GRANITE GATE SENIOR LIVING

Based on documentation 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 E4's personnel record revealed documentation of fall prevention and fall recovery training was not available for review at the time of inspection.

2. In an interview, E8 acknowledged E4's personnel record did not include documentation of a fall prevention and fall recovery training at the time of inspection.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of nine residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R8's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R8's date of acceptance, this documentation was required.

2. In an interview, E8 acknowledged R8 did not provide documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that was developed with assistance and review from the resident or resident's representative, for two of nine residents sampled. The deficient practice posed a risk if the resident or resident's representative were unable to participate in the development or review the service plan to provide essential information.

Findings include:

1. Review of R4's medical record contained a service plan dated September 8, 2024, for personal care services. The service plan revealed no signature of the resident or the resident's representative indicating the service plan was developed with assistance and reviewed by the resident or the resident's representative.

2. Review of R7's medical record contained a service plan dated June 24, 2024, for personal care services. The service plan revealed no signature of the resident or the resident's representative indicating the service plan was developed with assistance and reviewed by the resident or the resident's representative.

3. In an interview, E8 acknowledged the service plans for R4 and R7 were not signed to indicate the service plans were developed with assistance of the resident or the resident's representative.

This is a repeat deficiency from the compliance/complaint inspection conducted September 20, 2023.

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 influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d). 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 R8's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R8's acceptance date, this documentation was required.

3. In an interview, E8 acknowledged R8's medical record did not include current documentation that showed the flu and pneumonia vaccinations were received or refused.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a health risk to residents.

Findings include:

1. During an environmental tour of the facility, the Compliance Officer observed a shared bathroom located in the main hallway near the stairwell to the second level. Inside the bathroom, the Compliance Officer observed a trashcan next to the toilet. The trash can was lined with a plastic bag but did not have a lid. The trash can contained a soiled disposable sanitation pad.

2. During an environmental tour of the facility, the Compliance Officer observed uncovered garbage containers in the kitchen, located near the food preparation areas. The Compliance Officer also observed an uncovered trash can next to the medicine cart located in the kitchen in the memory care unit.

3. In an interview, E8 and E9 acknowledged garbage and refuse were not stored in covered containers at the time of inspection.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers away from food storage, kitchen, and dining areas. The deficient practice posed a health risk to the residents as infection control procedures were not implemented.

Findings include:

1. During an environmental inspection of the facility's central kitchen, the Compliance Officer observed a container full of soiled linen being stored uncovered in the facility's kitchen.

2. In an interview, E8 acknowledged the soiled linen was not stored in a closed container away from the kitchen.

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

Findings include:

1. During an environmental tour of the facility, the Compliance Officer observed an unlocked cabinet under the sink located in the memory care unit. The unlocked cabinet contained two cans of W-40.

2. In an interview, E8 acknowledged toxic materials were stored in an unlocked cabinet accessible to residents.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff.

Findings include:

1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB.

2. In an interview, E8 and E9 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not available.

Technical assistance was provided on this Rule during the compliance/complaint inspection conducted September 20, 2023.

Based on documentation review, record review, and interview, the administrator, who had a reasonable basis to believe abuse had occurred on the premises or while a resident was receiving services from a assisted living facility's manager, caregiver, or assistant caregiver, failed to report the suspected abuse of the resident for a resident 18 years of age or older according to A.R.S. \'a7 46-454(A), for one of one resident sampled.

Findings include:

A.R.S.\'a7 46-454(A) "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit."

R9-10-101.110 "Immediate" means without delay.

1. A review of Department documentation revealed a facility self-reported incident. E1 reported an alleged incident occurred June 26, 2023. E1 reported that bruises were observed on R1's arms on June 26, 2023.

2. In an on-site complaint investigation, E1 provided the printed documentation that was received after reporting the incident via the Public Health Licensing Online Complaint Form portal. The documentation reported the complaint was received by the Department at 3:44 PM on June 27, 2023.

3. Further review of facility documentation revealed the incident was reported to Adult Protective Services (APS) at 4:05 PM on June 27, 2024.

4. A review of the facility's policy and procedures revealed a policy titled, "Abuse, Neglect, and Exploitation Prohibition and Prevention Program." Under the heading "Reporting Requirements" the policy stated, "...2. Reporting to State Agencies. All "Covered Individuals," including mandated reporters, employees, and LTC communities, have an obligation to report any reasonable suspicions of a crime against a resident and all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to the appropriate state authorities, including the State Certification Agency and all other agencies, as required, after the allegation or occurrence. If the allegation or occurrence involves abuse or serious bodily injury, notification must occur immediately but no later than 2 hours. If the allegation or occurrence does not involve abuse or does not result in serious bodily injury, notification must occur immediately but no later than 24 hours..."

5. A review of facility documentation revealed an internal investigation was started June 26, 2023 and completed June 30, 2023. The documentation revealed the facility conducted numerous personnel interviews. The facility determined that R1 did not have any bruising on R1's arms on Sunday, June 25, 2023. The investigation concluded that R1's bruising occurred sometime Sunday night and the bruising was noticed Monday morning, June 26, 2023.

6. In an interview, E1 acknowledged the facility did not notify a peace officer or Adult Protective Services immediately as required in A.R.S. \'a7 46-454(A).

Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services for five of seven caregivers and assistant caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.

Findings include:

1. A review of E2's, E4's, E5's, E12's, and E13's personnel records revealed no documentation indicating skills and knowledge were verified.

2. In an interview, E1 acknowledged E2's, E4's, E5's, E12's, and E13's personnel records did not contain documentation showing E2's, E4's, E5's, E12's, and E13's skills and knowledge were verified. E1 reported E2, E4, and E5 were facility personnel. E1 reported E12 and E13 were hired through a staffing agency.

Based on record review and interview, the manager failed to ensure before providing assisted living services to a resident, two of seven sampled caregivers received orientation that was specific to the duties to be performed by the caregiver. The deficient practice posed a risk to the health and safety of residents if caregivers were not orientated to the specific duties to be performed.

Findings include:

1. A review of E12's and E13's personnel records revealed no documentation of completed orientation that was specific to the duties to be performed by E12 and E13.

2. In an interview, E1 acknowledged E12's and E13's personnel records did not contain documentation of completed orientation that was specific to the duties in their job descriptions. E1 reported E12 and E13 were hired through a staffing agency.

Based on record review and interview, the manager failed to ensure, before providing assisted living services to a resident, a caregiver provided current documentation cardiopulmonary resuscitation training certification specific to adults for one of seven personnel sampled. The deficient practice posed a risk to the health and safety of the residents as E13 may not have been able to meet the residents' needs during an emergency.

Findings include:

1. A review of E13's personnel record revealed no documentation of cardiopulmonary resuscitation training specific to adults.

2. In an interview, E1 reported E13 was hired through a staffing agency and the documentation was not provided. E1 requested the information (from the staffing agency) while the Compliance Officer was on-site. However, the information was not received for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that was developed with assistance and review from the resident or resident's representative, for three of ten residents sampled. The deficient practice posed a risk if the resident or resident's representative were unable to participate in the development or review the service plan to provide essential information.

Findings include:

1. A review of R3's medical record contained a service plan dated July 18, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

2. A review of R5's medical record contained a service plan dated September 14, 2023, for personal care services. The service plan revealed no signature of the resident indicating the service plan was developed with assistance and reviewed by the resident.

3. A review of R9's medical record contained a service plan dated July 7, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

4. In an interview, E1 acknowledged the service plans for R3, R5, and R9 were not signed to indicate the service plans were developed with assistance of the resident or the resident's representative.

Based on record review and interview, the manager failed to ensure four of seven resident records sampled contained a written service plan that included review by a nurse or medical practitioner for a resident that received medication administration. The deficient practice posed a risk to the physical health and safety of a resident without the review of a nurse or medical practitioner.

Findings include:

1. A review of R2's medical record revealed a service plan dated June 22, 2023. The service plan indicated R2 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner.

2. A review of R3's medical record revealed a service plan dated July 18, 2023. The service plan indicated R3 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner.

3. A review of R5's medical record revealed a service plan dated September 14, 2023. The service plan indicated R5 was a respite resident and received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner.

4. A review of R9's medical record revealed a service plan dated April 6, 2023. The service plan indicated R9 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner.

5. A review of R9's medical record revealed a service plan dated July 7, 2023. The service plan indicated R9 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner.

6. In an interview, E1 reported R2, R3, R5, and R9 received medication administration and acknowledged the service plans were not signed by a nurse or medical practitioner.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record for three of ten 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 R1's medical record revealed a care plan dated June 16, 2023. The care plan revealed R1 received assistance with activities of daily living services including:
-Toileting: Physical assistance with toileting tasks; timed toileting program; incontinent care...able to participate in some toileting activities...caregivers will toilet me, encourage me to assist with clothing, and to wash my hands after using restroom. The frequency stated was DEN (Day, Evening, Night).

2. A review of R1's activities of daily living documentation revealed R1 did not receive toileting assistance on the following days:
-August 1, 2023;
-August 6, 2023-August 8, 2023;
-August 14, 2023;
-August 16, 2023-August 28, 2023;
-August 31, 2023;
-September 3, 2023;
-September 7, 2023;
-September 10, 2023;
-September 13, 2023; and
-September 17, 2023.

3. A review of R2's medical record revealed a care plan with the latest revision dated June 22, 2023. The care plan revealed R2 received assistance with activities of daily living services including:
-Ambulation: physical assistance with ambulation on a regular basis, staff escort to all meals and events of choice;
-Transfers: minimal assist;
-Grooming: physical assistance for grooming; and
-Dressing: Dependent on staff for entire dressing activity.

4. A review of R2's activities of daily living documentation revealed R2 did not receive assistance with ambulation on the following days:
-August 1, 2023;
-August 6, 2023;
-August 19, 2023-August 20, 2023;
-August 23, 2023-August 27, 2023; and
-August 31, 2023.

5. A review of R2's activities of daily living documentation revealed R2 did not receive assistance with transfers on the following days:
-August 1, 2023;
-August 6, 2023;
-August 19, 2023-August 20, 2023;
-August 23, 2023-August 27, 2023;
-August 31, 2023;
-September 3, 2023;
-September 7, 2023;
-September 10, 2023;
-September 13, 2023; and
-September 17, 2023.

5. A review of R2's activities of daily living documentation revealed R2 did not receive assistance with grooming on the following days:
-August 1, 2023;
-August 4, 2023-August 6, 2023;
-August 19, 2023-August 20, 2023;
-August 23, 2023-August 27, 2023; and
-August 31, 2023.

6. A review of R2's activities of daily living documentation revealed R2 did not receive assistance with dressing on the following days:
-August 1, 2023;
-August 6, 2023;
-August 19, 2023-August 20, 2023;
-August 23, 2023-August 27, 2023;
-August 31, 2023;
-September 9, 2023-September 10, 2023; and
-September 17, 2023.

7. A review of R3's medical record revealed a care plan with the latest revision dated July 18, 2023. The care plan revealed R3 received assistance with activities of daily living services including:
-Ambulation: Physical assistance;
-Transfers: Physical assistance;
-Grooming: Dependent on staff;
-Dressing: Dependent on staff; and
-Toileting: Dependent on caregivers.

8. A review of R3's activities of daily living documentation revealed R3 did not receive assistance with ambulation on the following days:
-August 1, 2023; and
-August 4, 2023-August 31, 2023.

9. A review of R3's activities of daily living documentation revealed R3 did not receive assistance with transfers, grooming, dressing, or toileting on the following days:
-August 1, 2023;
-August 6, 2023-August 8, 2023;
-August 14, 2023;
-August 19, 2023-August 28, 2023; and
-August 31, 2023.

10. In an interview, E1 acknowledged the aforementioned services provided were not documented in R1's, R2's, and R3's medical records as required. E1 reported R1, R2, and R3 received the services per the service plans. However, the services were not documented as provided.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of nine 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 R2's medical record revealed a signed medication list dated July 12, 2023 for Olmesartan Medoxomil 5 mg tablet, two tablets by mouth every evening for high blood pressure.

2. A review of R2's September medication administration record (MAR) revealed R2 received Olmesartan Medoxomil 5 mg tablets, two tablets by mouth at noon.

3. A review of R2's medical record revealed a verbal order dated August 29, 2023 for Pramiprexole Dihydrochloride 0.125 mg, one-half tablet daily at 5:00 PM.

4. A review of R2's medical record revealed a verbal order dated August 29, 2023 for Pramiprexole Dihydrochloride 0.125 mg, one tablet daily at noon.

5. A review of R2's September MAR revealed R2 received Pramipexole 0.125 mg, one-half tablet at noon and a full tablet at 5:00 PM (opposite of the aforementioned medication order).

6. A review of R4's medical record revealed a medication administration record (MAR) for September 2023. The MAR indicated R4's received administration of the following medications, either scheduled or as needed:
-Aspirin 81 mg;
-Carvedilol 12.5 mg;
-Diltiazem 180 mg;
-Dorzolamide-Timolol 2%;
-Escitalopram 10 mg;
-Hydrochlorothiazide 12.5 mg;
-Losartan Potassium 25 mg;
-Pantoprazole 40 mg;
-Quetiapine Fumarate 25 mg;
-Tramadol 50 mg;
-Acetaminophen 325 mg;
-Albuterol Sulfate 90 micrograms;
-Ibuprofen 200 mg;
-Lorazepam 2 mg/ml; and
-Ondansetron 4 mg.

7. A review of R4's medical record revealed no valid signed medication orders for the aforementioned medications.

8. In an interview, E1 and E2 acknowledged the aforementioned medications were not administered to R2 in compliance with a medication order. E1 and E2 reported to believe a medication list from R4's hospice agency was acceptable as a medication order.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents.

Findings include:

1. The compliance officer requested to review documentation of the caregivers, medication technicians, and assistant caregivers assigned to work each day, including the hours worked, for the months of March 2023 and April 2023.

2. A review of the facility's personnel schedules revealed no one was scheduled to work in memory care on the following dates and times:
-March 30, 2023: 6:00 PM-6:00 AM; and
-April 2, 2023: 6:00 PM-6:00 AM.

3. A review of E2's personnel record revealed E2 (hire date February 27, 2023) was an assistant caregiver.

4. Further review of the facility's personnel schedules revealed E2 was scheduled to work alone/unsupervised in memory care on the following dates and times:
-March 6, 2023-March 7, 2023: 6:00 PM-6:00 AM;
-March 12, 2023-March 15, 2023: 6:00 PM-6:00 AM;
-March 19, 2023-March 22, 2023: 6:00 PM-6:00 AM; and
-April 9, 2023-April 10, 2023: 10:00 PM-6:00 AM.

5. In an interview, E1 acknowledged the documentation of the caregivers working each day was not maintained as required. E1 reported the open shifts on the personnel schedule were filled and E2 did not work unsupervised. However, the personnel member that covered the shift did not get documented.

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, for one of three 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 R1's medical record revealed a service plan dated March 30, 2023. Under the category, "Bathing" the service plan stated, "(1) I require staff standby supervision: set up, verbal cues and/or reminders to complete tasks. My caregivers will observe for any changes in my ability to participate in my care and report any changes in ADL function/need to the nurse and coordinator. My caregivers will observe the skin for any redness, open areas, scratches, cuts, tears, bruises/discolorations and report any changes to the nurse."

2. A review of R1's medical record revealed a document titled, "Schedule for April 2023." The document indicated R1 did not receive any bathing services in the month of April, as evidenced by no initials in the appropriate areas.

3. In an interview, E1 acknowledged the bathing services for R1 were not documented according to the service plan. E1 believed the services were provided. However, bathing services were not documented as received.