SWEET HOME ASSISTED LIVING

Assisted Living Home | Assisted Living

Facility Information

Address 752 East Megan Street, Chandler, AZ 85225
Phone 4805902595
License AL11202H (Active)
License Owner SWEET HOME ASSISTED LIVING, LLC
Administrator Ola Y Ojasope
Capacity 5
License Effective 9/1/2025 - 8/31/2026
Services:
2
Total Inspections
33
Total Deficiencies
1
Complaint Inspections

Inspection History

INSP-0107771

Complete
Date: 3/25/2025
Type: Compliance (Annual)
Worksheet: Assisted Living Home
SOD Sent: 2025-04-21

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on March 25, 2025:

Deficiencies Found: 14

Deficiency #1

Rule/Regulation Violated:
A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition<br> A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
Evidence/Findings:
<p><span style="background-color: transparent;">Based on documentation review and interview, the healthcare institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">1. A review of E1's personnel record did not include documentation of completed fall prevention and fall recovery training. Based on E1's date of hire, this documentation was required. </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">2. A review of E2's personnel record did not include documentation of completed fall prevention and fall recovery training. Based on E2's date of hire, this documentation was required. </span></p><p><br></p><p><br></p><p><span style="background-color: transparent;"></span></p><p><span style="background-color: transparent;">3. In an interview, E1 acknowledged documentation was not available that showed E1 and E2 completed fall prevention and fall recovery training. </span></p><p><br></p><p><span style="background-color: transparent;"></span></p><p><br></p><p><span style="background-color: transparent;">This is a repeat deficiency from the inspection conducted on February 7, 2023. </span></p>
Temporary Solution:
Ola Ojasope, Manager was able to immediately reach out to the facility RN to start the training for Fall Prevention and Fall Recovery.
Permanent Solution:
Ola Ojasope, Manager will make sure the Fall Prevention and Fall Recovery is always included in all the employees file and also have all the Caregivers have the CE's of Fall Prevention and Fall Recovery every year for the safety of all the resident.
Person Responsible:
Ola Ojasope, manager

Deficiency #2

Rule/Regulation Violated:
R9-10-113.A.1-2. Tuberculosis Screening<br> A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that:<br> 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and <br> 2. Include:<br> a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of:<br> i. Assessing risks of prior exposure to infectious tuberculosis,<br> ii. Determining if the individual has signs or symptoms of tuberculosis, and<br> iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1);<br> b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201:<br> i. Referring the individual for assessment or treatment; and<br> ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101;<br> c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;<br> d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis;<br> e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and<br> f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.
Evidence/Findings:
<p><span style="font-size: 10pt;">Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff.</span></p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 10pt;">Findings include:</span></p><p><span style="font-size: 10pt;"> </span></p><p><br></p><p><br></p><p><span style="font-size: 10pt;">1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available.</span></p><p><span style="font-size: 10pt;"> </span></p><p><br></p><p><span style="font-size: 10pt;"></span></p><p>2. In an interview, E1 acknowledged documentation was not available that showed the facility<span style="background-color: rgb(255, 255, 255); font-size: 13.3333px; color: rgb(68, 68, 68);"> had annually assessed the health care institution's risk of exposure to infectious TB. </span></p>
Permanent Solution:
Ola Ojasope, Manager, booked an appointment with our facility RN immediately after the survey to have the yearly facility TB assessment done.

Attachment:
Annual Facility TB Risk Assessment dated March 26th, 2025
Person Responsible:
Ola Ojasope, Manager

Deficiency #3

Rule/Regulation Violated:
R9-10-120.F.4.a-c. Opioid Prescribing and Treatment <br> F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: <br> 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: <br> a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; <br> b. Monitors the patient's response to the opioid; and <br> c. Documents in the patient's medical record: <br> i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and <br> ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided.
Evidence/Findings:
<p>Based on record review and interview, the healthcare institution failed to document in the patient’s medical record an identification of the patient’s need for the opioid before the opioid was administered, for one of two residents sampled. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p><br></p><p>1. A review of R1’s medical record revealed a signed order, dated January 16, 2025, for Oxycodone HCL 5 milligrams (mg), 2 tablets by mouth (po) twice a day (bid) as needed (PRN) for pain. </p><p><br></p><p><br></p><p><br></p><p>2. A review of R1’s medication administration record (MAR) for March 2025, revealed a form titled, “Narcotic Declining Form.” The form revealed R1 was administered Oxycodone 5 mg 2 tablets po at 8:00 AM and 8:00 PM on March 1, 2025 - present. However, the form did not include documentation of R1’s need for the opioid. </p><p><br></p><p><br></p><p><br></p><p><span style="font-size: 8.5pt;">3. A review of R1's medical record revealed no documentation stating R1 had an end of life condition or an active malignancy.  </span></p><p><br></p><p><br></p><p><br></p><p>4. In an interview, E1 acknowledged that the facility did not document R1’s need for the opioid before the opioid was administered to R1. </p>
Temporary Solution:
Ola Ojasope, Manager implement the use of NARCOTIC PRESCRIBING & TREATMENT to monitor any of our resident with Opioid medications with immediate effect after the survey
Permanent Solution:
Ola Ojasope, Manager developed separate two forms that monitor the resident the need of using the controlled medications. I also informed all the resident the need to follow the doctor's prescription on all the medication, especially the controlled medications. The form will be initialed by the caregiver after given. The level of pain before and after will also be recorded.

Attachment:
Opioid Document. Mary Braun
Opioid Document
Person Responsible:
Ola Ojasope, Manager

Deficiency #4

Rule/Regulation Violated:
R9-10-803.A.9. Administration<br> A. A governing authority shall: <br> 9. Ensure compliance with A.R.S. § 36-411.
Evidence/Findings:
<p><span style="background-color: transparent;">Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel sampled. The deficient practice posed a risk if E1 were a danger to a vulnerable population.</span></p><p><br></p><p><span style="background-color: transparent;"> </span></p><p><br></p><p><span style="background-color: transparent;">Findings include: </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">1. A.R.S. § 36-411(C)(2) states, "Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person’s fitness to work in a residential care institution, nursing care institution or home health agency. </span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">2. While on-site for the compliance inspection, the Compliance Officers observed E1 at the facility, providing services to residents.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">3. A review of E1's personnel record did not include documentation of the facility's good faith effort to contact E1's </span></p><p><span style="background-color: transparent;">previous employers.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">4.  In an interview, E1 acknowledged that the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2).</span></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68);">This is a repeat deficiency from the inspection conducted on February 7, 2023.</span></p>
Permanent Solution:
Ola Ojasope, Manager makes sure that all employees are been verified before they start working in the facility for the safety of all resident. The document was missing in the manager's file because he's still working on all other documents as at the time of the survey.

Attachment:
Employee Verification Check List for Ola Ojasope, Manager (Dated March 14th, 2025)
Person Responsible:
Ola Ojasope, Manager

Deficiency #5

Rule/Regulation Violated:
R9-10-806.A.4.a-b. Personnel<br> A. A manager shall ensure that: <br> 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: <br> a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and<br> b. According to policies and procedures;
Evidence/Findings:
<p>Based on documentation review, record 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, according to policies and procedures, for two of two personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of the facility's personnel schedule revealed E1 and E2 were scheduled to work and provide services at the facility from March 1, 2025, to March 29, 2025.</p><p><br></p><p><br></p><p><br></p><p>2. A review of E1's and E2's personnel records revealed E1 and E2 were hired as a caregiver.</p><p><br></p><p><br></p><p><br></p><p>3. A review of E1's and E2's personnel records did not include documentation of verification of skills and knowledge.</p><p><br></p><p><br></p><p><br></p><p>4. A review of the facility's policies and procedures revealed no policy that covered documentation of skills and knowledge.</p><p><br></p><p><br></p><p><br></p><p>5. In an interview, E1 acknowledged that E1's and E2's personnel records did not include documentation of the verification of E1's and E2's skills and knowledge before E1 and E2 provided physical health services.</p><p><br></p><p><br></p><p><br></p><p>This is a repeat deficiency from the inspection conducted on February 7, 2023.</p>
Temporary Solution:
Ola Ojasope, manager, immediately gathered all the files with immediate effect after the survey
Permanent Solution:
Ola Ojasope, Manager will make sure the Skill and Knowledge form is available for all the future employees on or before they were hire.

Attachement:
Skill and Knowledge for all employees
Person Responsible:
Ola Ojasope, Manager

Deficiency #6

Rule/Regulation Violated:
R9-10-806.A.9. Personnel<br> A. A manager shall ensure that: <br> 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and
Evidence/Findings:
<p><span style="background-color: transparent;">Based on documentation review, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver received orientation that was specific to the duties to be performed by the caregiver, for one of two sampled caregivers. </span><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">The deficient practice posed a risk if the employees were unable to meet residents’ needs.</span></p><p><span style="background-color: transparent;"></span></p><p><br></p><p><br></p><p><span style="background-color: transparent;">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); font-size: 14px;">1. A review of the facility's personnel schedule revealed E1 was scheduled to work and provide services at the facility from March 1, 2025, to March 29, 2025.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">2. A review of E1's personnel record revealed E1 had been hired as a caregiver.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">3. A review of E1's personnel record did not include documentation of E1's completed orientation.</span></p><p><br></p><p><br></p><p><br></p><p><span style="background-color: transparent;">4. In an interview, E1 acknowledged documentation was not available that showed E1 received orientation that was specific to the duties to be performed by E1.</span></p><p><br></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68);">This is a repeat deficiency from the inspection conducted on February 7, 2023.</span></p>
Temporary Solution:
Ola Ojasope, Manager immediately gathered the form and put it in the employee folder
Permanent Solution:
Ola Ojasope, manager will make sure that Employee Orientation & Skill Verification is made available for all new employee, verify and sign by both the employee and the manager on or before he/she is hire.

Attachement:
Employee Orientation & Skills -Ola Ojasope
Person Responsible:
Ola Ojasope, Manager

Deficiency #7

Rule/Regulation Violated:
R9-10-808.A.5.a. Service Plans<br> A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: <br> 5. When initially developed and when updated, is signed and dated by: <br> a. The resident or resident's representative;
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was signed and dated by the resident or resident’s representative, for one of three residents sampled. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.</span></p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R3's medical record revealed a service plan, dated February 1, 2025. However, the resident or resident's representative did not sign and date the service plan.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 reported R3's representative was not available to sign the service plan. E1 acknowledged R3's service plan was not signed and dated by the resident or resident's representative.</p><p><br></p><p><br></p><p><br></p><p>This is a repeat deficiency from the inspection conducted on February 7, 2023.</p>
Temporary Solution:
I quickly get a text message to the resident's representative and also followed up with call to remind him of the important of his signatures on his mum Care Plan.
Permanent Solution:
Ola Ojasope, Manager will make sure to have the residents who can sign for themselves or their representatives sign/date the Care Plan the same day it is established before putting it in their folder.

Attachment:
1. A resident Service Plan signed/dated after the survey
2. Most recent Service Plan signed/dated by RN, Manager and the representative to complied with DHS rule.
Person Responsible:
Ola Ojasope, Manager

Deficiency #8

Rule/Regulation Violated:
R9-10-808.A.5.b. Service Plans<br> A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: <br> 5. When initially developed and when updated, is signed and dated by: <br> b. The manager;
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was signed and dated by the manager, for two of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed a completed service plan, dated December 12, 2024. However, the facility's manager did not sign and date the service plan.</p><p><br></p><p><br></p><p><br></p><p>2. A review of R3's medical record revealed a service plan, dated February 1, 2025. However, the facility's manager did not sign and date the service plan.</p><p><br></p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged R2's and R3's service plans were not signed and dated by the facility's manager.</p><p><br></p><p><br></p><p><br></p><p>This is a repeat deficiency from the inspection conducted on February 7, 2023.</p>
Permanent Solution:
Ola Ojasope, Manager, signed/dated all the Service Plan with immediately effect and will make sure to always remember to sign/date it after it established.
Person Responsible:
Ola Ojasope, Manager

Deficiency #9

Rule/Regulation Violated:
R9-10-808.C.1.g. Service Plans<br> C. A manager shall ensure that: <br> 1. A caregiver or an assistant caregiver: <br> g. Documents the services provided in the resident's medical record; and
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a service plan that indicated R1 would receive colostomy care, as needed (PRN). </p><p><br></p><p><br></p><p><br></p><p>2. A review of R1's activities of daily living (ADL) documentation for March 2025, did not include documentation of colostomy care. </p><p><br></p><p><br></p><p><br></p><p>3. In an interview, E1 reported R1 received assistance with colostomy care once a week. E1 acknowledged that a caregiver failed to document the services provided in R1's medical record. </p><p><br></p><p><br></p><p><span style="font-size: 14px; background-color: rgb(255, 255, 255);">This is a repeat deficiency from the inspection conducted on February 7, 2023.</span></p>
Temporary Solution:
New ADL was developed for the resident with the special need (Colostomy)
Permanent Solution:
Ola Ojasope, manager was able to develop the new ADL that includes the special service for the R1 and have the caregiver's initial it anytime the service is rendered to the resident.

Attachment:
Mary's Colostomy ADL developed
Person Responsible:
Ola Ojasope, Manager

Deficiency #10

Rule/Regulation Violated:
R9-10-815.F.1. Directed Care Services<br> F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: <br> 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented that ensure the safety of a resident who may wander.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of the facility's policies and procedures did not include a policy to ensure the safety of a resident who may wander.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged policies were not established, documented, and implemented that ensured the safety of a resident who may wander.</p>
Temporary Solution:
Ola Ojasope, Manager reached out to the facility RN with immediate effect to develop a new Policy and Procedure base on the service will render in the facility especially to our Direct Care patient.
Permanent Solution:
Ola Ojasope, Manager make sure that a new Policy and Procedures was established, documented and implemented, also signed by our facility RN that ensure the safety of a resident who may wander

Attachment:
Policies and Procedures for wandering Residents signed by RN
Person Responsible:
Ola Ojasope

Deficiency #11

Rule/Regulation Violated:
R9-10-816.B.2.a. Medication Services<br> B. If an assisted living facility provides medication administration, a manager shall ensure that: <br> 2. Policies and procedures for medication administration: <br> a. Are reviewed and approved by a medical practitioner, registered nurse, or pharmacist;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of the facility's policies and procedures revealed a policy titled "Medication Services." However, the policy had not been reviewed and approved by a medical practitioner, registered nurse, or pharmacist.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.</p>
Permanent Solution:
Ola Ojasope, Manager make sure a new Policies and Procedures were established for Medication Administration, review and approved by the facility RN for the safety of our residents. This will be reviewed and approved by the RN every two(2) according to our Policies and Procedures.

Attachement:
Policies and Procedures for Medication Service
Person Responsible:
Ola Ojasope, Manager

Deficiency #12

Rule/Regulation Violated:
R9-10-818.D.2.a-f. Emergency and Safety Standards<br> D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: <br> 2. Documents the following: <br> a. The date and time of the accident, emergency, or injury;<br> b. A description of the accident, emergency, or injury; <br> c. The names of individuals who observed the accident, emergency, or injury; <br> d. The actions taken by the caregiver or assistant caregiver;<br> e. The individuals notified by the caregiver or assistant caregiver; and <br> f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a caregiver documented the time of the accident, emergency, or injury, the names of the individuals who observed the accident, emergency, or injury, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed R1 had a fall on January 15, 2025, that resulted in R1 needing medical services. However, the documentation did not include the following elements:</p><ul><li>the time of the accident;</li><li>the names of individuals who observed the accident;</li><li>the actions taken by the caregiver;</li><li>the individuals notified by the caregiver; and</li><li>any action taken to prevent the accident from occurring in the future.</li></ul><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged that when R1 had an accident, emergency, or injury that required medical services, a caregiver did not document all required elements per R9-10-818.D.2.</p>
Permanent Solution:
Ola Ojasope, Manager, include a complete form in all the resident folder immediately aftre the survey. The following forms are:

1. Falls Risk Assessment
2. Evaluation of Fall Incident
3. Physical Assessment following fall
4. Resident Notes, that will includes (the time of the accident, Emergency or injury, the name of the individuals who observed the accidents, the action taken by the caregiver, the individuals notified e.g. RN, POA/representative by the caregiver and also the action taken to prevent the accident.

Also, I will make sure to inform the caregiver on duty to make sure they follow all the steps in making sure that all information is written after every fall. Lastly, I also have a one-on-one meeting with all the resident in making sure they use the call button provided for them in their respective rooms anytime they are unsure they can fall.

Attachment:
Fall Risk Assessment complete forms
Person Responsible:
Ola Ojasope, Manager

Deficiency #13

Rule/Regulation Violated:
R9-10-819.A.11. Environmental Standards<br> A. A manager shall ensure that: <br> 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Evidence/Findings:
<p>Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area inaccessible to residents.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p><br></p><p><br></p><p><br></p><p>2. During the environmental inspection, the Compliance Officers observed the following poisonous or toxic materials stored in the unlocked garage:</p><ul><li>“Silicone” Surface Safe Lubricant spray;</li><li>Two "Clorox" bottles;</li><li>“Clorox” Clean Liquid;</li><li>“Deep Clean- Arm & Hammer Laundry Detergent”;</li><li>“Raid Ant & Roch” Spray;</li><li>“Lysol”; Power Clinging Gel;</li><li>“LA's Totally Awesome” Fabric Refresher;</li><li>“OdoBan” Eliminates Order Disinfectant Fabric & Air Refresher;</li><li>"Easy-Off” Cleaner Degreaser Heavy duty; and</li><li>“Fabuloso” multi-purpose cleaner.</li></ul><p><br></p><p><br></p><p>3. During an interview, E1 acknowledged <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.</span></p>
Permanent Solution:
Ola Ojasope, Manager makes sure that both doors that leads to the poisonous or toxic materials remains locked at all time. The sign on the doors were been changed for more clarity. This two(2) doors will be locked after every opening. The cabinet with the products will be locked with key and the key will only be accessible to the Manager and the caregivers on duty. Every other person must use the front door to gain access to the facility. If a car is parked in the garage, the person must use the front door to come inside and also, the garage outside door must be closed after parking at all time.

Attachment:
Cabinet and Garage doors before and after the survey.
Person Responsible:
Ola Ojasope, manager

Deficiency #14

Rule/Regulation Violated:
R9-10-819.A.6. Environmental Standards<br> A. A manager shall ensure that: <br> 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. </p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 150º F in R2's bathroom, a water temperature of 133° F in a shared bathroom for residents, and a water temperature of 150° F in the kitchen sink.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">hot water temperatures were not maintained between 95º F and 120º F in areas of an assisted living facility used by residents. </span></p>
Temporary Solution:
Ola Ojasope, Manager immediately reached out to the landlord and inform him the need to adjust the Hot Water temperature.
Permanent Solution:
Ola Ojasope, Manager was able to regulate the temperatures of the Hot Water to maintain between 95º F and 120º F in the garage for the safety of all the residents.
Person Responsible:
Ola Ojasope, Manager

INSP-0089120

Complete
Date: 2/7/2023
Type: Complaint;Compliance (Annual)
Worksheet: Assisted Living Home
SOD Sent: 2023-03-09

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaint #AZ00189008 conducted on February 7, 2023.

Deficiencies Found: 19

Deficiency #1

Rule/Regulation Violated:
A.R.S. § 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions
C. Owners shall make documented, good faith efforts to:
1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.
2. Verify the current status of a person's fingerprint clearance card.
Evidence/Findings:
Based on record review and interview, the owner failed to ensure compliance with A.R.S. \'a7 36-411(C)(1), for one of two employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E2's (unknown date of hire) personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

2. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E2 was not available for review.

Deficiency #2

Rule/Regulation Violated:
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
Evidence/Findings:
Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Employee Orientation & Ongoing Training" (dated February 1, 2017). However, evidence of a fall prevention and fall recovery training program was not available for review.

2. A review of E1's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

3. A review of E2's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

4. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Deficiency #3

Rule/Regulation Violated:
B. A manager:
3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is:
a. At least 21 years of age, and
b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.
Evidence/Findings:
Based on observation, documentation reivew, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as a caregiver was not present on the premises and accountable when the manager was not present on the premises. The Department was unable to determine substantial compliance documentation designating E2 was not available during the inspection, and the documentation was not provided within two hours after a Department's request.

Findings include:

1. The Compliance Officer observed E2 on the premises alone and working when the Compliance Officer arrived at 10:30 AM.

2. The Compliance Officer observed E3 arrive on the premises at 12:45 PM.

3. The Compliance Officer observed a document titled "DELEGATION OF AUTHORITY" (dated February 1, 2021) posted on the wall, located near the front door. The document stated "I, [E3] manager of SWEET HOME ASSISTED LIVING delegates authority to the following employees and/or caregivers who are over 21 years of age and to be responsible for the facility when I am not present." However, the document included names of individuals who were no longer employed by the facility, and documentation designating E2 to be present on the premises and accountable for the assisted living facility when E3 was not present on the premises was not available for review.

4. A review of E2's (unknown date of hire) revealed documentation designating E2 to be present on the premises and accountable for the assisted living facility when the manager was not present on the premises was not available for review.

5. In an interview, E1 acknowledged a designated individual was not present on the premises when the manager was not present on the premises.

Deficiency #4

Rule/Regulation Violated:
C. A manager shall ensure that policies and procedures are:
1. Established, documented, and implemented to protect the health and safety of a resident that:
e. Except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including:
i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation;
ii. The qualifications for an individual to provide cardiopulmonary resuscitation training;
iii. The time-frame for renewal of cardiopulmonary resuscitation training; and
iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training;
Evidence/Findings:
Based on observation, documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, including a demonstration. The deficient practice posed a risk as policies and procedures reinforce and clarify standards, the Department was unable to determine substantial compliance as the required CPR demonstration was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer observed E2 on the premises and working alone when the Compliance Officer arrived at 10:30 AM.

2. A review of the facility's policies and procedures revealed a policy titled "CPR AND FIRST AID" (dated February 20, 2022). The policy stated "Employees and volunteers shall provide documentation of CPR...and first aid training, to include the method and content of the training for such certification, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation...The Owner and or/Manager shall ensure that the individual who provide the cardiopulmonary resuscitation training is certified to provide the training."

3. A review of E2's personnel record revealed a CPR and first aid training (dated August 30, 2022). The document stated "RECOGNITION OF COMPLETION [E2] has successfully completed ASHI Online Training for: CPR, AED, and Basic First Aid All Ages (G2015)-DC (Blended)...Blended learning consists of computer-based, online lessons combined with hands-on skill practice and performance evaluation. This document confirms that the above-named individual has completed the required online lessons and is now eligible for hands-on skill practice and performance evaluation by a current and properly authorized ASHI Instructor."

4. In an interview, E1 acknowledged E2's CPR did not include the demonstration requirement and the policy and procedure was not implemented.

This is a repeat deficiency from the on-site compliance inspection conducted on February 15, 2022.

Deficiency #5

Rule/Regulation Violated:
E. A manager shall ensure that, unless otherwise stated:
1. Documentation required by this Article is provided to the Department within two hours after a Department request; and
Evidence/Findings:
Based on record review, documentation review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the following documentation was not provided for review: documentation designating E2; documentation of CPR demonstration for E2; documentation of skills and knowledge for E2; documentation of the caregivers and assistant caregivers working each day to include the hours worked for February 2023; E2's starting date of employment; documentation of experience for E2; documentation of completed orientation for E2; in-service education for E3; documentation of the requirements in R9-10-807(B)(1)(a)(b) for R1 and R2; documentation of the requirement in R9-10-808(A)(5)(a) for R1 and R2; documentation of the requirement in R9-10-808(A)(5)(b) for R1 and R2; documentation of services provided to R1, R3, and R4; documentation of planned activities at least one week in advance; documentation of date of termination of residency for R3 and R4; documentation of notification of the availability of vaccination for influenza and pneumonia for R1 and R2; documentation of the requirements in R9-10-814(B)(2)(b) for R1; documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E2; and evidence of a fall prevention and fall recovery training program.

Findings include:

1. A review of E2's personnel record revealed a CPR and first aid training (dated August 30, 2022). The document stated "RECOGNITION OF COMPLETION [E2] has successfully completed ASHI Online Training for: CPR, AED, and Basic First Aid All Ages (G2015)-DC (Blended)...Blended learning consists of computer-based, online lessons combined with hands-on skill practice and performance evaluation. This document confirms that the above-named individual has completed the required online lessons and is now eligible for hands-on skill practice and performance evaluation by a current and properly authorized ASHI Instructor." However, E2's CPR did not include the requirements and the policy and procedure was not implemented.

2. A review of E2's personnel record revealed a document titled "EMPLOYEE QUALIFICATION AND SKILLS" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were left blank.

3. A review of facility documentation revealed documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for February 1, 2023 through February 7, 2023 was not available for review.

4. A review of E2's personnel record revealed E2's starting date of employment was not available for review.

5. A review of E2's personnel record revealed documentation of experience applicable to E2's job duties was not available for review.

6. A review of E2's personnel record revealed a document titled "Employee Orientation Checklist" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were left blank.

7. A review of E3's personnel record revealed documentation of completion of in-service education for 2022 was not available for review.

8. A review of R1's medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

9. A review of R2's medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

10. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. However, the service plan was not signed and dated by the resident's representative.

11. A review of R2's medical record revealed the following written service plans for personal care:
-May 2021;
-November 2021;
-May 2022; and
-November 2022.
The service plan was signed and dated by the power of attorney (POA) on October 19, 2021. However, updated service plans were not signed and dated by the resident's POA.

12. A review of R1's medical record revealed a current service plan (dated in December 2022 ) for directed care services. However, the service plan was not signed and dated by the manager.

13. A review of R2's medical record revealed a current service plan (dated in November 2022) for personal care services. However, the service plan was not signed and dated by the manager.

14. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. The service plan stated the following services were to be provided to R1:
-"Mobility...requires positioning...Transfer assistance bedbound";
-Hygiene/Grooming/PRN...Brush teeth...Daily &/or PRN; Clean nails PRN; Assist Dressing; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent; Change every two hours/PRN; Peri Care PRN."

15. A review of R1's medical record revealed an activities of daily living (ADL) document for January 1-30 2023. However, the following services were not documented on January 1-31, 2023:
-Repositioning; and
-Incontinent care.

16. A review of R3's medical record revealed a service plan (dated in November 2022) for personal care services. The service plan stated the following services were to be provided to R3:
-"Elimination...Incontinent...Both; Use disposable undergarments; Change every two hours/PRN; Peri Care PRN."

17. A review of R3's medical record revealed an ADL document for December 1-9, 2022. However, the following service were not documented on December 1-9, 2022:
-Incontinent care.

18. A review of R4's medical record revealed a service plan (dated in August 2022) for personal care services. The service plan stated the following services were to be provided to R4:
-"Mobility...Transfer assistance 1x assist";
-"Bathing CG assist...shower; complete bath 2 X week/PRN; Wash Hair; With shower; Peri care; After each disposable change";
-"Hygiene/Grooming/PRN...Brush teeth; Daily &/or PRN; Clean nails PRN; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent...Both; Uses disposable undergarments; Change every two hours/PRN; Peri care PRN."

19. A review of R4's medical record revealed an ADL document for November 1-30, 2022. However, the following services were not documented on November 1-30, 2022.
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.

20. A review of R4's medical record revealed an ADL document for December 1-9, 2022. However, the following services were not documented on December 1-9, 2022:
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.

21. A review of R3's medical record revealed R3's date of termination of residency was not available for review.

22. A review of R4's medical record revealed R4's date of termination of residency was not available for review.

23. A review of R1's medical record revealed documentation of notification of R1 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.

24. A review of R2's medical record revealed documentation of notification of R2 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.

25. A review of R1's medical record revealed documentation to demonstrate the requirements in R9-10-814(B)(2)(b) w

Deficiency #6

Rule/Regulation Violated:
A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
e. The frequency of submitting a documented report required in subsection (2) to the governing authority;
Evidence/Findings:
Based on documentation review and interview, the manager failed to implement a plan for an ongoing quality management program for the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

R9-10-804.2. A documented report is submitted to the governing authority that includes:
a. An identification of each concern about the delivery of services related to resident care, and
b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

1. A review of the facility's policies and procedures revealed a policy titled "Quality Management" (dated February 28, 2017). The policy stated "...The manager shall evaluate all incident reports each month to identify any concerns about the delivery of services, upon discovery of a concern the manager shall take action to correct issue. The manager shall document the concern and the action taken to correct the concern. The report required in subsection (2) [sic] and the supporting documentation for the report are maintained for 12 months after the date the report is submitted to the governing authority...An Assurance checklist will be performed by manager/caregiver/designee every last Saturday of each month...A monthly report will be compiled for residents having falls medication errors, calling 911, weight loss, pressure sores, and residents admitted with C-Diff or. [sic] MRSA."

2. A review of facility documentation revealed a document titled "Quality Management" (January 3, 2018). The document stated "Owner, Manager, Caregiver, and Health Professional are responsible to provide the qualities of care the resident needs. Make sure it delivers appropriately the resident's care plan. Any significant changed [sic] must be put in writing..."

3. A review of the facility's documentation revealed documentation to demonstrate documented reports were submitted to the governing authority monthly were not available for review.

4. In an interview, E1 acknowledged documentation of quality management reports completed and submitted to the governing authority on a monthly basis, as required by the facility's quality management plan, were not available for review.

Deficiency #7

Rule/Regulation Violated:
A. A manager shall ensure that:
4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented:
a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and
b. According to policies and procedures;
Evidence/Findings:
Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of one caregiver sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer observed E2 on the premises and working alone when the Compliance Officer arrived at 10:30 AM.

2. A review of the facility's policies and procedures revealed a policy titled "MANAGER'S RESPONSIBILITIES" (dated February 1, 2017). The policy stated "Ensure that all employees have the required documentation, skills and training to perform the positions they are hired for."

3. A review of E2's (unknown date of hire) personnel record revealed a document titled "EMPLOYEE QUALIFICATION AND SKILLS" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were blank.

4. In an interview, E1 acknowledged E2's skills and knowledge were not verified and documented prior to E2 providing physical health services and according to the facility's policies and procedures.

This is a repeat deficiency from the on-site complaint investigation conducted on February 15, 2022.

Deficiency #8

Rule/Regulation Violated:
A. A manager shall ensure that:
7. Documentation is maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each;
Evidence/Findings:
Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained to include the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if shifts and tasks were covered, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. The Compliance Officer observed a document titled "WORK SCHEDULE" (dated January 2023) posted to a bulletin board, located in the hallway.

2. A review of facility documentation revealed documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for February 1, 2023 through February 7, 2023 was not available for review.

3. In an interview, E1 reported E1 had to print the documentation for February 2023. However, the documentation was not provided for review.

4. In an interview, E1 acknowledged documentation of caregivers and assistant caregivers working each day, including the hours worked by each, was not available for review.

Deficiency #9

Rule/Regulation Violated:
C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
Evidence/Findings:
Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for one of two personnel records sampled . The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline" (dated February 1, 2017). The policy stated "Upon being hired by the facility the applicant must...The starting date of employment..."

2. A review of E2's personnel record revealed E2's starting date of employment was not available for review.

3. In an interview, E1 acknowledged E2's personnel record did not include the starting date of employment.

Deficiency #10

Rule/Regulation Violated:
C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
ii. The individual's education and experience applicable to the individual's job duties;
Evidence/Findings:
Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documention of the individual's experience applicable to the individual's job duties, for one of two personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel record during inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline" (dated February 1, 2017). The policy stated "Upon being hired by the facility the applicant must...Verification of three months of Health Related experience...Verification of the individual's education and experience applicable to the individuals job duties."

2. A review of the facility's policies and procedures revealed a policy titled "Caregiver and Relievers Duties and Responsibilities" (dated February 1, 2017). The policy stated "A Caregiver will be required to provide the assisted living facility with verification of the type and duration of education or experience that may allow the caregiver or assistant caregiver to acquire the specific skills and knowledge for them to provide the ecpected assisted living services..."

3. A review of E2's (unknown date of hire) personnel record revealed documentation of experience applicable to E2's job duties was not available for review.

4. In an interview, E1 acknowledged E2's personnel record did not include E2's experience applicable to E2's job duties.

Deficiency #11

Rule/Regulation Violated:
C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
iii. The individual's completed orientation and in-service education required by policies and procedures;
Evidence/Findings:
Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documention of the individual's completed orientation, for one of two personnel records sampled; and documentation of the individual's in-service education required by policies and procedures, for one of two personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection and the documentation was not provided within two hours after a Department request.

Findings include:

R9-10-101.137. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

R9-10-101.115. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer

1. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline" (dated February 1, 2017). The policy stated "After the employee is hired by this facility, the employee shall ensure: That the new employee completes the New Employee Orientation ON or BEFORE the employee's date of hire."

2. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline" (dated February 1, 2017). The policy stated "That CEU's (ongoing training) are completed every 12 months from the starting date of employment for every employee and manager of the facility per ADHS mandates. That CEU's (ongoing training) for the facility manager are completed per NCIA guidelines at least 12 units a year."

3. A review of E2's (unknown date of hire) personnel record revealed a document titled "Employee Orientation Checklist" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were blank.

4. A review of E3's (hired in 2019) personnel record revealed documentation of completion of in-service education for 2022 was not available for review.

5. In an interview, E1 acknowledged documentation of completed orientation was not included in E2's personnel record and documentation of in-service education required by policies and procedures was not included in E3's personnel record.

Deficiency #12

Rule/Regulation Violated:
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two current residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in then medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (accepted in January 2020) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

2. A review of R2's (accepted in May 2018) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

3. In an interview, E1 acknowledged documentation to include whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

Deficiency #13

Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
Evidence/Findings:
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 two current residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. However, the service plan was not signed and dated by the resident's representative.

2. A review of R2's medical record revealed R2 had a power of attonery (POA).

3. A review of R2's medical record revealed the following written service plan for personnel care:
-May 2021;
-November 2021;
-May 2022; and
-November 2022.
The service plan was signed and dated by the POA on October 19, 2021. However, updated service plans were not signed and dated by the resident's POA.

4. In an interview, E1 acknowledged R1's and R2's written service plans did not include a signature and date from the resident or resident's representatives.

Deficiency #14

Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
b. The manager;
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the manager, for two of two current residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a current service plan (dated in December 2022 ) for directed care services. However, the service plan was not signed and dated by the manager.

2. A review of R2's medical record revealed a current service plan (dated in November 2022) for personal care services. However, the service plan was not signed and dated by the manager.

3. In an interview, E1 acknowledged R1's and R2's service plans were not signed and dated by the manager.

Deficiency #15

Rule/Regulation Violated:
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 record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical records, for one of two current residents sampled, and two of two terminated residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. The service plan stated the following services were to be provided to R1:
-"Mobility...requires positioning...Transfer assistance bedbound";
-Hygiene/Grooming/PRN...Brush teeth...Daily &/or PRN; Clean nails PRN; Assist Dressing; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent; Change every two hours/PRN; Peri Care PRN."

2. A review of R1's medical record revealed an activities of daily living (ADL) document for January 1-30 2023. However, the following services were not documented on January 1-31, 2023:
-Repositioning; and
-Incontinent care.

3. A review of R3's medical record revealed a service plan (dated in November 2022) for personal care services. The service plan stated the following services were to be provided to R3:
-"Elimination...Incontinent...Both; Use disposable undergarments; Change every two hours/PRN; Peri Care PRN."

4. A review of R3's medical record revealed an ADL document for December 1-9, 2022. However, the following service were not documented on December 1-9, 2022:
-Incontinent care.

5. A review of R4's medical record revealed a service plan (dated in August 2022) for personal care services. The service plan stated the following services were to be provided to R4:
-"Mobility...Transfer assistance 1x assist";
-"Bathing CG assist...shower; complete bath 2 X week/PRN; Wash Hair; With shower; Peri care; After each disposable change";
-"Hygiene/Grooming/PRN...Brush teeth; Daily &/or PRN; Clean nails PRN; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent...Both; Uses disposable undergarments; Change every two hours/PRN; Peri care PRN."

6. A review of R4's medical record revealed an ADL document for November 1-30, 2022. However, the following services were not documented on November 1-30, 2022.
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.

7. A review of R4's medical record revealed an ADL document for December 1-9, 2022. However, the following services were not documented on December 1-9, 2022:
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.

8. In a interview, E1 acknowledged services provided were not documented in R1's, R3's and R4's medical records.

Deficiency #16

Rule/Regulation Violated:
C. A manager shall ensure that a resident's medical record contains:
4. The date of acceptance and, if applicable, date of termination of residency;
Evidence/Findings:
Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency, for two of two terminated residents sampled. The deficient practice posed a risk as the department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of documentation revealed a complaint was received by the Department on December 12, 2022. The complaint revealed an incident involving two residents, later identified as R3 and R4.

2. A review of R3's medical record revealed R3's date of termination of residency was not available for review.

3. In an interview, E1 reported R3 was at AL11202 for a short period and was no longer a resident at AL11202.

4. A review of R4's medical record revealed R4's date of termination of residency was not available for review.

5. In an interview, E1 reported R4 was no longer a resident at AL11202.

6. In an interview, E1 acknowledged R3's and R4's medical records did not include the date of termination of residency.

Deficiency #17

Rule/Regulation Violated:
C. A manager shall ensure that a resident's medical record contains:
17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of notification of the residents of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d), for two of two current residents sampled. The deficient practice posed a potential illness risk to residents, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 36-406(1)(d): 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.

1. A review of R1's (admitted in 2020) medical record revealed documentation of notification of R1 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.

2. A review of R2's (admitted in 2018) medical record revealed documentation of notification of R2 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.

3. In an interview, E1 acknowledged R1's and R2's medical records did not contain documentation of notification of R1 and R2 availability of vaccination for influenza and pneumonia.

Deficiency #18

Rule/Regulation Violated:
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or
Evidence/Findings:
Based on record review and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in R9-10-814(B)(2), for one of one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk if the facility was unable to meet R1's needs, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan (dated in December 2022) for directed care services. The service plan stated "Mobility...Bedbound."

2. A review of R1's medical record revealed documentation to demonstrate the requirements in R9-10-814(B)(2)(b) were met every six months was not available for review.

3. In an interview, E1 acknowledged documentation to demonstrate the requirements in R9-10-814(B)(2) were met every six months for R1 was not available for review.

Deficiency #19

Rule/Regulation Violated:
A. A manager shall ensure that:
1. A food menu:
c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served,
Evidence/Findings:
Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served.

Findings include:

1. The Compliance Officer observed a menu conspicuously posted on a bulletin board located the hallway. However, the menu was dated January 2023.

2. A review of facility documentation provided by E1 revealed food menus for February 2023.

3. In an interview, E1 reported E1 had to print the menus and acknowledged a food menu was not conspicuously posted at least one calendar day before the first meal on the food menu was served.