CALICHE SENIOR LIVING

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of eight residents sampled.

Findings include:

1. A review of R4's medical record revealed a current service plan indicating R4 received personal care and was to receive the following services:

"Grooming: Cue resident to perform grooming task daily every morning...every night...stand by;"
"Denture Care: Requires assistance...daily;" and
"Assurance Checks: Observe resident for safety/needs every 2 hours."

2. A review of R4's medical record revealed a document titled "Documentation Survey Report," dated November 2024, used for documenting services provided and activities of daily living (ADLs). The document did not include evidence of documentation of provision of the following services, on the dates and times indicated:

"Grooming:
- Day [shift], November 8, 2024; and
- Evening [shift], November 4, 2024; November 8, 2024; November 11, 2024; November 14, 2024; November 18, 2024; November 29, 2024; and November 30, 2024."
"Denture Care:
-Evening [shift], November 12, 2024 and November 14, 2024."

Further, the ADL report included a section for documenting "Assurance Checks," which indicated R4 was to be observed "every 2 hours." However, the section only included areas for documentation of the service every four hours, and evidence of documentation the services was provided was unavailable for the following dates and times:

"November 12, 2024 at 2000 [hours];" and
"November 14, 2024 at 0400 [hours], and 2000 [hours]."

3. In an interview, E1 acknowledged services were not being documented as described in R4's service plan.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of eight residents sampled who received medication administration.

Findings include:

1. A review of R1's medical record revealed a current service plan which indicated R1 received medication administration. Further review revealed a medication order, dated September 16, 2024, for "Aspirin 81 MG Chew Tablet Chew 1 tablet by mouth and swallow once daily." A review of R1's medication administration record (MAR) for October 2024 revealed evidence of documentation indicating R1 was being administered "Aspirin 81 MG Chew Tablet" once daily on October 1 through October 6, 2024. The MAR reflected R1 refused the medication on October 7, 2024, and the medication was documented as not administered October 8 through October 31, 2024. A review of the MAR from November 2024 revealed the MAR did not contain a section for documentation of the administration of "Aspirin 81 MG Chew Tablet."

2. In an interview, E2 advised R1's medical provider had discontinued the Aspirin 81 MG medication after October 6, 2024. E2 acknowledged R1's medical record did not contain evidence of documentation of a discontinue order for the medication, from R1's medical provider.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, injury or emergency and needed medical services, as required per R9-10-818(D)(2).

Findings include:

1. A review of facility incident reports from September 2024 through November 2024 in which medical services were required for a resident experiencing an accident, injury or emergency, revealed a report dated September 19, 2024, involving R9. The report indicated R9 called for assistance because "[their] heart was fluttering, [they] had a headache, nausea and dizziness." The report included documentation required for R9-10-818(D)(2)(a-e), however failed to document what action was taken to prevent the accident, emergency or injury from occurring in the future.

2. In an interview, E1 agreed the incident reports did not contain all documention required per R9-10-818(D)(2).

Based on record review, document review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of five employees reviewed. The deficient practice posed a potential TB exposure risk to residents and the required information could not be verified.

Findings include:

1. A review of E4's E5's, E6's E7's and E8's personnel record revealed each employee was hired as a caregiver. Further review of E4's E5's, E6's E7's and E8's personnel record revealed a signs and symptoms and risk assessment, signed by an occupational health reviewer, who was at least a registered nurse was unavailable for review. In addition, E8's (hire date May 12, 2024) personnel record included evidence of a negative TB skin test which was conducted and read in November 2023. However, evidence of a second negative TB skin test conducted within twelve months of E8's date of hire was unavailable for review.

2. A review of facility polices and procedures, last reviewed on September 12, 2023, revealed a policy titled, "TB testing for Associates," which read as follows:
"II. Associate Risk Assessment
A. All associates must complete the Associate TB risk assessment and symptom screening form WRC-RM-F135 pre-employment and annually thereafter."
The policy further read:
"III. INITIAL Tuberculin Skin Test (TST) - No Prior Positive
A. New hires are required to obtain a 2 step TST..."

3. In an interview, E2 and E3 advised E4, E5, E6 E7 and E8 had more than eight hours of direct interaction with residents since their dates of hire. E1 acknowledged E4's E5's, E6's E7's and E8's personnel record did not contain sufficient evidence of freedom from infectious TB. E1 also acknowledged E4, E5, E6 E7 and E8 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

4. In an interview E1 agreed the facilities policy regarding TB testing for associates had been properly implemented. E1 also agreed they had failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, inaccessible to residents.

Findings include:

1. During a tour of the facility, the Compliance Officer observed an activities room across from numerous residential units. The activities room was equipped with a door which was able to be locked with a key. However, the door was propped open no facility employees were inside the room. The Compliance Officer observed numerous cabinets which were not able to be locked. Inside the cabinets were items for crafting, such as non-toxic paint, paper and non-toxic glue. Also inside the cabinets were items such as "Super Fabric Adhesive," which was marked "MAY PRODUCE NUMBNESS OR WEAKNESS, SKIN AND EYE IRRITANT OR CARDIAC SENSITIZATION...KEEP OUT OF REACH OF CHILDREN." Also inside one cabinet, under a utility sink, was an open canister of "Comet," cleanser which was marked "CAUTION: EYE ADN SKIN IRRITANT...KEEP OUT OF REACH OF CHILDREN AND PETS." Another cabinet was found to contain a canister of "Elmer's Spray Adhesive," which was marked "DANGER: EXTREMELY FLAMMABLE...VAPOR HARMFUL. EYE IRRITANT...KEEP OUT OF REACH OF CHILDREN."

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

Based on document review and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the report made to a peace officer or to the adult protective services central intake unit. The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported as required.

Findings include:

1. A review of facility incident reports in 2024 revealed two reports documenting a single incident of alleged abuse between two residents, in which one resident received an injury. The reports documented immediate action taken to stop the alleged abuse, however they did not indicate if the suspected abuse was reported, as required. Further, the incident reports indicated "No Witnesses found." Lastly, the incident reports did not indicate any action taken to prevent such an incident from occurring in the future.

2. A review documentation of the manager's investigation of the alleged abuse required in R9-10-806.J.5 revealed evidence of such documentation was unavailable for review.

3. In an interview, E1 reported the the incident reports represented the complete documentation of the investigation initiated after the incident of alleged abuse. E1 indicated the incident between the two residents was not reported according to A.R.S. \'a7 46-454. E1 advised there were other residents who witnessed the events described in the incident reports, however, E1 agreed the names of those witnesses were not included in the incident reports. E1 acknowledged an investigation into the incident was conducted, however the incident was not reported and the investigation was not documented as required.

This is a repeat citation from a complaint investigation conducted on January 31, 2024.

Based on document review and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the report made to a peace officer or to the adult protective services central intake unit. The deficient practice posed a potential safety risk for residents and potential rights violation if alleged abuse, neglect, or exploitation was not reported as required.

Findings include:

1. A review of facility incident reports in 2023 revealed two reports documenting a single incident of alleged abuse between two residents. The reports documented action taken to stop the alleged abuse, however they did not indicate if the suspected abuse was reported, as required.

2. In an interview, E1 reported the incident reports represented the complete documentation of the investigation initiated after the incident of alleged abuse. E2 acknowledged the reports did not include documentation indicating the alleged abuse had been reported as required.

Based on record review, document review and interview, 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 for one of five personnel sampled. The deficient practice posed a health and safety risk to residents if E8 was unable to meet the needs of residents.

Findings include:

1. A review of E8's personnel record (hire date 2023) revealed no documented evidence E8's skills and knowledge were observed and verified before E8 provided physical health services.

2. In an interview, E1 acknowledged E8 had worked regular shifts as a caregiver since there date of hire. E1 agreed verification of E8's skills and knowledge prior to providing physical health services had not been documented.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record for five of eight residents sampled.

Findings include:

1. A review of R2's, R7's and R8's medical record revealed current service plans for personal care services. Each service plan indicated R1, R7 and R8 would receive the service, "Assurance Checks, Observe resident for safety/needs, Q4h."

2. A review of R2's, R7's and R8's flowsheet, used for documenting services provided and activities of daily living, revealed a section titled, "Assurance Checks," to document daily safety checks, every four hours. The documented reflected the service had been provided daily, every four hours during the month of January. However, evidence was unavailable for review to indicate the service was provided to R2, R7 or R8 daily every four hours, as follows:

R2 - January 8, 10, 14, 18 and 20, 2024;
R7 - January 6, 8, 10, 18 and 20, 2024; and
R8 - January 6, 8 - 10, 13, 14, and 18 - 20, 2024.

3. A review of R4's medical record revealed a current service plan for directed care services. R4's service plan indicated R4 would receive the service, "Assurance Checks, Wandering/Elopement, Q1 hour assurance checks."

4. A review of R4's flowsheet revealed a section titled, "Assurance Checks," to document daily safety checks, every hour. The documented reflected the service had been provided daily, every hour during the month of January. However, evidence was unavailable for review to indicate the service was provided to R4 daily every hour, as follows:

R4 - January 3, 9, 13, 19, 21, 28, and 30, 2024.

5. A review of R3's medical record revealed a current service plan for personal care services. R3's service plan indicated R3 would receive the service, "Bathing: resident requires stand by assist for safety when bathing on Tuesday, Thursday & Saturdays."

6. A review of R3's flowsheet revealed a section titled, "Bathing/Showering," to document bathing service. The document reflected the service had been provided Tuesdays and Saturdays for the month of January 2024, however evidence the service was provided on Saturdays was unavailable for review.

7. In an interview, E1 acknowledged the caregivers were not documenting all services provided for R2, R3, R4, R7 or R8.

Based on record review, documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury which resulted in the resident needing medical services, a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider, or completed documentation required in R9-10-818.D.2.a-f. The deficient practice posed a risk as individuals were not informed of the resident's condition, required information could not be verified, based upon discrepancies in documentation discussed below, and if the Department was provided false or misleading information.

Findings include:

1. During the on-site complaint investigation, conducted on Wednesday, January 31, 2024, a review of 2023 incident reports revealed a report dated October 1, 2023 regarding a fall involving R9. The report was authored by E2 and indicated a time of "12:00." The report described an incident in which staff reported "hearing yelling," entered R9's room and encountered R9 "laying on [R9's] back on the floor." The report reflected emergency services were called and R9 was taken to the hospital. The incident report included a section for documenting injuries which stated, "No Injuries observed at time of incident," and a section for reporting injuries after the incident which stated, "No Injuries Observed Post Incident." In addition, the report included a section for documenting witness which read, "No Witnesses Found." Documentation of notification of R9's emergency contact and primary care provider, the name(s) of the individual(s) who observed the accident or emergency, the individuals notified by the caregiver or assistant caregiver or any action taken to prevent the accident or emergency from occurring in the future were not available for review.

2. A review of progress notes pertaining to R9 revealed an entry on October 1, 2023, documenting an event at "0056" hours. The note entry did not identify an author, but indicated "Heard resident screaming," and indicated R9 was found between a wall and R9's bed. According to the note, an assessment was performed and a "large bump on the left side towards the back of [R9's] head," was observed. The note reflects R9 was complaining of pain in [R9's] left femur. The report further reflects, "911 called," and "Family and Manager notified," however evidence R9's emergency contact or primary care provider was unavailable for review. Further, documentation of the name of the individual who observed the emergency or injury, the individuals notified by the caregiver or assistant caregiver, or any action taken to prevent the accident or emergency from occurring in the future were not available for review.

3. In an interview, E2 reported the incident had occurred at approximately midnight on October 1, 2023. E2 acknowledged they were not working at midnight on October 1, 2023 and did not witness the incident. E2 advised the caregiver who witnessed the incident provided E2 with a hand-written report, and E2 created the corresponding incident report based upon the hand-written report the caregiver had provided. E2 stated E2 destroyed the hand-written report after creating the incident report.

4. In an interview, E1 agreed the incident repot was not an accurate reflection of the information provided in the progress note. E1 also agreed when a resident had an accident, emergency or injury which resulted in the resident needing medical services, a caregiver or an assistant caregiver did not immediately notify the resident's emergency contact and primary care provider, or complete all documentation as required per R9-10-818.D.2

Based on record review, and interview, the administrator failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery, for one of five personnel sampled. The deficient practice posed a risk to the health and safety of residents if employees were not trained to prevent or recover a resident in the event of a fall.

Findings include:

1. A review of E3's personnel record did not reveal documented evidence of Fall Prevention and Fall Recovery training.

2. In an interview, E1 acknowledged E3's personnel record did not reveal documented evidence of Fall Prevention and Fall Recovery training.

This is a repeat deficiency from the annual compliance inspection conducted on August 11, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that was completed no later than 14 days after the resident's date of acceptance for one of eight residents sampled. The deficient practiced posed a risk to the health and safety of residents if a service plan was not completed, detailing how the resident's needs would be met.

Findings include:.

1. A review of R5's medical record did not reveal evidence of a service plan, which was completed no later than 14 days after the resident's date of acceptance.

2. In an interview, E1 acknowledged R5's medical record did not reveal evidence of a service plan which was completed no later than 14 days after the resident's date of acceptance, as the service plan did not exist.

Based on record review and interview, the manger failed to ensure each resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; the level of service the resident was expected to receive; 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 for one of eight residents sampled.

Findings include:

1. A review of R5's medical record did not reveal a service plan had been completed upon R5's admission, which included:

"A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; the level of service the resident was expected to receive; 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".

2. In an interview, E1 acknowledged R5's medical record did not have a service plan available for review as it did not exist.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the resident or resident's representative for two of eight residents sampled.

Findings include:

1. A review of R2's medical record, revealed a service plan date November 9, 2020. However, the service plan was not signed and dated by R2 or R2's representative.

2. A review of R4's medical record, revealed a service plan date October 20, 2022. However, the service plan was not signed and dated by R4 or R4's representative

3. In an interview, E1 acknowledged R2's and R4's service plans were not signed by R2 and R4 or R2's and R4's representative.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required owners to make documented, good faith efforts to verify the current status of a person's fingerprint clearance card; for two of seven personnel records reviewed which posted a safety risk.

Findings include:

1. Review of the caregivers' and assistant caregivers' personnel records that were working at the time of this incident revealed E3 was hired November 11, 2022. E3's record contained a copy of a fingerprint clearance card that was issued February 13, 2018. There was no documentation that E3's fingerprint card was verified with the Department of Public Safety (DPS) at the time of hire nor anytime since. E3's fingerprint clearance card was issued prior to the date of hire. E1 reported that E3 was hired as an assistant caregiver.

2. Review of E4 personnel record revealed E4 was hired November 11, 2022. E4's record contained a copy of a fingerprint clearance card that was issued September 28, 2021. There was no documentation that E4's fingerprint card was verified with DPS at the time of hire nor anytime since. E4's fingerprint clearance card was issued prior to the date of hire. E4 was hired as a caregiver/med tech.

3. In an interview, E1 acknowledged there was no documentation from DPS that E3's and E4's fingerprint clearance cards were valid. The compliance officer observed E1 going on the DPS website at the time of the investigation to verify other fingerprint cards of the facility's employees.

4. The Arizona Department of Public Safety (DPS) website and O2, criminal intake specialist from DPS, revealed E3 and E4 did have valid fingerprint clearance cards.

Based on documentation reviewed and interview, a manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide, which posed a health and safety risk.

Findings include:

1. Review of the facility's documentation revealed the facility had no established, documented, and implemented a policy and procedure regarding the whereabouts of a resident based upon the assisted living services provided by the facility. The facility has eighty-three residents residing at the facility.

2. Based on incident report, the written testimonies of the involved employees, and interviews with E1 and E2 revealed R1 was last seen with R1's POA approximately 7:45 PM on November 27, 2022.

4. In an interview, E2 reported some assisted living residents require "assurance checks" every two hours during the night. E2 reported R1 was assessed as not needing that service.

5. During the interview, E1 reported that there are no alarms on any of the assisted living exit doors that would alert an employee if someone exited the facility during the night. E1 reported that E1 thought R1 exited one of the back doors of the facility based on where R1's body was found. E1 reported some but not all doors have cameras. E1 reported the police downloaded the video and found the video "grainy". E1 reported all the exit doors are locked from the outside to prevent anyone from entering the building during the night unless someone from the inside opened the door.

6. A tour of R1's unit provided no evidence of any issues, everything seemed in order. R1 did have access to a call system if R1 wanted to alert the staff of any needs.

7. Review of the personnel schedule revealed that two assistant caregivers and one med tech were on duty the night of the incident: E3, E4, and E7. The involved employees on both the night shift and the next morning provided written testimony of the incident and offered no concerns regarding R1 and R1's behavior or activities.

8. During the interview, E1 and E2 reported R1 was very independent with ambulation and daily activities. R1 was called the "social butterfly" of the facility.

9. During the interview, E1 reported the different ways the facility does keep track of the whereabouts of residents, however, nothing could be located regarding any documented policy and procedure.

Based on documentation review, record review and interview, the manager failed to provide written notification to the Department of a resident's death within one working day after the resident's death, which was unexpected according to A.R.S. \'a7 11-593.

Findings include:

1. Review of R1's medical record revealed that R1 required personal care and medication administration services.

2. Based on documentation reviewed and an interview with E1, on the morning of November 28, 2022 the facility realized R1 was missing from the facility; after an extensive search of the building by the employees and the Casa Grande Police Department a silver alert was activated. The search was extended to outside the facility where R1 was found by E6 laying on the ground out in the desert. E1 reported that R1 was laying on R1's back, it appeared no visual harm had come to R1, however, R1 was deceased.

3. During the interview, E1 acknowledged the facility had not notified the Department within one working day of the unexpected death of R1. E1 reported the Department was notified five days after on December 2nd.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive, which posed a health and safety risk for one of one sampled residents.

Findings include:

1. Review of R1's apparently current service plan dated June 27, 2022, according to the computer printout, did not state the level of service the resident required.

2. In an interview, E1 and E2 reported R1 was receiving personal care services. E1 and E2 acknowledged R1's service plan did not include the level of care the resident required.

This is a repeat deficiency from the compliance inspection conducted on August 11, 2022.

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

Finding included:

1. Review of R1's most current service plan dated June 27, 2022, according to the computer printout, had not been signed and dated by the resident or the representative, manager, and the nurse or medical practitioner.

2. In an interview, E1 and E2 reported R1 was receiving personal care and medication administration services.

3. In an interview, E1 and E2 acknowledged R1's service plan had not been signed and dated as required.