LINCOLN RESIDENTIAL ASSISTED LIVING, LLC

<p style="text-align: justify;"><span style="font-size: 12pt;">Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage and was safe for human consumption. The deficient practice posed a risk for potential food borne illnesses.</span></p><p style="text-align: justify;"><span style="font-size: 12pt;"> </span></p><p style="text-align: justify;"><span style="font-size: 12pt;">Findings include:</span></p><p style="text-align: justify;"><span style="font-size: 12pt;"> </span></p><p style="text-align: justify;"><span style="font-size: 12pt;">1. The Compliance Officer observed cucumbers stored in the fridge with fuzzy grey spots that appeared to be mold.</span></p><p style="text-align: justify;"><span style="font-size: 12pt;"> </span></p><p style="text-align: justify;"><span style="font-size: 12pt;">2. In an interview, E1 acknowledged that food stored by the facility was not free from spoilage</span></p><p><span style="font-size: 12pt;"> </span></p>

<p><span style="font-size: 16px;">Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. </span></p><p><span style="font-size: 16px;"> </span></p><p><span style="font-size: 16px;">Findings include:</span></p><p><span style="font-size: 16px;"> </span></p><p><span style="font-size: 16px;">1. A review of facility documentation revealed annual disaster plan reviews for 2020, 2021, 2022, and 2023. However, a disaster plan review for 2024 was not available. </span></p><p><span style="font-size: 16px;"> </span></p><p><span style="font-size: 16px;">2. In an interview, E1 acknowledged that the annual disaster plan review was not available for review.</span></p>

Based on documentation review, record review, and interview, for one resident reviewed, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall.

Findings include:

1. In review of facility policies and procedures revealed a policy titled "Fall Prevention and Fall Recovery," which documented "Facility shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The program shall include initial training and continued competency training in Fall Prevention and Fall Recovery." Upon further review, "falls recovery" was included in this policy and stated, "discuss the range of Fall Prevention strategies that can be offered within the ALF. Identify preparation strategies for fall recovery, to provide a safe environment for both resident and caregiver."

2. In documentation review, the department received a report from O1 which documented, "... staff failed to recover patient per ARS 36-420...On April 9th, 2024 at 0350 hrs, E92 was dispatched... in reference fall injury...made contact with R1 who was awake, alert and did not appear to be in distress, stated... needed assistance to get up...was overweight and possibly obese...was located on the floor of a back bedroom...was assisted... to feet and onto chair located in the room... R1 declined any further medical attention and declined transport to the ER."

3. In documentation review, facility reports, dated March 30, 2024, and March 31, 2024, indicated R1 had fallen. The reports included a section titled "Part of Body and extent of Bodily Injury indicated No apparent injury." Another section titled "treatment/Type of First Aid rendered" documented "called for non-emergency help." Neither report indicated the type of first aid rendered. The facility did not provide documentation of the resident's fall on April 9, 2024.

4. In an interview, E1 and E2 acknowledged R1 had fallen at the facility, and was uninjured; however, due to R1's weight, the facility called 911, did not recover the resident from the floor, and failed to provide appropriate first aid for a non-injured resident.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency for one resident reviewed.

Findings include:

1. A review of R1's medical record revealed R1's date of termination of residency was not available for review.

2. In an interview, E1 and E2 reported R1 was no longer a resident at this facility.

3. In an interview, E1 and E2 acknowledged that R1's termination date was not included in the medical record and E1 and E2 did not recall R1's date of termination.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During an environmental inspection, the Compliance Officers observed two doors leading to the backyard, one on each side of the patio, located in hallway adjacent to resident bedrooms. These doors did not control or alert employees of the egress of a resident from the facility.

3. In an interview, E2 acknowledged the patio doors were not controlled and did not alert the employees of the egress of a resident from the facility. E1 reported the alarm goes off in the kitchen but when the Compliance Officer attempted to set the alarm off, no alert was heard in the kitchen.