THE WATERMARK AT MORRISON RANCH

Based on record review and interview, the assisted living center who contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all required documentation, for one of one applicable resident sampled.

Findings include:

1. A review of R2's medical record revealed an incident report dated January 4, 2025. The incident report revealed R2 had an accident, emergency, or injury, the facility contacted an emergency responder, and R2 was taken to the hospital. However, the documented form provided to the emergency responder did not include the following:
-A copy of R2's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R2's discharge.

2. In an interview, E1 reported E1 was familiar with this statute. E1 reported the facility had standardized forms for the information in Arizona Revised Statutes (A.R.S.) \'a7 36-420.04(A)(3)-(7) and printed other documents to meet the rest of the requirements in A.R.S. \'a7 36-420.04(A) as needed. However, E1 acknowledged the form did not include all required information. E1 reported not knowing the form needed to include a copy of a resident's HIPAA release.

Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented; for five of ten sampled residents' records reviewed. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency.

Findings include:

1. A review of R1, R4, R5, R6, and R7's medical records revealed there was no documentation indicating the sampled residents received orientation to the exits from the facility and the route to be used when evacuating the facility.

2. In an interview, E1 acknowledged R1, R4, R5, R6 and R7's medical records did not contain documentation of orientation to exits from the assisted living facility at the time of the inspection.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services a caregiver immediately notified the resident's emergency contact and primary care provider. The deficient practice posed a health and safety risk.

Findings include:

1. A review of facility incident reports revealed an incident report for R2 dated January 4, 2025. The incident report documented emergency medical services were contacted for R2 after being unresponsive. However, there was no documentation of a call being made to R2's emergency contact and primary care provider.

2. In an interview E1 acknowledged the incident report for R2 did not include documentation of the immediate notification of R2's primary care provider and emergency contact.

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to residents, for one of ten sampled personnel records reviewed.

Findings include:

1. Review of the facility's documentation revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all staff.

2. Review of ten sampled personnel records revealed there was no documentation that E7 had completed the required training.

3. In an interview, E1 and E2 acknowledged the facility did not have documentation that all the sampled employees had completed fall prevention and fall recovery training as required. E2 reported that E7 did not attend the training.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employees to have a valid fingerprint clearance card or fingerprint clearance card application within 20 working days of hire for three of twelve sampled personnel records reviewed, which posted a safety risk.

Findings include:

1. Review of randomly selected personnel records found that E8's personnel record, who was hired on February 20, 2023, contained no documentation of a fingerprint clearance card nor fingerprint clearance card application. There was no documentation that E8 had a fingerprint clearance card that was verified with the Department of Public Safety (DPS) or DPS website at the time of hire nor anytime since. E8 was hired as the maintenance director. Part of E8's responsibilities is going in and out of residents' units as needed for repairs.

2. In an interview, E8 reported the E8 had a fingerprint clearance card, but lost it.

3. The compliance officer call DPS day after the compliance inspection. In an interview, O1 after searching by E8's date of birth and social security number, reported, "does not have a fingerprint clearance card". The compliance officer notified the facility of the findings.

4. Review of E9's personnel record, who was hired on March 30, 2023, contained no documentation of a fingerprint clearance card nor fingerprint clearance card application. There was no documentation that E9 had a fingerprint clearance card that was verified with DPS or DPS website at the time of hire nor anytime since. E9 was hired as a resident van driver. Part of E9's responsibilities is taking a resident to appointments and activity events.

5. Review of E10's personnel record, who was hired on April 17, 2023, contained no documentation of a fingerprint clearance card nor fingerprint clearance card application. There was no documentation that E10 had a fingerprint clearance card that was verified with DPS or DPS website at the time of hire nor anytime since. E10 was hired as a housekeeper. Part of E10's responsibilities is cleaning residents' units.

6. During an interview, E1 acknowledged there was no documentation from the DPS website nor any other documented evidence that these three sampled employees had a fingerprint clearance card that was valid.

Based on observation, documentation review, record review, and interview, the manager failed to establish, document, and implement a policy and procedure 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 was authorized to provide which is a health and safety risk.

Findings include:

1. An unannounced onsite complaint investigation was conducted regarding R12. The compliance officer requested and was not provided with the facility's policy and procedure that cover the methods by which the facility is aware of the general whereabouts of a resident based on the level of assisted living services provided to the resident. The compliance officer observed the facility had residents residing at the facility.

2. Review of R12's medical record and interview with E1 and E2 revealed R12 was receiving personal care services.

3. In an interview, E1 acknowledged there was no documented policy and procedure available that covered the whereabouts of assisted living residents at the facility.

Based on record review, documentation review, and interview, the manager failed to ensure personnel records contained documentation indicating a caregiver's or assistant caregiver's skills and knowledge were verified and documented before physical health services were provided. For two of four caregivers' records reviewed which posed a health a safety risk to residents.

Findings include:

1. Review of E6's personnel record who was hired on January 31, 2023 revealed E6 was hired as a caregiver. There was no documentation that E6's skills and knowledge were verified before providing physical health services.

2. Review of E7's personnel record who was hired on July 29, 2023 revealed E7 was hired as a caregiver. There was no documentation that E7's skills and knowledge were verified before providing physical health services.

3. In an interview, E1 and E2 acknowledged E6 and E7 were hired as caregivers and there was no documentation these two caregivers had their skills and knowledge verified before physical health services were provided.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for two of eight personnel reviewed who were required to complete first aid and CPR training.

Findings include:

1. Review of E5's personnel record revealed that the caregiver was hired on July 29, 2023 to work as a caregiver. E5's personnel record contained a document from NaionalCPR Foundation that was issued on March 16, 2022 and valid for two years. This training is an online-only CPR training and did not include a return demonstration.

2. In an interview, E1 acknowledged this online CPR training program and that E5 was working as a caregiver.

3. Review of E12's personnel record revealed that the caregiver was hired on November 25, 2022 to work as a caregiver. E12's personnel record contained CPR training that had expired on July 10, 2023.

4. In an interview, E1 and E2 acknowledged E5's CPR training was online training, E12's CPR had expired and both caregivers had continued to work as caregivers.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

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

Findings include:

1. In an interview, E2 reported that R9 self-administers R9's own medications. Review of R9's current service plan dated July 5, 2023 did not state how the resident will store and control R9's medications in R9's unit.

2. During an interview, E2 acknowledged R9's current service plan did not state how the medications would be stored and controlled in the resident's unit.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on records reviewed and interview, the manager failed to ensure that one of five sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk.

Findings include:

1. Review of R4's medical record revealed R4's written service plans were dated January 11, 2023 and August 29, 2023. The service plans stated the resident required personal services. The service plan should have been updated no later than July of 2023.

2. In an interview, E2 acknowledged R4's service plan did not appear to have been updated as required. R4 required personal care service.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on record review and interview, the manager failed to ensure that two of two sampled residents' record reviewed, who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. The determination was to completed at least once every six months throughout the duration of the residents' condition to determine if the residents' needs were being met. This determination was to be based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. In an interview, E2 reported R2 and R4 were unable to ambulate even with assistance for the past several months.

2. Review of R2's medical record contained two documented determinations dated November 29, 2022 and June 6, 2023. The updated determinations were not completed at least every six months throughout the duration of the resident's condition and did not include a current examination with each of the determinations. Each determination should have been based on a current resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required directed care services.

3. Review of R4's medical record contained one documented determination dated December 21, 2022. The determination was not completed at least every six months throughout the duration of the resident's condition. Each determination should be based on a current resident's examination and the facility's scope of services that the resident's needs could be met. The service plan stated the resident required personal care services.

4. In an interview, E2 acknowledged that R2's and R4's determinations were not completed as required.

This is a repeat deficiency from the compliance inspection conducted on October 21, 2022.

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members which posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking.

Findings include:

1. During the compliance inspection the compliance officer observed the facility was providing medication administration services. The most resent facility's current drug reference guide was the Nursing 2022 Drug Handbook by Wolters Kluwer.

2. A Google search found Nursing 2023 Drug Handbook by Wolters Kluwer and also the 2024 edition.

3. In an interview, E2 acknowledged the facility's drug reference guide was not current.

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

Findings include:

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

2. In an interview, E1 reported not done.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented which posed a safety risk.

Findings include:

1. During an interview, E1 and E2 reported the facility had three shifts: First shift from 6:00 AM to 2:00 PM, the second shift from 2:00 PM to 10:00 PM, and the third shift from 10:00 PM to 6:00 AM.

2. Review of the first shift employee disaster drills documentation for the past 12 months revealed on: July 28, 2023 an employee disaster drill was conducted.

3. Review of the second shift employee disaster drills documentation for the past 12 months revealed on: March 9, 2023 and August 3, 2023 employee disaster drills were conducted.

4. Review of the third shift employee disaster drills documentation for the past 12 months revealed on: January 27, 2023, March 9, 2023, and June 5, 2023 employee disaster drills were conducted.

5. In an interview, E1 acknowledged the facility's employee disaster drills were not conducted at least once every three months on each shift as required.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months, which posed a safety risk.

Findings include:
1. A review of the facility's documentation revealed one evacuation drill for employees and residents dated January 27, 2023 was conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during this time period.

2. There was documentation of an evacuation drill dated May 30, 2023, however, the drill only included the nursing staff and no residents nor other personnel.

3. In an interview, E1 acknowledged employee and residents evacuation drill were not conducted at least every six months during the past twelve months and documented as required.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 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, which posed a health and safety risk.

Findings include:

1. During a facility tour, E1 and the compliance officer observed an unlocked housekeeping cart in the facility's common residents' hallway near unit 217. In this unlocked housekeeping cart there was stored window cleaner, toilet bowl cleaner, furniture polish, oven cleaner, and all purpose cleaner.

2. In an interview, E1 acknowledged the unlocked poisonous or toxic materials. Later, E1 was informed the lock to this cart was broken.

Based on observation, record review, and interview, the manager failed to ensure one sampled dog residing at the facility was licensed consistent with local ordinances.

Finding include:

1. During a facility tour, E1 and the surveyor observed a dog, O4, residing at the facility with R9.

2. The surveyor requested and was not provided with any documentation that O4 had a current license from Maricopa County Animal Care and Control, as required.

3. In an interview, E1 acknowledged there was no record that O4 had a current license, as required.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on documentation review and interview for the complaint investigation, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to the residents, for three of eight sampled staff records reviewed.

Findings include:

1. Review of the facility's documents revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all staff.

2. Reviewed of the staff records for the individuals who had been involved in each of the allegations found there was no documentation that E4, E6, and E7 had completed the required training.

3. In an interview, E2 and E3 reported the facility had established the fall prevention and fall recovery training program however had not been implemented to all staff.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.

Based on observation, documentation review, record review, and interview, the governing authority failed to designate a manager who had either a temporary or permanent manager's certificate from the Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers, which posed a health and safety risk.

Findings include:

1. During the complaint investigation the compliance officer was informed by the facility's staff that E1 was no longer the manager at the facility. E5 was "in charge".

2. Conspicuously posted near the front door of the facility the compliance officer observed a printed notice from E1 who E1 had designated to be the manager's designee when the manager was not physically present at the facility. The compliance officer observed in this same area that E1's manager's certificate was not posted; nor any other place was E1's manager's certificate posted.

2. In an interview, E5 reported that E1 was no longer the manager as of March 27, 2023. E5 reported E5 was not a certified manager in the State of Arizona. E5 reported that E5 started at the facility on March 28, 2023. E5 reported, a new manager has been named as of April 27, 2023, however, has not begun to work at the facility until May 5, 2023.

3. Review of the Department's database as of May 4, 2023 revealed that E1 was still the manager of the facility.

4. During the interview, E5 acknowledged there was no documented evidence the Department had been notified that E1 was no longer the manager at the facility, and that the facility had been without a manager for thirty days.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for three of eight personnel records reviewed who were required to complete first aid and CPR training.

Findings include:

1. In an interview, E2 and E3 identified the caregivers who were involved in each of the allegations that were investigated.

2. Review of E4's personnel record revealed that the employee was hired on November 16, 2021 to work as a caregiver, however there was documented evidence that E4's first aid and CPR training had expired in January 2023.

3. Review of E7's personnel record revealed that the employee was hired on August 4, 2022 to work as a caregiver, however there was documented evidence that E7's first aid and CPR training had expired on March 12, 2023.

4. Review of E9's personnel record revealed that the employee was hired on December 23, 2022 to work as a caregiver, however there was documented evidence that E9's first aid and CPR training had expired on February 8, 2023.

5. In an interview, E2, E3, and E5 acknowledged these three caregivers' first aid and CPR had expired and they continue to work as caregivers.

This is a repeat deficiency from the compliance inspection conducted on October 20-21, 2022.