ORCHARD POINTE AT TERRAZZA

<p>Based on observation, documentation review, and interview, the manager failed to ensure the health care institution operated and maintained a valid license only for the establishment, operation and maintenance of the class or subclass of health care institution specified on the license.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection, the Compliance Officer observed OnCare Hospice was occupying a room in the corner on the second floor.</p><p><br></p><p><br></p><p>2 . During an interview, E2 reported that OnCare Hospice used that room while providing services to residents at the facility.</p><p><br></p><p><br></p><p>3. A review of Department records revealed OnCare Hospice had a license issued by the Department.</p><p><br></p><p><br></p><p>4. During an interview, E1 reported that E1 was unaware that the hospice company could not occupy a room in the facility. E1 notified the corporate office to have the hospice move locations. E1 acknowledged that the licensed hospice was operating at the facility's address.</p>

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of ten caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "On-going Associate Training" reviewed and signed by E1 July 25, 2023. This policy stated " ...6. CPR training is required for all direct care associated ...c. Training shall be obtained from the American Red Cross, American Heart Association, a community college, hospital, rescue squad, fire department, or similarly approved program ..."

2. Review of E10's personnel record revealed E10 worked as a caregiver and had a hire date of July 10, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on May 22, 2023, and valid for two years. There was no other current documentation of CPR training available for review that documented E10 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR.

3. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only."

4. Review of the January 2024 personnel schedule revealed E10 worked the 6am - 2pm shift January 1st, 15th, and 16th.

5. In an interview, E1 and E2 acknowledged E10 did not have current documentation of CPR training, that included a demonstration of the individual's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who had a change of condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R10's medical record revealed a signed doctor's order dated December 29, 2023 that stated "Order to clean wound with cleanser, apply non-adherent dressing, wrap with gauze every other day until seen by home health nurse."

2. Review of R10's medical record revealed a current written service plan dated December 5, 2023. This service plan stated " ...Skin Evaluation - Intact..."

3. Review of R10's medical record revealed R10's service plan was not updated to show this significant change.

4. In an interview, E1 and E2 acknowledged R10's service plan was not updated after a significant change of condition.

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 pneumonia, according to A.R.S. \'a7 36-406(1)(d), to four of six residents 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 R1's medical record revealed R1 requested the pneumonia vaccination February 28, 2023. However, current documentation was not available that showed the pneumonia vaccination was received. Based on R1's acceptance date, this documentation was required.

3. Review of R4's medical record revealed no documentation that showed the pneumonia vaccination was offered or received. Based on R4's acceptance date, this documentation was required.

4. Review of R8's medical record revealed R8 requested the pneumonia vaccination February 28, 2023. However, current documentation was not available that showed the pneumonia vaccination was received. Based on R8's acceptance date, this documentation was required.

5. Review of R9's medical record revealed no documentation that showed the pneumonia vaccination was offered or received. Based on R9's acceptance date, this documentation was required.

6. In an interview, E1 and E2 acknowledged R1's, R4's, R8's, and R9's medical records did not include current documentation that showed the pneumonia vaccination was offered or received.

7. This is a repeat deficiency from the compliance inspection conducted July 13, 2022.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for three of three residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R3's medical record revealed a current written service plan dated November 10, 2023. This service plan stated " ...Resident requires 1 staff hands on assistance with transfers and or changes in position ..."

2. Review of R3's medical record revealed no documentation indicating R3's medical practitioner examined R3 upon acceptance and every six months thereafter, signed and dated a determination that stated R3's needs could be met by the facility, and reviewed the facility's scope of services.

3. Review of R5's medical record revealed a current written service plan dated November 27, 2023. This service plan stated " ...Resident requires 1 staff hands on assistance with transfers and or changes in position ..."

4. Review of R5's medical record revealed no documentation indicating R5's medical practitioner examined R5 upon acceptance and every six months thereafter, signed and dated a determination that stated R5's needs could be met by the facility, and reviewed the facility's scope of services.

5. Review of R7's medical record revealed a current written service plan dated November 2, 2023. This service plan stated " ...Resident requires 1-2 staff hands on assistance with transfers and or changes in position ..."

6. Review of R7's medical record revealed a written determination from R7's medical practitioner signed and dated September 18, 2022. However, documentation was not available that stated R7's needs could be met by the facility and R7's needs were within the facility's scope of services, at least once every six months.

7. In an interview, E1 and E2 reported R3, R5, and R7 were unable to ambulate even with assistance since acceptance and acknowledged R3's, R5's, and R7's medical practitioners did not provide a written determination upon acceptance and every six months thereafter.

Based on documentation review and interview, the manager failed to ensure a dog was licensed with Maricopa County. The deficient posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements.

Findings include:

1. Review of the Maricopa County Animal Care and Control website stated "all dogs three months of age and older are required to have a license..."

2. Review of the pet records revealed O1, O2, and O3 were over three months of age.

3. Review of O1's and O3's records revealed no documentation of a license with Maricopa County.

4. Review of O2's record revealed O2's Maricopa County license expired May 3, 2020.

5. In an interview, E1 reported O1, O2, and O3 still lived at the facility and E1 and E2 acknowledged documentation was not available that showed O1, O2, and O3 had a current Maricopa County license.