INSPIRATIONS OF TEMPE

INSP-0119728

Complete

Date: 4/3/2025 - 4/7/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-01

Summary:

The following deficiencies were found during the on-site investigation of complaint 00123698 conducted on April 3, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-808.C.1.a. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident's service plan;

Evidence/Findings:

Based on observation, 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. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R1's medical record revealed a service plan for directed care dated March 2025.The service plan stated the following services were required:- "Provide personal laundry service Laundry 1/week. Laundry is being provided as needed more than 1x per week as resident is soiling clothes with urine and feces throughout the day." -"Housekeeping is cleaning room more frequently than once a week and at a PRN basis as the resident is relieving [self] on the floor." 2. During the environmental inspection of the facility, the Compliance Officer observed R1 walking barefoot through urine which was on the bathroom, living room, and bedroom floors of R1's unit. The Compliance Officer observed a strong smell of urine on R1's clothing. 3. In an interview, E6 reported that the unit was last cleaned a week before the inspection. 4. In an interview, E2 and E4 acknowledged that a caregiver or assistant caregiver did not provide R1 with the assisted living services in the resident's service plan.

Temporary Solution:

On April 4, 2025 new flooring was ordered for the apartment to replace with only hard wood and remove carpet. On April 7, 2025 we implemented the housekeeping daily documentation form. On April 7th the new flooring was installed. The housekeeper assigned to the apartment was termed on March 28, 2025 for job performance. On April 4, 2025 the service plan was changed to daily showers.

Permanent Solution:

On April 4, 2025 a notice of termination of the residency agreement was given for needing higher level of care. A weekly meeting is to be conducted to go over care needs of all residents. The Wellness Director and Executive Director and/or designee will attend the meetings.

Person Responsible:

Executive Director and/or Designee

Deficiency #2

Rule/Regulation Violated:

R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. Findings include: 1. During the environmental inspection of the facility with E1 and E4 around 10 a.m. the Compliance Officer observed R1's unit had a very strong urine smell and had urine leading from R1's bathroom to the living room and bedroom area. The bedroom area had carpet, the carpet had tracks of urine from where the resident was walking to and from the bathroom and living room area. The Compliance Officer also observed R1 walking through the urine. The Compliance Officer's shoes were sticking to the floor due to the dry, sticky urine on the floor. The Compliance Officer also observed the toilet had dry urine on the seat of the toilet. 2. A review of R1's service plan for directed care services. The services plan revealed R1 was to receive Housekeeping, “housekeeping is cleaning the room more frequently than once a week and at a PRN bases as resident is relieving themselves on the floor’. 3. In an interview, E1 acknowledged the urine on the bathroom floor, living room floor, and in bedroom carpeted flooring had been there for at least a week. 4. In an interview, E1 acknowledged that R1 was not treated with dignity, respect, and consideration.

Temporary Solution:

Permanent Solution:

On April 4, 2025 a notice of termination of the residency agreement was given for needing higher level of care

Person Responsible:

Executive Director and/or Designee

Deficiency #3

Rule/Regulation Violated:

R9-10-819.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected to prevent, minimize, and control illness or infection. Findings include: 1. During the environmental inspection of the facility with E1 and E4 around 10 a.m. the Compliance Officer observed R1's unit had a very strong urine smell and had urine leading from R1's bathroom to the living room and bedroom area. The bedroom area had carpet, the carpet had tracks of urine from where the resident was walking to and from the bathroom and living room area. The Compliance Officer also observed R1 walking through the urine. The Compliance Officer's shoes were sticking to the floor due to the dry, sticky urine on the floor. The Compliance Officer also observed the toilet had dry urine on the seat of the toilet. 2. In an interview, E6 reported R1's unit was last cleaned a week before the date of the inspection. 3. In an interview, E1 and E6 acknowledged R1's bedroom had urine leading from the bathroom to the living room and the bedroom area. E1 acknowledged the facility staff was aware of the issue of R1 dragging urine-soaked briefs across the unit. E1 acknowledged R1 had been walking through the urine for about at least a week. 4. In an interview, E1 and E2 acknowledged the premises used at the assisted living facility was not cleaned and disinfected to prevent, minimize, and control illness or infection.

Temporary Solution:

On April 4, 2025 a new floor was ordered. On April 7th the new flooring was installed and carpet was removed from the apartment to all hard wood.

Permanent Solution:

On April 16, 2025 the safety committee met and addressed and reviewed Community Cleaning Protocols. The committee also introduced the housekeeping sanitizing/cleaning checklist. On April 17, 2025 at the all staff meeting, Community Cleaning Protocols were addressed.

Person Responsible:

Executive Director and/or Designee

Facility Information

Inspection History

INSP-0157971

Summary:

INSP-0135090

Summary:

INSP-0119728

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0072926

Summary: