THUNDERBIRD SENIOR LIVING

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of facility documentation revealed the curriculum for the facility's fall prevention training program. However, the training program did not cover fall recovery.

2. A review of the personnel records of E1, E2, E3, E4, and E5 revealed documentation of fall prevention training for E2, E3, and E5. However, there was no documentation of fall recovery training for E1, E2, E3, E4, and E5.

3. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for five of five personnel members sampled. The deficient practice posed a risk if the personnel members were a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(1)-(2) states, "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card."

2. A review of the personnel records of E1, E2, E3, E4, and E5 revealed copies of E1's, E2's E3's, and E5's fingerprint clearance cards, a copy of a fingerprint clearance card application for E4. However, the personnel records contained no documentation to indicate the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E1's, E2's, E3's, E4's, and E5's fitness to work in a residential care institution, or documentation demonstrating the governing authority made documented, good faith efforts to verify the current status of E1's, E2's, E3's, and E5's fingerprint clearance cards.

3. A review of the Arizona Department of Public Safety website revealed E1's, E2's, E3's, and E5's fingerprint clearance cards were valid. The website indicated E4's fingerprint clearance card application was "In Process" and "Waiting On Applicant Fingerprints." The review revealed E4 did not have a valid fingerprint clearance card.

4. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on interview and documentation review, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if the facility did not establish a procedure to ensure personnel members possessed the required skills and knowledge to perform required job duties.

Findings include:

1. In an interview conducted at 1:20 PM on October 25, 2023, the Compliance Officers requested the entirety of the facility's policies and procedures. In a series of interviews conducted on October 26, 2023, the Compliance Officers again requested the entirety of the facility's policies and procedures, specifically mentioning policies and procedures covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. In two emails received on October 26, 2023, at 12:12 PM and 2:54 PM, E6 and E2 provided the facility's policies and procedures.

2. A review of facility documentation revealed no policy and procedure covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers.

3. In an interview, E2 stated if E6 did not send the policy and procedures covering this rule, "We don't have it."

Based on documentation review and interview, the manager failed to ensure if a manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager complied with all the requirements in Arizona Administrative Code (A.A.C.) R9-10-803(J). The deficient practice posed a risk to the health and safety of residents at the facility if abuse, neglect, or exploitation was not investigated.

Findings include:

1. A review of facility documentation revealed an incident report completed by E1 involving an unnamed employee and R2. The incident took place on February 6, 2023. The incident report description stated, "While dressing resident, 'employee kept rubbing residents' stomach like a dog." However, the incident report did not document the actions taken according to subsection (J)(1), the names of the witnesses who reported the incident, and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. Furthermore, the incident report included a section titled "Actions Taken," however, this section was not completed.

2. A review of facility documentation revealed an incident report completed by E7 involving E8 and R6. The incident took place on April 17, 2023. The incident report description stated: "[E7] walked into [R6's apartment] and into the bathroom. [E7] saw [R6] sitting on the floor in the shower wearing pants and sneakers [while another] associate [E8 was] holding shower head handle with water running pointed towards [R6]." The incident report documented R6 stated, "Stop, get away from me, I don't want you in here." However, the incident report did not document the actions taken according to subsection (J)(1), and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. The incident report included a section titled "Actions Taken", however, the documentation indicated local police and other regulatory agencies were not contacted as required in A.R.S. \'a7 46-454.

3. A review of the facility's digital policies and procedures revealed a policy titled, "Abuse & Neglect Reporting Policy." The policy stated: "It is the policy of Senior Lifestyle to ensure that all reporting of abuse and neglect is handled in accordance with state rules and regulations. This policy will ensure that proper reporting procedures are followed when a case of abuse, neglect, or exploitation is reported...Residents must not be subjected to abuse, neglect, or mistreatment by anyone, including, but not limited to facility or agency staff, other residents, family members or other visitors." However, the policy revealed no procedures for contacting local police and Adult Protective Services (APS).

4. In an interview regarding the incident reports, E2 reported there were additional documents for internal use only and E2 did not have access to them. In a later interview, E1 reported E1 would have to look into the incident reports. E1 and E2 acknowledged the facility's incident reports were not completely filled out and did not include the actions taken according to subsection (J)(1), the names of the witnesses who reported the incident, the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future, and the actions taken to report suspect abuse to local police and APS.

Based on interview, documentation review, and record review, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for four of four applicable personnel members sampled. The deficient practice posed a risk if employees were unable to meet a resident's needs.

Findings include:

1. In an interview conducted at 1:20 PM on October 25, 2023, the Compliance Officers requested the entirety of the facility's policies and procedures. In a series of interviews conducted on October 26, 2023, the Compliance Officers again requested the entirety of the facility's policies and procedures, specifically mentioning policies and procedures covering verification of skills and knowledge for caregivers and assistant caregivers. In two emails received on October 26, 2023, at 12:12 PM and 2:54 PM, E6 and E2 provided the facility's policies and procedures.

2. A review of facility documentation revealed no policy and procedure covering how to verify and document a caregiver's or assistant caregiver's skills and knowledge.

3. In an interview, E2 stated if E6 did not send the policy and procedures covering this rule, "We don't have it."

4. A review of facility documentation revealed a series of personnel schedules dated between January 1, 2023, and October 25, 2023. The schedules revealed the following:
-E3 worked several shifts providing physical health services each month between March 2023 and October 2023;
-E4 worked several shifts providing physical health services each month between February 2023 and October 2023; and
-E5 worked several shifts providing physical health services each month between January 2023 and October 2023.

5. A review of the personnel records of E1, E3, E4, and E5 revealed El was hired as the manager of the facility, E3 and E4 were hired as medication technicians/caregivers, and E5 was hired as a caregiver. However, E1's, E3's, E4's, and E5's personnel records did not contain documented verification of E1's, E3's, E4's, or E5's skills and knowledge.

6. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on documentation review, record review, and interview, the manager failed to ensure a manager and a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, for two of four applicable personnel sampled. The deficient practice posed a potential tuberculosis exposure risk to residents.

Findings include:

1. A review of facility documentation revealed a series of personnel schedules dated between March 1, 2023, and October 25, 2023. The schedules revealed E3 worked several shifts providing physical health services each month between March 28, 2023, and October 25, 2023.

2. A review of E1's personnel record revealed E1 was hired as the manager of the facility. However, E1's personnel record contained no documented evidence of freedom from infectious TB.

3. A review of E3's personnel record revealed E3 was hired as a medication technician/caregiver. E3's personnel record contained documentation of a TB skin test administered on March 29, 2023, and read on April 1, 2023, three days after E3 began providing services at or on behalf of the assisted living facility.

4. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed by the caregiver or assistant caregiver before providing assisted living services to a resident, for three of four applicable personnel members sampled. The deficient practice posed a risk if the employees were unable to meet resident's needs.

Findings include:

1. A review of facility documentation revealed a series of personnel schedules dated between January 1, 2023, and October 25, 2023. The schedules revealed E4 worked several shifts providing physical health services each month between February 2023 and October 2023, and E5 worked several shifts providing physical health services each month between January 2023 and October 2023.

2. A review of E3's, E4's, and E5's personnel records revealed a blank "Orientation Training Checklist" form for E3, and no documentation of E4's and E5's completed orientation.

3. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on documentation review, record review, and interview, the manager failed to ensure a manager or caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for four of four applicable personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of facility documentation revealed a series of personnel schedules dated between January 1, 2023, and October 25, 2023. The schedules revealed the following:
-E3 worked several shifts providing physical health services each month between March 2023 and October 2023;
-E4 worked several shifts providing physical health services each month between February 2023 and October 2023; and
-E5 worked several shifts providing physical health services each month between January 2023 and October 25, 2023, including after October 7, 2023.

2. A review of E1's, E3's, E4's, and E5's personnel records revealed the following:
-A photocopy of E1's "CPR/AED/First-Aid" training certificate from American Emergency Response Training dated as issued on July 27, 2023, and expired in July 2023;
-A printout of E3's "Basic Life Support (CPR and AED) Program" training certificate from the American Heart Association dated as issued on March 19, 2023, and expired in March 2023;
-No documentation of first aid training for E3;
-A printout of E4's "CPR/AED/First-Aid" training certificate from NationalCPRFoundation dated as issued on January 23, 2023; and
-A photocopy of E5's "CPR, AED, and Basic First Aid" training certificate from Health and Safety Institute dated as issued on October 7, 2021, and expired on October 7, 2023.

3. A review of the NationalCPRFoundation website revealed the training was online-only and did not include a demonstration of an individual's ability to perform CPR.

4. In an interview, E2 reported all required documentation should have been in the records. The Compliance Officers informed E2 the personnel records were missing items and asked if there were any records waiting to be filed, and E2 stated, "If it's not in there then we don't have it."

Based on record review, documentation review, and interview, the manager failed to ensure when a resident's written service plan was initially developed and when updated, the service plan was signed and dated by the manager and the nurse or medical practitioner who reviewed the service plan, for one of eight resident 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 R6's medical recored revealed a current service plan. The service plan indicated R6 required medication administration services. However, the service plan was not signed by the manager and the nurse or medical practitioner who reviewed the service plan.

2. A review of the facility's policies and procedures revealed a policy titled, "Individualized Service Plan [ISP] Policy." The policy stated, "The ISP is completed with the evaluation by the HWD [Health and Wellness Director] or designee and signed by resident/responsible party."

3. In an interview, E1 and E2 acknowledged R6's current service plan was not signed and dated by the manager and the nurse or medical practitioner who reviewed R6's service plan.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for two of eight residents sampled. The deficient practice posed a risk to the health and safety of the residents as the residents were not provided with the required services.

Findings include:

1. A review of R3's medical record revealed a current service plan indicating R3 received personal care services. The service plan indicated R3 required one-person staff assistance with bathing one to two times per week. Further review of R3's medical record revealed a "monthly task log" dated October 2023. The document revealed no documentation indicating R3 received assistance with bathing as required.

2. A review of R6's medical record revealed a current service plan indicating R6 received direct care services. The service plan indicated R6 required one-person staff assistance with bathing one to two times per week. Further review of R6's medical record revealed a "monthly task log" dated October 2023. The document revealed R6 was to receive bathing assistance on Tuesdays and Saturdays. However, R6's log revealed R6 did not receive one-person staff assistance with bathing on Saturday, October 14, 2023, and on Tuesday, October 24, 2023. The log stated "TNC" which the legend defined as "Task Not Completed."

3. In an interview, E1 and E2 acknowledged the assisted living services in R3's and R6's service plans were not provided according to the frequencies identified in R3's and R6's service plans.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration, for two of eight residents sampled.

Findings include:

1. A review of facility documentation revealed an incident report completed by E1 involving an unnamed employee and R2. The incident took place on February 6, 2023. The incident report description stated, "While dressing resident, 'employee kept rubbing residents' stomach like a dog." However, the incident report did not document the actions taken according to subsection (J)(1), the names of the witnesses who reported the incident, and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. Furthermore, the incident report included a section titled "Actions Taken," however, this section was not completed.

2. A review of facility documentation revealed an incident report completed by E7 involving E8 and R6. The incident took place on April 17, 2023. The incident report description stated: "[E7] walked into [R6's apartment] and into the bathroom. [E7] saw [R6] sitting on the floor in the shower wearing pants and sneakers [while another] associate [E8 was] holding shower head handle with water running pointed towards [R6]." The incident report documented R6 stated, "Stop, get away from me, I don't want you in here." However, the incident report did not document the actions taken according to subsection (J)(1), and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. The incident report included a section titled "Actions Taken", however, the documentation indicated local police and other regulatory agencies were not contacted as required in A.R.S. \'a7 46-454.

3. A review of the facility's posted resident rights stated, "The Resident will be treated with dignity, respect and consideration."

4. In an interview regarding incident reports, E2 reported there were additional documents for internal use only and E2 did not have access to them. In a later interview, E1 reported E1 would have to look into the incident reports. E1 and E2 acknowledged residents were not treated with dignity, respect, and consideration.

Based on record review, documentation review, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of eight residents sampled. The deficient practice posed a risk as administration of medication could not be verified against a medication order.

Findings include:

1. A review of R3's medical record revealed a current service plan indicating R3 received medication administration services. Further review of R3's medical record revealed R3 received "Furosemide Oral Tablet 20 MG" on September 11, 2023, at 7:00 AM and 7:00 PM. However, R3's medical record did not contain a signed order for "Furosemide."

2. A review of the facility's policies and procedures revealed a policy titled, "Medication Policy." The policy stated: "It is the policy of this community to supervise or administer all medications that the residents receive as ordered by their physician...All orders are obtained from a licensed physician before administering medications...Each dose administered is properly recorded in the MAR/MOR as indicated by medication technician initials in appropriate block or in electronic health record."

3. In an interview, E1 and E2 acknowledged "Furosemide" was administered to R3 without a medication order.

Based on interview and documentation review, the manager failed to ensure policies and procedures for medication administration included a process for documenting an individual, authorized, according to the definition of "administer" in A.R.S. \'a7 32-1901, by a medical practitioner to administer medication under the direction of the medical practitioner.

Findings include:

1. In an interview conducted at 1:20 PM on October 25, 2023, one of the Compliance Officers requested the entirety of the facility's policies and procedures.

2. In a series of interviews conducted on October 26, 2023, the Compliance Officers again requested the entirety of the facility's policies and procedures, specifically mentioning this policy and procedure.

3. In two emails received on October 26, 2023, at 12:12 PM and 2:54 PM respectively, E6 and E2 provided the facility's policies and procedures.

4. A review of facility documentation revealed no policy and procedure which included a process for documenting an individual, authorized, according to the definition of "administer" in A.R.S. \'a7 32-1901, by a medical practitioner to administer medication under the direction of the medical practitioner.

5. In an interview, E2 stated if E6 did not send the policy and procedures covering this rule, "We don't have it."

Based on record review, documentation review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of eight residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R3's and R5's medical record revealed current service plans indicating R3 and R5 received medication administration services.

2. A review of R3's medical record revealed a signed medication order for "Eliquis Oral Tablet 2.5 MG (milligrams)." Further review of R3's medical record revealed an electronic medication administration record (eMAR). The eMAR for September-October 2023 revealed R3's "Eliquis" was not provided on the following dates at the following times:
-On September 20-22, 2023, at 7:00 PM. The eMAR stated "DNG", which the legend defined as "Drug Not Given;"
-On September 23-29, 2023, at 7:00 PM. The eMAR stated, "DNA" which the legend defined as "Drug Not Available;"
-On September 24-28, 2023, at 7:00 AM. The eMAR stated "DNA;"
-On October, 1, 2, and 19, 2023, at 7:00 AM. The eMAR stated "DNA;" and
-On October 1, 2023, at 7:00 PM. The eMAR stated "DNA."

3. A review of R5's medical record revealed a signed order for "Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG." The order stated, "Take 1 tablet by oral route every day at bedtime." Further review of R5's medical record revealed an eMAR for September-October 2023. The eMAR revealed R5's "Seroquel" was not provided on September 12, 18, and 19, 2023 at 7:00 PM. The eMAR stated, "DNG." The eMAR also contained a dash symbol indicating on October 19, 2023, at 7:00 PM, the medication was not administered as ordered.

4. A review of the facility's policies and procedures revealed a policy titled, "Medication Policy." The policy stated: "It is the policy of this community to supervise or administer all medications that the residents receive as ordered by their physician...All orders are obtained from a licensed physician before administering medications...Each dose administered is properly recorded in the MAR/MOR as indicated by medication technician initials in appropriate block or in electronic health record."

5. In an interview, E1 and E2 acknowledged medications were not administered to R3 and R5 in compliance with medication orders.

This is a repeat citation from the complaint inspection conducted on April 16, 2021.

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. The deficient practice posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan.

Findings include:

1. A review of facility documentation revealed a binder of disaster drills. The drill binder revealed disaster drills were conducted with employees on each shift every three months. However, the binder revealed no documentation of evacuation drills.

2. In an interview, E1 and E2 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months.

Based on documentation review, record review, and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for four of eight residents sampled. The deficient practice posed a potential risk of re-injury.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Fall Response." The policy stated: "If the resident answers 'yes' to hitting their head or if there are any signs of a head injury or other injuries, call 911...Complete Page 1 of Post Fall Investigation Tool."

2. A review of R1's medical record revealed an incident report which revealed R1 sustained a head injury after falling on the floor near R1's bed. The report stated, "Resident on the floor next to [R1's] bed during rounds and was covered in feces." Further review of the report revealed a section titled "Actions Taken." The "Actions Taken" section stated: "Contacted Emergency Response: No." Additionally, the incident report revealed a "Fall Risk review tool" was not completed.

3. A review of R2's medical record revealed an incident report which revealed R2 sustained a head injury and scratch after falling. The report stated: "Resident fell forward...found on floor." Further review of the report revealed a section titled "Actions Taken." The "Actions Taken" section stated: "Contacted Emergency Response: No." Additionally, the incident report revealed a "Fall Risk review tool" was not completed.

4. A review of R6's medical record revealed an incident report which revealed R6 sustained a head injury and cut after falling in the patio. The report stated, "Found resident in patio lying backward." Further review of the report revealed a section titled "Actions Taken." The "Actions Taken" section stated: "Contacted Emergency Response: No."

5. A review of R8's medical record revealed an incident report which revealed R8 sustained a head injury after falling in the bathroom. The report stated, "...got resident out of shower sitting on toilet on a towel...[the resident] moved a little and fell into the shower." Further review of the report revealed a section titled "Actions Taken." The "Actions Taken" section stated: "Contacted Emergency Response: No."

6. In an interview, E2 reported the fall risk review tool is what the facility used to prevent future falls. E2 stated, "I don't have anything other than that." E1 and E2 acknowledged when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver did not document any action taken to prevent the incident from occurring in the future or did not take the action required by facility P&Ps.