THE ENCLAVE AT GILBERT SENIOR LIVING

Based on record review and interview, the governing authority failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of E2's, E7's, and E8's personnel records revealed documentation of fall prevention and fall recovery training was not available for review.

2. A review of E5's personnel record revealed documentation of fall prevention and fall recovery training since 2022. However, no documentation of further fall prevention and fall recovery training was available for review.

3. In an interview, E1 acknowledged E2, E5, E7, and E8 personnel records did not include required documentation of a fall prevention and fall recovery training.

This is a repeat deficiency from the complaint investigation conducted August 15, 2024.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every six months, for one of five personal care residents sampled. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. A review of R4's medical record revealed a service plan for personal care services that was last updated on September 1, 2023.

2. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every six months.

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 inspection of the facility with E1, the Compliance Officer observed an unlocked housekeeping room that contained two Windex spray bottles, and a container filled with liquid "Rapid Multi Surface Disinfectant Cleaner." The unlocked room was located in a hallway across from resident rooms.

2. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

This is a repeat deficiency from the compliance/complaint inspection conducted March 2, 2023.

Based on record review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance.

Findings include:

1. In record review, the personnel records for E2 (hired June 19, 2019), E4 (hired on January 17, 2024), E5 (April 18, 2019), E7 (hired on May 17, 2024), and E8 (hired on February 2, 2024) did not include documentation of training and education related to recognizing the signs and symptoms of TB.

2. In an interview, E1 acknowledged E2's, E4's, E5's, and E7's records did not include annual training on recognizing the signs and symptoms of TB.

Based on documentation review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk of a potential residents rights violation if the the resident was subjected to abuse.

Findings include:

1. A.R.S. \'a7 46-454(A) states, "...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 ... All of the above reports shall be made immediately by telephone or online."

2. R9-10-101.111 states, "'Immediate' means without delay."

3. A review of facility incident reports revealed an incident report dated August 11, 2024 at 7:00 PM. The incident report stated, "While the care staff was busy getting residents ready to bed, this resident was found walking in the hallway, without walker, and when RA noticed that [R5's] face was kinda red. When asked what had happened? the resident said that [R8], behind [R5] went into [R5's] room claiming the room was [R8's]. and when [R5] told [R8] to get out, [R8] punched [R5] in the face. The resident c/o pain and jaw clicking when [R5] open [R5's] mouth. Both resident were separated and seated to the dining room. ED, AL Man, DON, hospice and family as well were notified." However, the incident report did not document the immediate notification to a peace officer or to Adult Protective Services of the alleged abuse.

4. In an interview, E1, E2, and E3 acknowledged the incident report did not document reporting of the alleged abuse according to A.R.S. \'a7 46-454.

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

Findings include:

1. A review of R4's medical record revealed a service plan dated July 18, 2024, for directed care services. However, the service plan was not signed and dated by R4 or R4's representative.

2. A review of R5's medical record revealed a service plan dated July 18, 2024, for directed care services. However, the service plan was not signed and dated by R5 or R5's representative.

3. A review of R6's medical record revealed a service plan dated August 15, 2024, for directed care services. However, the service plan was not signed and dated by R6 or R6's representative.

4. In an interview, E1, E2, and E3 acknowledged the service plans provided for R4, R5, and R6 had not been signed and dated by each resident or their representative when the service plans were updated.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.

Findings include:

1. A review of facility incident reports revealed an incident report for R6, dated, August 10, 2024. The incident report documented emergency medical services were contacted for R6 after a fall. However, the incident report documented R6's medical provider was not notified of the incident until August 18, 2024.

2. A review of facility incident reports revealed an incident report for R6, dated, August 16, 2024 . The incident report documented emergency medical services were contacted for R6 after a fall. However, the incident report documented R6's medical provider was not notified of the incident until August 18, 2024.

3. A review of facility incident reports revealed an incident report for R6, dated, August 17, 2024 . The incident report documented emergency medical services were contacted for R6 after a fall. However, the incident report documented R6's medical provider was not notified of the incident until August 18, 2024.

4. In an interview, E1, E2, and E3 acknowledged the incident reports for R6 did not include documentation of the immediate notification of R6's primary care provider each time R6 had an accident, emergency, or injury that resulted in R6 needing medical services.

Based on documentation review and interview, the health care institution failed to implement a training program regarding fall prevention and fall recovery training to include initial training and continued competency. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed an undated fall prevention and recovery program, however the program did not include a method to ensure continued competency in fall prevention and fall recovery.

2. In an interview E1 acknowledged the fall prevention and fall recovery program did not include continued competency training as required.

Based on documentation review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future. The deficient practice posed a health and safety risk to residents.

Findings include:

1. A review of documentation provided by E1 revealed the following:

- R1 had an incident resulting in the resident needing medical services on July 27, 2024;
- R2 had an incident resulting in the resident needing medical services on August 10, 2024;
- R3 had an incident resulting in the resident needing medical services on August 10, 2024; and
- R4 had an incident resulting in the resident needing medical services on August 3, 2024.

The documents did not include "any action taken to prevent the incident from occurring in the future".

2. During an interview, E1, and E5 acknowledged the incident reports did not include documentation showing any action taken to prevent the incident from occurring in the future.

Based on record review, documentation review, and interview, for one caregiver reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, and according to policies and procedures. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident.

Findings include:

1. In record review, E4's personnel record (hired as a caregiver on February 1, 2022) did not include documentation of the verification of E4's skills and knowledge.

2. In documentation review, a facility policy, titled, "Team Member Training/Orientation - Arizona Specific," documented, "All ... Caregiver ... team members will receive orientation and training specific to the duties to be performed by the Caregiver team member prior to providing services to a resident. The ... Caregiver ... team member's skills and knowledge will be verified and documented... 1. Caregiver and Assistant Caregiver Team Members will be checked off and documented on training, skills and knowledge prior to providing services to residents. Medication Assistants (MA) and Resident Assistants (RA), prior to providing services to our residents, a. The training for resident care team members to include, but not limited to: i. Three (3) days of onsite shadowing
1. An existing caregiver will verify and sign off skills and knowledge using the SRC's CAREGIVER SKILLS CHECKLIST (Skills Checklist) 2. The Skills Checklist is verified and approved by Care Manager (Director of Nursing, Manager of Assisted Living or Manager of Memory Care)..."

3. During an interview, the Compliance Officer requested E4's personnel record, including documentation of E4's verification of skills and knowledge. O1 provided E4's personnel record for review, and reported the documentation of the verification of skills and knowledge was in the record. The CO informed E4 the documentation was not found, and no further documentation was provided for review.

Based on document review and interview, the manager failed to ensure the policies and procedures were reviewed at least once every three years and updated as needed.

Findings include:

1. In an interview, the compliance officer requested documented evidence the manager had reviewed the facility's policies and procedure at least every three years. O3 reported there was no documentation that E1 had reviewed the facility's policies and procedures at least every three years. E1's date of hire was July 18, 2022.

2. During an interview, O3 acknowledged there was no documented evidence the facility's policies and procedures had been reviewed by the manager at least once every three years and updated as needed.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed; for two of two sampled residents.

Findings include:

1. Review of R4's record revealed a documented residency agreement. The residency agreement was signed by the resident or the representative, however, the residency agreement did not contain the manager's signature and date until two days after the expected date of acceptance.

2. Review of R5's record revealed a documented residency agreement. The residency agreement was signed by the resident or the representative, however, the residency agreement did not contain the manager's signature and date until four days after the expected date of acceptance.

3. In an interview, O3 acknowledged the manager did not sign and date the residency agreement before or at the time these sampled residents were accepted into the assisted living facility.

Based on record review and interviews, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of one sampled resident who was storing medications in the resident's unit, which posed a health and safety risk.

Findings include:

1. In interview, E3 reported that R4 was allowed to manage R4's own medications. An interview with R4 confirmed that R4 was allowed to manage R4's own medications.

2. Review of R4's current service plan dated January 11, 2023 failed to state how R4's medications will be stored and controlled in R4's unit.

3. In an interview, E3 acknowledged the sampled resident was allowed to self-administer R4's own medications, however, R4's service plan did not include how these medications will be stored and controlled.

This is a repeat deficiency from the compliance inspection conducted on February 10-11, 2022.

Based on record review and interview, the manager failed to ensure three of nine sampled residents' written service plans when initially developed and updated were signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Review of R1's medical record and the current service plan that was dated January 8, 2023, stated the resident was receiving personal care and medication administration services. The service plan contained no dated signature by the nurse or medical practitioner who reviewed the service plan.

2. Review of R6's medical record and the current service plan that was dated February 8, 2023, stated the resident was receiving personal care and medication administration services. The service plan contained no dated signature by the nurse or medical practitioner who reviewed the service plan.

3. Review of R9's medical record and the current service plan that was dated October 25, 2022, stated the resident was receiving personal care and medication administration services. The service plan contained no dated signature by the nurse or medical practitioner who reviewed the service plan.

4. In an interview, E3 acknowledged the sampled residents' service plans had not been signed and dated as required. E3 acknowledged all three residents were receiving personal care and medication administration services.

This is a repeat deficiency from the compliance inspection conducted on February 10-11, 2022.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months which posed a safety risk.

Findings include:

1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months.

2. In an interview, O3 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection which posed a health and safety risk.

Findings include:

1. During a facility tour of randomly selected residents' units, E3 and the compliance officer observed in R1's unit the bedroom carpet had numerous spill like marks on the on the side of the bed that R1 could exit from, which gave the appearance the carpet was not kept clean. In R3's unit the carpet throughout the unit had numerous dark marks and spill like marks which gave the appearance the carpet was not kept clean.

2. In an interview, E3 acknowledged R1's and R3's carpets did not appear clean.

This is a repeat deficiency from the compliance inspection conducted on February 10-11, 2022.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were maintained in a locked area and inaccessible to residents which poses a health and safety risk.

Findings include:

1. During a facility tour of randomly selected areas of the facility, E3 and the compliance officer observed in the unlocked facility's first floor laundry adjacent to residents' units there were stored antibacterial kitchen cleaner and Lysol spray. In the unlocked memory care kitchenette under the sink in an unlocked cabinet there were stored Odol Ban Disinfectant and Peroxide multi-purpose cleaner. At the facility's front desk there were stored unlocked in a basket Oxygen Orange all-purpose cleaner spray and Revitalize Miracle carpet cleaner.

2. In an interview, E3 and O3 acknowledged the unlocked poisonous or toxic materials stored by the facility.

During the compliance inspection February 11-12, 2022 the facility was given technical assistance regarding storing poisonous or toxic materials at the facility's front desk unlocked.

Based on documentation review and interview, the manager failed to ensure a cat residing at the facility was vaccinated against rabies, which posed a health and safety risk.

Findings include:

1. In an interview, E3 reported that R5 had a cat, however, when the compliance officer requested to review this cat's rabies vaccination record, the record was not provided.

2. During an interview, O3 acknowledged there was no cat rabies vaccination record for O1 available for review.