AEGIS AT FAIRVIEW ASSISTED LIVING HOME

<p>Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice poses a health and safety risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officer observed the facility's hose draped across the walkway of the facility's patio area. </p><p><br></p><p><br></p><p>2. The Compliance Officer observed the following materials stored in the facility's backyard, accessible to residents: </p><ul><li>Approximately 12 small planters filled with soil and herbs; </li><li>Two buckets of gardening soil; </li><li>A rake;</li><li>Two large planters; </li><li>Multiple cardboard boxes; </li><li>Broken plastic bins; </li><li>Bags of trash</li><li>A laundry basket; and </li><li>A grill, covered in cardboard boxes and other waste materials. </li></ul><p><br></p><p><br></p><p>3. The Compliance Officer also observed the following materials stored next to the facility's door that led out to the patio area: </p><ul><li>An empty plastic tote; </li><li>Yard clippings</li><li>A propane tank; </li><li>A bag of charcoal; </li><li>A mop head and bucket; </li><li>A worn recliner; </li><li>A bike; and </li><li>A step ladder. </li></ul><p><br></p><p><br></p><p>4. In an interview, E1 acknowledged R1 was ambulatory and able to walk into the backyard. E1 acknowledged the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p>

Based on record review and interview, the residential care institution failed to ensure compliance with A.R.S. \'a7 36-411(A), for one of one manager sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E2's (hired in 2020) personnel record revealed a fingerprint clearance card with an expiration date of March 13, 2023.

2. A review of the Arizona Department of Public Safety fingerprint clearance card verification website revealed E2's fingerprint clearance card status was "Expired."

3. In an interview, E2 acknowledged E2's fingerprint clearance card was expired. E2 would not disclose whether E2 had or had not re-applied for a fingerprint clearance card.

Based on record review, documentation review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of R1's medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review.

2. A review of R2's medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review.

3. A review of R1's medical record revealed a service plan dated in February 2023 for directed care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 23, 2023 through March 29, 2023 were not available for review.

4. A review of R1's medication administration record (MAR) dated March 2023 revealed R1 received medication administration of Duloxetine HCl 60 mg caps on March 1, 2023 through March 29, 2023. However, a medication order for the aforementioned medication was not available for review.

5. A review of E2's personnel record revealed a fingerprint clearance card with an expiration date of March 13, 2023.

6. In an interview, E2 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's signed residency agreement and any amendments, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (admitted in 2022) medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review.

2. A review of R2's (admitted in 2016) medical record revealed a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10) was not available for review.

3. In an interview, E2 reported R1's and R2's residency agreements were completed, however, the agreements were not located at the assisted living facility. E2 acknowledged R1's and R2's medical records did not contain signed residency agreements.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan dated in February 2023 for directed care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 23, 2023 through March 29, 2023 were not available for review.

2. In an interview, E1 reported assisted living services were provided to R1. However, E2 reported E2 had not documented the services provided to R1.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer observed Duloxetine HCl 60 mg caps medication bottle belonging to R1.

2. A review of R1's medication administration record dated March 2023 revealed R1 received medication administration of Duloxetine HCl 60 mg caps on March 1, 2023 through March 29, 2023. However, a medication order for the aforementioned medication was not available for review.

3. In an interview, E2 acknowledged R1 received medication administration of the aforementioned medication without a medication order.