1. A review of R6’s medical record revealed an order for “Glucerna Oral Liquid, Give 237 ml by mouth one time a day.” In addition, the record contained an order for “SITagliptin Oral Tablet 100 MG, Give 1 tablet by mouth one time a day for diabetes.” Further review revealed a medication administration record (MAR) for documenting the administration of medications during June 2025. The record included sections for documenting the administration of “Glucerna Oral Liquid, 237 ml, by mouth daily,” and “SITagliptin 100 MG, 1 tablet by mouth daily.” The record reflected documentation indicating R6 refused to take Glucerna every day in June, and SITagliptin from June 1 through June 24, 2025. 2. A review of R6’s medical record revealed a document titled “Physician Communication Form,” dated June 30, 2025. Documentation of any attempt to contact R6's physician regarding R6's refusal to take ordered medication before June 30, 2025, was unavailable for review. The Physician Communication Form included a section titled “Message,” which read “[R6] refusing to take med. Please advise.” The form also included a section titled “Physician Orders/Response:” which read “Okay to D/C 1-Sitagliptin 100mg, 2-Glucerna oral Liquid,” and was signed by R6’s primary care provider on July 1, 2025. 3. In an interview, E1 advised R6 had been refusing to take Glucerna and Sitagliptin as ordered. E1 said they were not aware of any efforts to contact R6’s medical provider prior to June 30, 2025. E1 agreed R6 had not received medication as ordered.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. During a tour of randomly selected residents' units, E1 and the compliance officer observed in R8's unit there were piles of personal items piled high throughout the unit. E1 asked R8 where R8 slept since the bed was not visible. R8 responded, "I sleep in the chair". The floor was grimy in appearance. R8 reported that R8 did not want housekeeping to mop the floor. R8 was sitting in a recliner style chair with both legs wrapped in wound care type dressings. R8's feet were on a disposable pad. There was a medium sized unkempt dog walking around the unit. 2. Review of R8's medical record revealed the resident was receiving personal care services and was allowed to self-administer R8's own medications. E1 reported the R8 goes to a wound clinic weekly for wound care on both legs. 3. In an interview, E1 acknowledged that R8's unit did not did not appear clean which could pose a health risk to the resident. This is a repeat deficiency from the compliance inspection conducted on March 23-24, 2023.