ORCHARD POINTE AT SURPRISE

Based on documentation review and interview, the governing authority failed to designate a certified manager, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules.

Findings include:

1. A review of the Department records for the facility revealed that O1 was the current manager; no information was received from the governing authority to indicate that a new manager had been appointed.

2. The Compliance Officer observed an assisted living facility manager's license conspicuously posted in the facility with O2's name identified on the license.

3. In a telephonic interview, E1 reported the previous manager O1 was terminated on April 12, 2024 and O2 became the manager with an effective date of April 12, 2024. E1 reported O2 was recently terminated on August 26, 2024. In addition, E1 reported the facility did not have a manager with a certificate or a temporary certificate as an assisted living facility manager, as required. E1 acknowledged the facility did not designate in writing a manager who either had a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for flu and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to four of nine residents reviewed. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R3's medical record revealed R3 requested the flu and pneumonia vaccinations, however this documentation was not dated. Current documentation was not available that showed the flu and pneumonia vaccinations were received or refused. Based on R3's acceptance date, this documentation was required.

3. Review of R4's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R4's acceptance date, this documentation was required.

4. Review of R5's medical record revealed R5 refused the flu and pneumonia vaccinations, however this documentation was not dated. Current documentation was not available that showed the flu and pneumonia vaccinations were received or refused. Based on R5's acceptance date, this documentation was required.

5. Review of R8's medical record revealed R8 requested the flu vaccinations and refused the pneumonia vaccination, however this documentation was not dated. Current documentation was not available that showed the flu and pneumonia vaccinations were received or refused. Based on R5's acceptance date, this documentation was required.

6. In an interview, E1, E2, E3, E4, and E5 acknowledged R3's, R4's, R5's, and R8's medical records did not include current documentation that showed the flu and pneumonia vaccinations were received or refused.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for two of three residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R6's medical record revealed a current written service plan dated August 9, 2023. This service plan stated "...Resident requires 1 staff hands on assistance with transfers and or changes in position...".

2. Review of R6's medical record revealed a written determination from R6's medical practitioner signed and dated April 14, 2022. However, documentation was not available that stated R6's needs could be met by the facility and R6's needs were within the facility's scope of services, at least once every six months.

3. Review of R8's medical record revealed a current written service plan dated January 20, 2024. This service plan stated "...Resident requires 1-2 staff hands on assistance with transfers and or changes in position...".

4. Review of R8's medical record revealed a written determination from R8's medical practitioner signed and dated June 21, 2022. However, documentation was not available that stated R8's needs could be met by the facility and R8's needs were within the facility's scope of services, at least once every six months.

5. In an interview, E2 reported R6 and R8 were unable to ambulate even with assistance since acceptance and E1, E2, E3, E4, and E5 acknowledged R6's and R8's medical practitioner did not provide a written determination at least once every six months.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for two of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R2's medical record revealed the following:
- A document titled "Progress Notes" dated December 24, 2023 that stated "Resident was sent out 911..." Documentation was not available that showed R2's primary care provider was notified of the incident that required medical services.
- A document titled "Progress Notes" dated January 2, 2024 that stated "Resident fell and hit the back of (R2's) head this morning was sent out to Banner Del Webb 911..." Documentation was not available that showed R2's emergency contact and primary care provider were notified of the incident that required medical services.
- A document titled "Progress Notes" dated January 21, 2024 that stated "...Resident found it difficult to bear weight, complained of hip and lower back pain...Resident was sent out 911..." Documentation was not available that showed R2's primary care provider was notified of the incident that required medical services.

2. Review of R11's medical record revealed the following:
- A document titled "Incident Form" dated July 28, 2023 that stated "Resident was yelling for help, staff walked in and found (R11) on the floor...Resident was sent out 911..." Documentation was not available that showed R2's primary care provider was notified of the incident that required medical services.
- A document titled "Progress Notes" dated August 4, 2023 that stated "...Resident was transported to Banner Del Webb..." Documentation was not available that showed R2's primary care provider was notified of the incident that required medical services.

3. In an interview, E1, E2, E3, E4, and E5 acknowledged R2's and R11's medical records did not include documentation that showed a caregiver immediately notified the emergency contact and primary care provider when the resident had an incident that required medical services.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for two of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R2's medical record revealed the following:
- A document titled "Progress Notes" dated December 24, 2023 that stated "Resident was sent out 911..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future.
- A document titled "Progress Notes" dated January 2, 2024 that stated "Resident fell and hit the back of (R2's) head this morning was sent out to Banner Del Webb 911..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future.

2. Review of R11's medical record revealed the following:
- A document titled "Incident Form" dated July 28, 2023 that stated "Resident was yelling for help, staff walked in and found (R11) on the floor...Resident was sent out 911..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future.
- A document titled "Progress Notes" dated August 4, 2023 that stated "...Resident was transported to Banner Del Webb..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future.

3. In an interview, E1, E2, E3, E4, and E5 acknowledged R2's and R11's medical records did not include documentation of any action taken to prevent the incident from occurring in the future.