HACIENDA AT THE RIVER

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, when initially developed and when updated, for one of one residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.


Findings include:

1. A review of R1's medical record revealed a service plan dated April 25, 2024. However, the service plan was not signed and dated by the resident or the resident's representative or the manager.

2. A review of 12's medical record revealed a service plan updated June 5, 2024. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan.

3. In an interview, E1 and E2 acknowledged the service plans provided for R1 did not include all required signatures.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022 and the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for one of one residents sampled who received directed care services. The deficient practice posed a risk if employees were unaware of a significant change in a resident's condition.

Findings include:

1. A review of R1's medical record revealed a service plan, dated April 25, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

2. A review of R1's medical record revealed a service plan, dated June 5, 2024, for directed care services. However, the service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

3. In an interview, E1 and E2 acknowledged R1's service plans did not include R1's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022, and the on-site compliance and complaint inspection conducted on October 17, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of seven personnel members sampled. The deficient practice posed a risk if E6 and E8 were a danger to a vulnerable population.

Findings include:

1. A review of E6's personnel record revealed E6 was hired as a caregiver in September of 2023. The record included a copy of E6's fingerprint clearance card, which was issued on September 20, 2019, with an expiration date of September 20, 2025. In addition, the record included an employment application which outlined E6's work history between May 2017 and October 2018, and between May 2022 and September 2023. However the application indicated E6 was "Unemployed" between November 2018 and April 2022. Further, the record included a resume for E6 which included a section titled, "Work Experience," which identified E6's work history between May 2017 thorough October 2018, and May 2022 through "present." However, evidence of employment between November 2018 and April 2022 was unavailable for review.

2. A review of E8's personnel record revealed E8 was hired as a caregiver in March of 2022. The record included a copy of E8's fingerprint clearance card, which was issued on August 14, 2020, with an expiration date of August 14, 2026. In addition, the record included an employment application which outlined E8's work history between June 2019 and February 2021. However the application indicated E8 was "Unemployed" between March 2019 and January 2021, and between February 2021 and March 2022.

3. In an interview E1 acknowledged E6's and E8's employment history contained more than a six month gap in employment prior to being hired as caregivers.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on record 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.

Findings include:

1. On October 17, 2023, the Compliance Officers requested the following document during the on-site inspection:
- a Therapeutic Diet Manual;
- the Policies and Procedures;
- Current medication orders for R2, R3, and R5; and
- Work schedules for the previous 12 months.
However, this documentation was not provided for review within the two hour window.

2. In an interview, E1 and E2 acknowledged the requested documentation had not been provided for review within two hours after a Department request.

Technical assistance for this rule was provided during the on-site compliance inspection conducted on October 27, 2022.

Based on interview and documentation review, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe exploitation had occurred on the premises, the manager complied with all the requirements in R9-10-803(J), which posed a health and safety risk.

Findings include:

1. In an interview, E1 reported R5 was missing a ring and the facility investigated the allegation of exploitation. E1 reported adult protective services and the police were contacted. E1 reported R5's family confirmed they had not taken the ring and it was missing. E1 reported no witnesses reported seeing anyone taking the ring. E1 reported after investigating this incident as well as other allegations of missing items, an employee and their lead were both terminated due to credible concerns of missing food taken from the facility, however, the facility was not able to determine if the resident's missing items were stolen. E1 provided an incident investigation report to the Compliance Officers.

2. A review of facility documentation revealed an incident investigation report which concluded with the termination of E8 due to "theft". However, the investigation report was not dated within five days following the alleged incident and did not include the following:
- documentation of the reports made to Adult Protective Services and to the police;
- the dates, times and a description of the suspected exploitation of R5, only of other residents;
- A description of any change to R5's emotional condition; and
- the names of witnesses to the suspected exploitation.

3. In an interview, E1 and E2 acknowledged the provided investigation report did not include all of the required items and did not include any documentation of the specific incident regarding R5's missing property.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, and included medication administration or assistance in the self-administration of medications, for six of six sampled residents.

Findings include:

1. A review of R1's medical record revealed a service plan, dated July 20, 2023, for Personal Care Services. However, R1's service plan did not include the following required information:
- Whether R1 would receive medication administration or assistance in the self-administration of medications;
- The type, amount and frequency of, "breathing treatments";
- The amount and frequency of, "laundry" services; and
- The type, amount, and frequency of "skin maintenance."

2. A review of R2's medical record revealed a service plan, dated August 11, 2022 , for Directed Care Services. However, R2's service plan did not include the following required information:
- The type, amount and frequency of, "Joint Limitations."

3. A review of R3's medical record revealed a service plan, dated April 27, 2023, for Directed Care Services. However, R3's service plan did not include the following required information:
- Whether R3 would receive medication administration or assistance in the self-administration of medications; and
- The frequency of, "bathing" services.

4. A review of R4's medical record revealed a service plan, dated August 21, 2023, for Personal Care Services. However, R4's service plan did not include the following required information:
- Whether R4 would receive medication administration or assistance in the self-administration of medications;
- The frequency of, "skin maintenance";
- The frequency of, "grooming" services; and
- The type, amount, and frequency of, "toileting" services.

5. A review of R5's medical record revealed a service plan, dated December 02, 2022, for Directed Care Services. However, R5's service plan did not include the following required information:
- The frequency of, "Showers";
- The frequency of, "Brushing Hair/Teeth, Shave & Wash Face, Applying Lotion";
- The frequency of, "Housekeeping/Trash Liners/Soiled Clothing/Incontinence Supplies;" and
- Whether R3 would receive medication administration or assistance in the self-administration of medications

6. A review of R6's medical record revealed a service plan, dated October 17, 2023, for Personal Care Services. However, R6's service plan did not include the following required information:
- The frequency of "Grooming/Oral Hygiene" services.

7. In an interview, E1 and E2 acknowledged the service plans provided for each resident did not accurately include the amount, type and frequency of assisted living services being provided to each resident, and did not include whether each resident would receive medication administration or assistance in the self-administration of medications,

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for three of six residents sampled who received directed care services.

Findings include:

1. A review of R2's medical record revealed a service plan, dated August 11, 2022, for directed care services. A current service plan was requested, however, the second service plan provided for review was dated October 17, 2023, the date of the inspection.

2. A review of R3's medical record revealed a service plan, dated April 27, 2023, for directed care services. A current service plan was requested, however, a current service plan was not provided for review.

3. A review of R5's medical record revealed a service plan, dated December 02, 2022, for directed care services. A current service plan was requested, however, a current service plan was not provided for review.

4. In an interview, E1 and E2 acknowledged the service plans provided for R2, R3 and R5 indicated service plans for directed care residents had not been reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, when initially developed and when updated, for three of six residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan dated August 11, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan.

2. A review of R2's medical record revealed a service plan dated October 17, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan.

3. A review of R5's medical record revealed a service plan dated December 02, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan.

4. A review of R6's medical record revealed a service plan dated October 17, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plan.

5. In an interview, E1 and E2 acknowledged the provided service plans for R2, R5 and R6 had not been signed and dated by the resident or the resident's representative, the manager, or the nurse who reviewed the service plans, when initiated or when updated.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for five of five sampled residents reviewed.

Findings include:

1. A review of the facility work schedule revealed the facility worked on three shifts per day, a first shift from 6 a.m. to 2:30 p.m., a second shift from 2 p.m. to 10:30 p.m., and a third shift from 10 p.m. to 6:30 a.m.

2. A review of five sampled resident medical records revealed all five resident's records included a service plan detailing the services to be provided to each resident.

3. A review of five sampled resident' electronic medical records revealed electronic documentation of services provide to each resident. For each required service, the electronic record documented the initials of the caregiver and the time the service was provided. However, for all five residents, the electronic service records included gaps during which a caregiver had not documented services provided during their shift.

4. In an interview, E1 and E2 acknowledged the provided medical records did not include documentation of all of the services provided to each resident on each shift by each caregiver.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for three of three residents sampled who received directed care services.

Findings include:

1. A review of R2's medical record revealed a service plan, dated August 11, 2022, for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated.

2. A review of R3's medical record revealed a service plan, dated April 27, 2023, for directed care services. However, the service plan did not include documentation of R3's weight or documentation from a medical practitioner stating weighing R3 was contraindicated.

3. A review of R5's medical record revealed a service plan, dated December 2, 2022, for directed care services. The service plan included documentation of R5's weight in July and August 2023, however documentation of R5's weight in September and October, or documentation from a medical practitioner stating weighing R5 was contraindicated was unavailable for review.

4. In an interview, E2 reported vital sheets are used to collect this information on a monthly basis. E1 and E2 acknowledged R2's, R3's and R5's service plans did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officers observed a cabinet in R6's bathroom which did not have a lock and was accessible to R6 at all times. Inside the cabinet, the Compliance Officers observed tubes of, triamcinolone acetonide, "Preparation H," and Hydrocortisone cream.

2. A review of R6's medical record revealed a service plan, updated October 17, 2023, for personal care services which included the service, "[R6's] medications will be stored in the locked medication cabinet in [R6's] room and administered as prescribed by the physician."

3. In an interview, E1 and E2 acknowledged medication required to be stored by the assisted living facility had not been stored in a locked area.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022, and from the on-site compliance inspection conducted on November 8, 2021.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below.

Findings include:

1. During a facility tour, the Compliance Officers observed a refrigerator located in the directed care building, "Cottonwood", contained a thermometer which registered at 45\'b0F. The Compliance Officers observed the refrigerator contained foods requiring refrigeration.

2. In an interview, E1 and E2 acknowledged potentially hazardous foods requiring refrigeration were not maintained at 41\'b0F or below.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator.

Findings include:

1. During the facility tour, the Compliance Officers observed a refrigerator in the personal care building. The refrigerator contained foods requiring refrigeration. However, the refrigerator did not contain a thermometer

2. In an interview, E2 reported the refrigerator is provided by the facility for resident use, and it is used by residents to store their own food or snack items.

3. In an interview, E1 and E2 acknowledged the refrigerator did not contain a thermometer.

Based on documentation review and interview, the manager failed to ensure a disaster plan review was documented according to R9-10-818(A)(3)(a-d).

Findings include:

1. A review of the facility's policies and procedures revealed a disaster plan. The disaster plan had been signed and dated annually by the manager to indicate a review. However, the time of the review, the name of each employee who participated, and a critique of the review were not available.

2. In an interview, E1 and E2 acknowledged the annual disaster plan review was not documented as required by the rule.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:

1. A review of the facility work schedule revealed the facility worked on three shifts per day, a first shift from 6 a.m. to 2:30 p.m., a second shift from 2 p.m. to 10:30 p.m., and a third shift from 10 p.m. to 6:30 a.m.

2. A review of facility disaster drills conducted during the previous twelve months revealed documentation of the following drills conducted during the previous twelve months:
- No drills conducted between October 2022 and December 2022;
- First shift drills were conducted on January 27, 2023, April 11, 2023, May 16, 2023 and August 10, 2023;
- Second shift drills were conducted on April 11, 2023, June 26, 2023, July 18, 2023 and September 14, 2023; and
- Third shift drills were conducted on February 9, 2023, April 11, 2023, July 5, 2023, and October 13, 2023.

3. In an interview, E1 and E2 acknowledged documentation of disaster drills conducted on each shift at least once every three months for the previous twelve months had not been provided to the Compliance Officers upon request.

This is a repeat deficiency from the on-site compliance inspection conducted on October 27, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of facility documentation revealed documented evacuation drills during the previous twelve months were conducted on November 17, 2022. However, documentation of an evacuation drill due on or before May 17, 2023 was not provided for review.

2. In an interview, E1 and E2 acknowledged documentation of evacuation drills conducted at least once every six months had not been provided to the Compliance Officers upon request.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officers observed the hot water temperature measured at 125.1\'b0 F in a resident's private bathroom in the personal care services building.

2. In an interview, E1 and E2 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Based on documentation review and interview the manager failed to ensure a dog residing at the facility was licensed consistent with local ordinances.

Finding include:

1. A review of facility documentation revealed a current rabies vaccination for a resident's dog. However, documentation of current licensure in Pima County for the dog was not provided for review.

2. In an interview, E1 and E2 acknowledged a current license for the resident's dog had not been provided for review.