MARY & PETE'S ASSISTED LIVING

INSP-0097751

Complete

Date: 2/11/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-03-14

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00215152, AZ00220286, and AZ00219609 conducted on February 11, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-808.A.3.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included a description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. Findings include: 1. A review of R1’s medical record revealed a service plan, dated November 10, 2024, for personal care services, which reflected R1’s “Medical Diagnosis and History” as “Chronic ulceration of skin of sites w/ necrosis of the bone. Atypical flutter, presence of cardiac pacemaker, altered mental status, unspecified.” The service plan included a section titled “Integumentary,” which read,” No Issues,” and “Keep resident’s skin clean and dry, apply hydrating lotion, check resident’s skin at every shower, bath, and PRN, ensure good hygiene and nutrition.” In addition, the service plan contained a section titled "Hospice Services," which identified Arista Hospice as R1's provider. The section indicated R1 was seen by a "CNA...2 times per Week and as needed." The section also indicated R1 was seen by a hospice provider "1 time per Week and as needed." 2. A review of R1’s medical record revealed a document titled “IDG Meeting Review,” documenting notes and diagnoses from R1’s hospice provider, signed on February 5, 2025. The document notes indicated R1 was admitted to hospice for a primary diagnosis of“protein calorie malnutrition” and identified R1’s “Primary” diagnosis as “Unspecified severe protein-calorie malnutrition Start Effective Date: 11/06/2024.” Furthermore, the document identified a "Start of Care Date" of November 4, 2024, six days prior to the formation of R1's service plan. 3. In an interview, E1 advised all caregivers were aware of R1’s medical conditions, including R1’s primary diagnosis. E1 acknowledged R1’s service plan did not include an accurate description of R1’s medical issues.

Temporary Solution:

Change That Will Be Implemented:
Person in charge of service plans will do a double check when they have completed the service plans. They will then inform a second person, which will be the manager, that they are ready to be submitted.

Permanent Solution:

The second person, the manager, will check a third time to make sure that all plans including residents medical and health diagnosis match the residents medical records and needs before they submit the service plans. When they receive the final service plan the caregiver will look through to make sure the service plan was created exactly to match the residents and their needs.

Person Responsible:

Patricia Gonzales Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-808.C.1.g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and

Evidence/Findings:

Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's service plan for one of two residents sampled. Findings include: 1. A review of facility staff schedules revealed the facility operated two shifts per day, 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m. 2. A review of R2’s medical record revealed a service plan, dated September 17, 2024, for directed care services. The service plan contained sections titled “Transferring,” which indicated R2 required “total care, daily,” and “Dressing,” which indicated, “Requires total care, twice daily.” The service plan also included a section titled “Mobility,” which indicated “Bed Ridden” and “Requires Positioning: Yes 2 Hour(s).” In addition, the service plan contained a section titled “Strategies to ensure resident’s personal Safety,” which indicated “Resident is checked on every 3-4 hours at night time…” 3. A review of R2’s medical record revealed a document used for tracking activities of daily living (ADLs) for October 2024 and November 2024. The document included sections for documenting the services “Transfers” and "Dressing.” While the record reflected documentation indicating the service “Transfers” was provided every shift during October 2024 and November 2024, the record did not include a section for documenting the service “Mobility” every two hours. In addition, evidence that this service was provided was unavailable for review. Further, evidence of documentation R2 was provided the service “Dressing” twice daily was unavailable for review. 4. In an interview, E1 agreed caregivers were not documenting the services provided in a resident’s service plan as required.

Temporary Solution:

#1
A. I will implement my two hour window right to produce requested paperwork to the inspector upon inspection.
B. We have implemented a new filing system that makes it easier to produce documents to the inspector when requested. This system will help to locate “Turn Charts” as well as other important documents much quicker when needed.

#2:Caregivers who are documenting in ADL’s will properly document in the “Dressing” section of a residents ADL that a resident “refuses to wear clothes”, or “resident only uses sheets”. Caregivers will no longer make any unnecessary marks on the ADL’s.

Permanent Solution:

#1: Caregivers were shown the new filing system and instructed on how to file residents’ documents in the proper filing system.

#2: Manager will double check that ADLS are matching what is documented in the resident’s service plan.

Person Responsible:

Patricia Gonzales Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-811.A.2.a-c. Medical Records A. A manager shall ensure that: 2. An entry in a resident's medical record is: a. Only recorded by an individual authorized by policies and procedures to make the entry; b. Dated, legible, and authenticated; and c. Not changed to make the initial entry illegible;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure an entry in a resident’s medical record was not changed to make the initial entry illegible. Findings include: 1. A review of R2’s medical record revealed a document titled “Individual Control Drug Record,” used for documenting and tracking the administration of a controlled substance. The record included a column titled “Date,” which contained documentation of dates of administration and receipt of a controlled substance. Entries on November 7, 2024 and November 8, 2024, were written over correction tape, which made the original date entries illegible. In addition, the document contained a column titled “Balance,” used for documenting and reconciling the amount of controlled substance on hand after administration. Entries on October 25, 2024; November 14, 2024; November 17, 2024; and November 20, 2024 were written over the original entry, making the original entry illegible. 2. In an interview, E1 agreed entries into a resident’s medical record were changed to make the original entry illegible.

Temporary Solution:

Manager has enforced with all caregivers or persons designated to make entries into resident’s medical records that no correction tape is to be used for absolutely no reason.

Permanent Solution:

Manager has enforced that correction tape is not to be brought into the home for no reason. Caregivers and anyone designated to make entries into residents files were instructed on how to correct a mistake on any file SPECIFICALLY MEDICATION DOCUMENTATION should a mistake occur.

Person Responsible:

Patricia Gonzales Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-816.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a medication was administered to a resident under the direction of a medical practitioner for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan for personal care services, which included medication administration. Further review revealed a document used by medical providers to authorize “staff trained in medication administration…to administer medications and treatments that I may prescribe for my patient.” The document identified the name of R1’s physician; however, it was not signed by the physician identified but rather a registered nurse. 2. In an interview, E1 advised R1 was being administered medication as ordered. E1 agreed medication was being administered to R1 without the specific direction of a medical practitioner as required.

Temporary Solution:

Manager will ensure that required documents upon entry into the home which require a physicians signature are indeed signed by the physician. Manager will also ensure that any health or medical changes made on the residents medical records by anyone other than the residents physician will be signed by the residents actual physician within the seven day grace period.

Permanent Solution:

Manager will require that caregivers inform her of any changes that are made on any residents medical records be reported to her at the time of change. Caregivers were trained to recognize signatures are done by the proper authorities.

Person Responsible:

Patricia Gonzales Manager

No deficiencies were found during the on-site compliance inspection conducted on January 10, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.

Facility Information

Inspection History

INSP-0097751

Summary:

Deficiencies Found: 4

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:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0076090

Summary:

INSP-0076089

Summary: