WEST VALLEY HELPING HANDS

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager.

Findings include:

1. A review of Department records revealed E4 was listed as the manager.

2. During the environmental inspection, the Compliance Officer observed E1's manager's certificate posted near the front door of the facility.

3. In an interview, E2 and E3 reported E4 was no longer the manager and E1 was the new manager.

4. A review of E1's personnel record revealed a hire date of April 10, 2024.

5. In a telephonic interview, E1 reported notifying the Department, however, E1 provided incorrect information, including an inaccurate Facility Name and Address, when providing the notification to the Department. E1 acknowledged the Department was not notified in writing of the change in manager.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of Department records revealed the facility was licensed to provide directed care services.

2. During the environmental tour, the Compliance Officer observed the front door leading to the front yard, which lead to the street. The door leading out to the front yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was not functioning.

3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are triggered will be investigated immediately by the caregiver on duty."

4. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of Department records revealed the facility was licensed to provide directed care services.

2. During the environmental tour, the Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. The door leading out to the back yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was not functioning.

3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are triggered will be investigated immediately by the caregiver on duty."

4. In an interview, E2 and E3 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of four residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive.

Findings include:

1. Review of R3's medical record revealed no documentation of a written service plan. Based on R3's date of acceptance, a service plan was required.

2. In an interview, E1 acknowledged R3's personnel record did not include a written service plan and reported R3's service plan was given to R3 upon R3's discharge.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of two residents reviewed. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated June 8, 2023. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed no documentation of a signed medication order or a verbal medication order for Cyclobenzaprine.

3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Cyclobenzaprine 5mg 1 PO TID" and indicated one tab was administered at 8am, 1pm, and 8pm August 1st - present.

4. During an observation of R2's medications, Cyclobenzaprine 5mg was observed and one tab was observed prefilled in the "Morn," "Noon," and "Bed" slot of R2's medication organizer.

5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medical record did not contain a medication order from a medical practitioner for a medication that was administered.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R2's medical record revealed R2 refused the flu and pneumonia vaccinations November 1, 2021. However, current documentation was not available showing the flu and pneumonia vaccinations were offered or received. Based on R2's acceptance date, this documentation was required.

3. In an interview, E1 acknowledged R2's medical record did not include current documentation showing the flu and pneumonia vaccinations were offered or received.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated June 8, 2023. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed no documentation of a signed medication order or a verbal medication order for Cyclobenzaprine.

3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Cyclobenzaprine 5mg 1 PO TID" and indicated one tab was administered at 8am, 1pm, and 8pm August 1st - present.

4. During an observation of R2's medications, Cyclobenzaprine 5mg was observed and one tab was observed prefilled in the "Morn," "Noon," and "Bed" slot of R2's medication organizer.

5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with an available medication order.

6. This is a repeat deficiency from the compliance inspection conducted December 5, 2022.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of two residents reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents.

Findings include:

1. Review of R1's record revealed a current written service plan for directed care services dated October 10, 2022. This service plan revealed no documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

2. Review of R2's record revealed a current written service plan for directed care services dated September 8, 2022. This service plan revealed no documentation of R2's weight. In addition, R2's record revealed no documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated.

3. During an interview, E1 acknowledged R1's and R2's service plans did not include documentation of weight and documentation was not available in R1's and R2's records from a medical practitioner stating weighing R1 and R2 was contraindicated.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R2's record revealed a current written service plan dated September 8, 2022. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed no documentation of signed medication orders or verbal medication orders for Aspirin, Senna, and Trazodone.

3. Review of R2's medical record revealed signed medication orders dated September 1, 2022. These medication orders stated the following:
"Nifedipine ER Tablet Extended Release 24 hour 30mg Give 2 tablets by mouth one time a day"
"Warfarin Sodium Tablet 1mg Give 1 tablet by mouth in the evening"

4. Review of R2's medical record revealed a December 2022 medication administration record (MAR). This MAR stated the following:
"Aspirin 81mg 1 PO QD" and indicated 1 tab was administered at 8pm December 1st - present.
"Senna-S 8.6/50mg 1 PO QD" and indicated 1 tab was administered at 8am December 1st - present.
"Trazodone 50mg 1 PO QHS" and indicated 1 tab was administered at 8pm December 1st - present.
"Nifedipine 30mg 1 PO QD " and indicated 1 tab was administered at 8pm December 1st - present.
"Warfarin SOD 2mg 2 PO THU & FRI" and indicated 2 tabs were administered at 8am December 1st and 2nd.
"Warfarin SOD 2mg 1 PO M, TU, WED, SAT, SUN" and indicated 1 tab was administered at 8am December 3rd and 4th.

5. During an observation of R2's medications, the following was observed:
Aspirin 81mg was observed and 1 tab was observed prefilled in the "Bed" slot of R2's medication organizer.
Senna S 8.6/50mg was observed and 1 tab was observed prefilled in the "Morn" slot of R2's medication organizer.
Trazodone 50mg was observed and 1 tab was observed prefilled in the "Bed" slot of R2's medication organizer.
Nifedipine 30mg was observed and 1 tab was observed prefilled in the "Morn" slot of R2's medication organizer.
Warfarin 2mg was observed and 2 tabs were observed prefilled in the "Morn" slot of R2's medication organizer in the Thursday row.
Warfarin 2mg was observed and 1 tab was observed prefilled in the "Morn" slot of R2's medication organizer in the Tuesday and Wednesday row.

6. During an interview, E1 reported the medications were administered per the December MAR and medication organizer and acknowledged the medications were not administered in compliance with an available medication order.