GIFTS OF GRACE ASSISTED LIVING HOMES

INSP-0124391

Complete

Date: 4/15/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-05-23

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 15, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-803.C.1.a-w. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers; b. Cover orientation and in-service education for employees and volunteers; c. Include how an employee may submit a complaint related to resident care; d. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11; e. Except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training; f. Cover first aid training; g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual; h. Cover staffing and recordkeeping; i. Cover resident acceptance and resident rights; j. Cover termination of residency, including: i. Termination initiated by the manager of an assisted living facility, and ii. Termination initiated by a resident or the resident's representative; k. Cover the provision of assisted living services, including: i. Coordinating the provision of assisted living services, ii. Making vaccination for influenza and pneumonia available to residents according to A.R.S. § 36-406(1)(d), and iii. Obtaining resident preferences for food and the provision of assisted living services; l. Cover the provision of respite services or adult day health services, if applicable; m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts 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; n. Cover resident medical records, including electronic medical records; o. Cover personal funds accounts, if applicable; p. Cover specific steps for: i. A resident to file a complaint, and ii. The assisted living facility to respond to a resident's complaint; q. Cover health care directives; r. Cover assistance in the self-administration of medication, and medication administration; s. Cover food services; t. Cover contracted services; u. Cover equipment inspection and maintenance, if applicable; v. Cover infection control; and w. Cover a quality management program, including incident report and supporting documentation;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure there were policies and procedures that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident. Findings include: 1. The facility was licensed for Directed Care. 2. Compliance officers observed ambulatory residents. 3. A review of facility Policy and Procedures, July 2016, revealed that there was no policy to address the whereabouts of residents. 4. In an interview, E1 acknowledged that there were no policies and procedures that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident.

Temporary Solution:

After the inspection, the owner/facility manager reviewed the policies and procedures that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident and acknowledged it was not there. She furnished the missing policy and updated the facility policy. The owner also reviewed the rest of the policy so it would be completed and would cover the services/ methods of operations of the facility.

Permanent Solution:

She furnished the missing policy and updated the facility policy. The owner also reviewed the rest of the policy so it would be completed and would cover the services/ methods of operations of the facility.

Person Responsible:

Lin Lee, Facility Manager/ Owner

Deficiency #2

Rule/Regulation Violated:

R9-10-815.E.1-2. Directed Care Services E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or 2. An assisted living facility has implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services for three of nine residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1.The facility is licensed for Directed Care 2. During the environmental tour the Compliance Officers observed three of nine residents that did not have a means to alert employees of their needs or emergencies while in bed. 3. In an interview, E1 acknowledged that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services.

Temporary Solution:

After the inspection, the owner/ facility manager checked the rooms of all the residents and noticed that some of the bells or baby monitor for bedridden resident were not on the side table while the resident was in bed. She then searched for the missing bell or baby monitor and placed them on the side table resident was in bed.

Permanent Solution:

Manager instructed her staff to ensure that the bell or baby monitor should be on the side table while the resident is in bed.

Person Responsible:

Lin Lee, Facility Manager/ Owner

Deficiency #3

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on observation and interview the manager failed to ensure there was a means of exiting the facility to control or alert employees of the egress of a resident from the facility for four of four doors. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Facility is licensed for Directed Care 2. Compliance officers observed ambulatory residents within the facility. 3. Compliance officers observed the following:-The front entry door had an alarm that was turned off-R1 had a door in their bedroom that led to the outside and the alarm was turned off-R2 had a door in their bedroom that led to the outside and the alarm was turned off-A door leading to the backyard had the alarm turned off and the batteries were not functioning. 4. In an interview, E1 acknowledged that these exits did not alert employees of the egress of a resident from the facility.

Temporary Solution:

After the inspection, the owner/ facility manager checked the exit door and
acknowledged that the alarm device failed to make any sound to alert the employees of egress from the facility. The owner ordered door alarm batteries so she could replace the old batteries, and the alarm would be in working condition.

Permanent Solution:

Person Responsible:

Lin Lee, Facility Manager/ Owner

Deficiency #4

Rule/Regulation Violated:

R9-10-819.A.10. Environmental Standards A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure that oxygen containers were secured. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the facility inspection, the Compliance Officers observed oxygen tanks in the living room closet that were not secured. 2. A review of facility policy and procedure revealed a policy titled "Environmental Safety" which stated, "A manager shall ensure that oxygen containers are secured in an upright position". 3. In an interview, E1 acknowledged that there were Oxygen tanks stored and not secured.

Temporary Solution:

After the inspection, the owner/ facility manager moved the oxygen tanks in the closet in a secured manner and placed it in an upright position.

Permanent Solution:

The owner will remind the staffs that the oxygen tanks to in a secured manner and placed in an upright position.

Person Responsible:

Lin Lee, Facility Manager/ Owner

INSP-0068482

Complete

Date: 7/27/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-09-08

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint #AZ00195420 conducted on July 27, 2023:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

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 no documented policy for fall prevention and fall recovery.

2. A review of E2's and E3's personnel records revealed no documentation of fall prevention and fall recovery training.

3. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of fall prevention and fall recovery training. E1 indicated E2 and E3 completed the training and it was listed on their "ongoing training forms." E1 was unable to name the course trainer or provide a course curriculum or description to the Compliance Officer within the two-hour time limit required by the Department.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and

Evidence/Findings:

Based on interview, record review, and documentation review, the manager failed to ensure that a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services. The deficient practice posed a risk to the health and safety of residents if the caregivers and assistant caregivers were unable to meet the needs of the residents.

Findings include:

1. In an interview, R3 reported E4 frequently administered medication to R3 during the evening while E3 was on vacation.

2. A record review revealed no personnel record for E4.

3. A review of the facility's policies and procedures included a policy titled, "Staff Documentation and Record Keeping." The policy's copyright date was 2016; however, the facility's policies and procedures were most recently updated on July 1, 2023. The policy indicated a job applicant's references and fingerprint clearance card would be verified once the decision to hire the applicant was made.

4. In an interview, E1 reported the facility's procedure for verifying a caregiver's or assistant caregiver's skills and knowledge included contacting their references and verifying the fingerprint clearance card issued to them by the Department of Public Safety was valid. E1 reported E4's skills and knowledge were not verified and documented because E4 was not an employee or volunteer of the facility. E1 acknowledged E4 administered medications, transferred, and provided other physical health services to residents.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to:
a. Provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living facility's scope of services;

Evidence/Findings:

Based on interview, documentation review, and record review, the manager failed to ensure that the assisted living facility had a caregiver with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the assisted living facility's scope of services. The deficient practice posed a risk to the health and safety of residents if the caregivers and assistant caregivers were unable to meet the needs of the residents.

Findings include:

1. In an interview, R3 reported E4 frequently administered medication to R3 during the evening while E3 was on vacation.

2. A record review revealed no personnel record for E4.

3. A review of the facility's policies and procedures included a policy titled, "Scope of Practice of the Assisted Living Facility." The policy's copyright date was 2016; however, the facility's policies and procedures were most recently updated on July 1, 2023. The policy indicated the facility provided assistance in the self-administration of medication and medication administration services.

4. In an interview, E1 reported E4 was not an employee or volunteer for the facility, but rather a friend who was helping out while E3 was on vacation. E1 reported E4 completed housekeeping duties. E1 acknowledged E4 entered the residents rooms to complete some housekeeping duties. E1 acknowledged E4 administered medication to residents. E1 indicated E4 provided assisted living services to residents during the nighttime hours while the live-in caregiver slept. E1 acknowledged there was no personnel file with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services in the facility's scope of services. E1 did not know E4's last name or if E4 had the qualifications necessary to provide the services E4 had provided to residents.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on interview and record review, the manager failed to ensure a personnel record was available for one of three sampled employees or volunteers. The deficient practice posed a risk as the Department was unable to verify the job duties of E4 and if E4 was safe to work with a vulnerable population.

Findings include:

1. In an interview, R3 reported E4 sometimes administered medications to R3 at nighttime.

2. In an interview, R2 reported to have observed E4 cooking and cleaning in the facility.

3. In an interview, E1 acknowledged E4 administered medication to residents, cooked for the residents, and cleaned the facility. E1 did not know E4's last name.

4. A record review revealed no personnel record for E4.

Deficiency #5

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of three residents sampled. The deficient practice posed a risk if the needs and services were not agreed upon before providing these services.

Findings include:

1. A review of R1's medical record revealed a service plan dated June 29, 2023. The service plan identified that R1 received medication administration and personal care services. The service plan was not signed and dated by the resident's representative, the manager, and a nurse or medical practitioner who reviewed the service plan.

2. In an interview, E1 acknowledged R1's service plan was not signed by the resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. E1 reported R1's representative refused to sign the service plan because they did not want to pay R1's outstanding bills to the facility.

Deficiency #6

Rule/Regulation Violated:

B. A manager shall ensure that:
1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk to resident safety.

Findings include:

1. During a facility tour, the Compliance Officer observed E2 providing personal care services to R5 in a room directly off the dining room. The doors were open to the dining and living rooms. The Compliance Officer was able to see the entire bedroom from the dining room.

2. In an interview, R1 reported having to ask the caregivers to close the door frequently when changing R1's ileostomy bag. R1 also reported times when the bile from the bag burned R1's skin because the bag had not been changed overnight. R1 reported being unable to call for assistance because the call bell was out of reach.

3. In an interview, R1 reported R1 asked E2 to no longer wash R1's private areas because E2 was "too harsh." E2 said R1 smelled bad and continued to wash R1's private areas. R1 asked E1 to speak to E2 about being too harsh.

4. In an interview, R1 reported E2 said R1 was "too fat" when R1 asked E2 for food. R1 said sometimes E2 would withhold food from R1 using the same reason.

5. In an interview, E1 acknowledged there were times R4's doors remained open while the caregivers provided services. E1 reported R4's bed was pushed back far enough that only R4's feet can be seen from outside the bedroom doors. E1 reiterated that there was cloth covering on the glass doors to R5's bedroom and indicated this provided some privacy while the doors were open.

6. In an interview, E1 acknowledged R1 reportied E2 did not honor R1's request to stop bathing R1's private areas. E1 reported E2 stopped the behavior immediately after E1 addressed the issue with E2.

7. In an interview, E1 acknowledged that E2 called R1 "too fat." E1 indicated these were human relations (HR) issues that had been discussed with E2. E1 acknowledged E2 required much improvement in this area.

8. In an interview, E1 acknowledged residents had not been treated with consideration, dignity, or respect during the aforementioned incidents.

Deficiency #7

Rule/Regulation Violated:

C. A resident has the following rights:
3. To receive privacy in:
a. Care for personal needs;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure a resident received privacy in care for personal needs. The deficient practice posed a risk of a privacy rights violation to the residents.

Findings include:

1. During a facility tour, the Compliance Officer observed E2 providing assisted living services to R5 in a room directly off the dining room. The doors were open to the dining and living rooms. The Compliance Officer was able to see the entire bedroom from the dining room.

2. In an interview, R1 reported asking E2 to ask R4, R1's roommate, to leave the room while R1 was being bathed or receiving other private assisted living services in bed. R1 attempted to ask R4 to leave several times, as R4 was ambulatory. However, R4 did not respond to R1's requests. R1 asked E2 for assistance on more than one occasion and E2 refused, using time constraints as the justification.

3. In an interview, E1 acknowledged there were times R4 's doors remained open while the caregivers provided services. E1 reported R4's bed is pushed back far enough that only R4's feet can be seen from outside the bedroom doors. E1 reiterated that there was cloth covering on the glass doors to R5's bedroom and indicated this provided some privacy while the doors were open.

Deficiency #8

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
a. Is administered by an individual under direction of a medical practitioner,

Evidence/Findings:

Based on interview and record review, a manager failed to ensure a medication was administered to a resident by an individual under the direction of a medical practitioner, for one of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. In an interview, R3 reported E4 administered medications to E4 sometimes at night time.

2. In an interview, E1 acknowledged E4 sometimes administered medications to residents. E4 acknowledged E4 was not administering medication under the direction of a medical practitioner.

3. A record review revealed no personnel record for E4. Therefore, there was no documentation to indicate E4 was under the direction of a medical practitioner while administering medication to R3.

Deficiency #9

Rule/Regulation Violated:

A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During a tour of the facility, the Compliance Officer observed Comet cleaner, Palmolive dish soap,window cleaner, and Glade air freshener in an unlocked cabinet under the kitchen sink. The cabinet had two doors; one was locked and the other was not.

2. In an interview, E1 acknowledged the aforementioned toxins were stored in an unlocked cabinet accessible to residents.

Deficiency #10

Rule/Regulation Violated:

B. A manager shall ensure that:
4. At least one bathroom is accessible from a common area and:
c. Contains the following:
v. Paper towels in a dispenser or a mechanical air hand dryer,

Evidence/Findings:

Based on observation and interview, the manager failed to ensure at least one common bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer.

Findings include:

1. During a facility tour, the Compliance Officer observed one common bathroom in the facility. The bathrooms did not contain paper towels in a dispenser or a mechanical air hand dryer.

2. In an interview E1 acknowledged the common bathroom did not contain paper towels in a dispenser or a mechanical air hand dryer. E1 indicated the residents clog the toilet with paper towels and this is the reason the bathroom did not contain paper towels in a dispenser.

GIFTS OF GRACE ASSISTED LIVING HOMES

Facility Information

Inspection History

INSP-0124391

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0068482

Summary:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings: