GOLDEN AGE ASSISTED LIVING LLC

INSP-0124485

Complete

Date: 4/11/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-04-22

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00125129, 00125130 conducted on April 11, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1 . A review of R1's medical record revealed signed document titled "Agave Hospice Physician Order" dated January 30, 2025 for the following medication:<ul><li>HOLD Senna every Sunday and Wednesday.</li></ul> 2. A review of R1's medical record revealed a Medication Administration Record (MAR) for April 2025 documenting R1 was administered the following:<ul><li>Senna-S 8.6-50 milligram(MG) Tablet - Give one tab by mouth twice a day for constipation hold for diarrhea.</li></ul> 3 . A review of R1's MAR revealed Senna-S 8.6-50 milligram(MG) Table was administered at the following dates and times:<ul><li>April 1, 2025 to April 11, 2025 at 8:00AM; and</li><li>April 1, 2025 to April 10, 2025 at 8:00PM.</li></ul>However, no documentation that the medication was held on Sunday and Wednesday per order was available for review. 4 . In an interview, E1 acknowledged medication administered to R1 was not administered in compliance with a medication order.

Permanent Solution:

A permanent solution was instituted immediately on this resident and all other residents moving forward.
1. The manager will ensure that all residents medication administration record with similar order will be marked with an X on the days that medications are to be held.
2. The Mediset will also be checked by the manager to ensure that medications are not filled according to the doctor's order.
3. All caregivers were educated on medication administration and transcription following doctors' orders.
Please see attached medication record (MAR)

Person Responsible:

Gladys Tih Owuor, Manager

Deficiency #2

Rule/Regulation Violated:

A.R.S. § 36-420.04.A.1-9. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives.

Evidence/Findings:

Based on record review and interview, the manager did not ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's and R2's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9). However, the following were not included in the documentation:- A standardized space to be filled in with the reason or reasons the emergency responder was requested on behalf of the resident. 2. In an interview, E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Permanent Solution:

The manager immediately implemented a new standardized form provided to her by the surveyor that has a space to be filled in with the reason the emergency responder was requested on behalf of the resident.
This form is currently in all residents' emergency packet in the facility.
Caregivers were all educated on how to complete this form on all emergency transfer.
Please see attached

Person Responsible:

Gladys Tih Owuor, Manager

INSP-0068543

Complete

Date: 3/5/2024

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2024-03-27

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on March 5, 2024:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

A. A manager shall ensure that:
2. An assistant caregiver:
b. Interacts with residents under the supervision of a manager or caregiver;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as E3 and E4 were not qualified to provide the required services.

Findings include:

A.R.S. \'a7 36-401.A.42. "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity.

1. Review of E2's and E3's personnel records revealed E2 and E3 were hired as assistant caregivers in January 2024.

2. The Compliance Officers observed E2 at the time of the inspection providing direct services to residents. The direct services witnessed included assisting a resident walking to the bathroom using a walker and spoon feeding a resident lunch without the direct supervision of a manager or caregiver.

3. In an interview, R2 reported E3 provided R2 bed baths alone with no caregiver or manager present.

4. In an interview, E2 acknowledged E2 assisted a resident from their bed to the bathroom using their walker and fed a resident lunch without being under the direct supervision of a manger or caregiver.

5. In an interview, E1 acknowledged E2 and E3 were assistant caregivers. E1 acknowledged E2 and E3 provided services to residents without being under the direct supervision of a caregiver or manager.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregivers' skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for two of two assistant caregivers reviewed. The deficient practice posed a health and safety risk.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "Assistant Caregivers". The policy stated "Assistant Caregivers Services will be provided to the resident only after receiving specific training, documentation and under the supervision and direction of another caregiver or manager."

2. Review of E2's and E3's personnel records revealed E2 and E3 were hired as assistant caregivers in January 2024. The personnel records revealed no documentation of E2's and E3's skills and knowledge verified as assistant caregivers.

3. In an interview, E1 reported E2 and E3 were working at the facility prior to E1 working at the facility and were hired by the previous manager. E1 acknowledged E2's and E3's personnel records did not include documentation of skills and knowledge verified.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;

Evidence/Findings:

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

Findings include:

1. The Compliance Officers observed E1 and E2 working at the facility at the time of the inspection.

2. A request for the March 2024 personnel schedule revealed no schedule was available for review.

3. In an interview, E1 reported E1 needed to create the March 2024 schedule. E1 reported E1 was unaware assistant caregivers were to be documented on the schedule. E1 acknowledged documentation was not maintained of the assistant caregiver working each day, including the hours worked for the month of March 2024.

Deficiency #4

Rule/Regulation Violated:

D. Before or at the time of an individual's acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes:
5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a residency agreement included whether the manager or a caregiver was awake during nighttime hours, for one of two residents reviewed accepted by the assisted living home on or after July 1, 2014. The deficient practice posed a health and safety risk if a resident was unable to awaken the caregivers during nighttime hours.

Findings include:

1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of whether the manager or a caregiver was awake during nighttime hours. Based on R1's acceptance date, this documentation was required.

2. In an interview, E1 reported caregivers sleep at night and wake up if the residents need assistance. E1 acknowledged R1's residency agreement did not include that information.

Deficiency #5

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the amount, type, and frequency of assisted living services being provided to the resident, for one of two residents sampled.

Findings include:

1. Review of R2's medical record revealed a personal care service plan. The service plan stated "Bathing, twice weekly and as needed Caregivers to help with showers and bed baths." However, the resident was bed bound and can only receive bed baths.

2. In an interview, E1 reported R2 only received bed baths and could not receive a shower as indicated in R2's service plan. E1 acknowledged R2's service plan did not include the correct type of bathing service to meet R2's needs.

GOLDEN AGE ASSISTED LIVING LLC

Facility Information

Inspection History

INSP-0124485

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0068543

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

INSP-0068541

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings: