ESTANCIA ASSISTED LIVING, LLC

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in in A.R.S. 36-420.04.A.

Findings include:

1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:
1. The reason or reasons the emergency responder was requested on behalf of the resident.
2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered.
3. The name, address and telephone number of the resident's current pharmacy.
4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive.
5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative.
6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known.
7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week.
8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization.
9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives."

2. A review of facility documentation did not include a standardized form that included the aforementioned information for each resident of the facility.

3. A review of R1's and R2's medical records revealed all required information, however, a standardized form with all aforementioned information was not available for review.

4. In an interview, E1 reported the facility provided emergency responders with all required information, however E1 acknowledged the facility did not maintain a standardized form for each resident that included the information prescribed in in A.R.S. 36-420.04.A.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three personnel sampled. The deficient practice posed a potential illness risk to residents.

Findings include:

1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."

3. A review of the facility's personnel schedule, for November 2024, revealed E3 was scheduled to work in the facility on the following dates:
- November 3, 2024 - November 6, 2024;
- November 10, 2024 - November 13, 2024; and
- November 17, 2024 - November 19, 2024.

4. A review of E3's personnel record revealed two negative TB skin tests, however, the skin tests were completed after E3 began providing services at the facility.

5. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A.R.S 36-401.A.50 states, ""Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in self-administering prescribed medications."

2. A.R.S 36-401.A.41 states, ""Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law."

3. A review of R1's service plan, dated December 12, 2023, revealed R1 received supervisory care services.

4. A review of R1's service plan, dated December 12, 2023, revealed R1 required the following services:
- Assistance with hair care;
- Assistance with dressing;
- Assistance with bathing;
- Assistance with toileting;
- Assistance with transferring; and
- Assistance with wheelchair propelling.
However, R1's level of care did not indicate R1's need for assistance with the aforementioned services.

5. In an interview, E1 acknowledged R1's service plan did not include the level of service R1 was expected to receive.

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R2's service plan, dated September 19, 2024, revealed R2 required the following services:
- Apply lotion, daily;
- Shower, weekly on Tuesdays and Fridays;
- Brief change, four times a day; and
- Routine vitals, weekly on Mondays and Fridays.

2. A review of R2's activities of daily living (ADL) documentation for November 2024 and December 2024, did not include documentation of lotion applied on the following dates:
- November 25, 2024 - November 26, 2024;
- December 18, 2024 - December 20, 2024; and
- December 22, 2024.

3. A review of R2's ADL documentation for November 2024 and December 2024, did not include documentation of a shower provided on the following dates:
- November 26, 2024; and
- December 20, 2024.

4. A review of R2's ADL documentation for November 2024 and December 2024, did not include documentation of brief changes on the following dates and times:
- November 25, 2024 at 6:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM;
- November 26, 2024 at 6:00 AM, 11:00 AM, and 3:00 PM;
- December 9, 2024 - December 10, 2024 at 7:00 PM;
- December 17, 2024 at 7:00 PM;
- December 18, 2024 - December 20, 2024 at 6:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM;
- December 21, 2024 at 6:00 AM; and
- December 22, 2024 at 11:00 AM, 3:00 PM, and 7:00 PM.

5. A review of R2's ADL documentation for November 2024 and December 2024, did not include documentation of routine vitals taken on the following dates:
- November 25, 2024;
- December 16, 2024; and
- December 20, 2024.

6. In an interview, E1 reported R2 received the required services; however, E1 acknowledged that a caregiver did not document the services provided in R2's medical record.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained the document signed by the resident consenting for the resident's representative to act of the resident's behalf for one of one directed care resident sampled.

Findings include:

1. A review of R2's medical record revealed R2 received directed care services.

2. A review of R2's medical record did not include documentation signed by R2 which consented for the resident's representative to act on the resident's behalf.

3. In an interview, E1 acknowledged R2's medical record did not include documentation signed by R2 which consented for the resident's representative to act on the resident's behalf.

Based on record review and interview, the manager failed to ensure that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility, for one of two residents sampled.

Findings include;

1. A review of R1's medical record revealed documentation of orientation to the facility's evacuation plan. However, the orientation was not completed within 24 hours of acceptance. Based on R1's date of acceptance, this documentation was required.

2. In an interview, E1 acknowledged R1 did not receive orientation to the exits from the assisted living facility within 24 hours of R1's acceptance by the facility.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services a caregiver immediately notified the resident's emergency contact and primary care provider.

Findings include:

1. A review of R2's medical record revealed an incident report, dated September 29, 2024, that indicated R2 required medical services. However, documentation that the caregiver immediately notified R2's emergency contact and primary care provider was not available.

2. A review of R2's medical record revealed an incident report, dated October 5, 2024, that indicated R2 required medical services. However, documentation that the caregiver immediately notified R2's emergency contact and primary care provider was not available.

3. In an interview, E1 acknowledged that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver did not immediately notify the resident's emergency contact and primary care provider.

Based on documentation review, observation, and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Equipment Inspection and Maintenance." The policy stated, "Equipment used will be cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection."

2. A review of the facility's policies and procedures revealed a policy titled "Physical Plant Standards." The policy stated, "Estancia Assisted Living, LLC will keep the premises and equipment in sufficient order to best accommodate our residents' needs according to their service."

3. While on-site for the compliance and complaint inspection, the Compliance Officer observed the floors in a resident's room to be covered in dirt and debris. Additionally, the Compliance Officer observed trash, dirty laundry, and other waste on the floor of the resident's room.

4. In an interview, E3 reported the rooms are cleaned daily, and would be cleaned later that day. E1 acknowledged the premises used at the assisted living facility were not cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents.

Findings include:

1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 129.2\'ba F in a resident's bathroom.

2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas used by residents.

Based on record review, documentation review, and interview, the manager failed to ensure that if pets are allowed in the assisted living facility, that pets or animals were vaccinated against rabies.

Findings include:

1. A review of R1's medical record revealed R1 was permitted by the facility to have a pet.

2. A review of the facility's pet documentation revealed a rabies vaccine, for R1's pet, with an expiration date of September 16, 2024. However, documentation of a current rabies vaccination was not available for review.

3. In an interview, E1 acknowledged that pets allowed in the assisted living facility were not vaccinated against rabies.