COPPER SKY ASSISTED LIVING

INSP-0115529

Complete

Date: 4/1/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-05-05

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00105710 and 00105171 conducted on April 1, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411 by failing to make documented good faith efforts to contact previous employers to obtain information or recommendations which may be relevant to a person's fitness to work in a residential care institution. The deficient practice posed a risk if E4, E5, or E6 were a danger to a vulnerable population. Findings include: 1. A review of E4’s, E5’s, and E6’s personnel records revealed each caregiver had a valid fingerprint clearance card on each employee's respective date of hire. 2. A review of E4’s personnel record revealed an employment application dated September 6, 2024. The application included a section for documenting prior work history, which included the names of three prior employers, and respective dates of employment. The application contained a section for documenting contact with “Work or Professional References,” however, the section was completely blank. Further review of E4’s personnel record revealed evidence of documentation of good faith efforts to contact E4’s previous employers was unavailable for review. 3. A review of E5’s personnel record revealed an employment application dated February 10, 2025. The application included a section for documenting prior work history, which included the names of three prior employers, and respective dates of employment. The application contained a section for documenting contact with “Work or Professional References.” The section included names of individuals contacted, their opinions of the applicant, and dates of contact. However, the documentation of the individual’s relationship with the applicant, such as a previous manager, supervisor, or other indication they were a previous employer, was unavailable for review. Further review of E5’s personnel record revealed evidence of documentation of good faith efforts to contact E5’s previous employers was unavailable for review. 4. A review of E6’s personnel record revealed an employment application dated January 31, 2024. The application included a section for documenting prior work history, which was not completed. The application contained a section for documenting contact with “Work or Professional References,” which was also blank. E6’s personnel record did contain a resume which included names of previous employers and respective dates of employment. However, further review of E6’s personnel record revealed evidence of documentation of good faith efforts to contact E6’s previous employers was unavailable for review. 5. In an interview, E1 advised efforts were made to contact E4’s and E6’s previous employers, but those efforts had not been documented. E1 agreed E4’s, E5’s, and E6’s employment records did not include documented good faith efforts to contact previous employers as required in A.R.S. § 36-411.

Temporary Solution:

Our temporary solution for this plan of correction was to perform a proper previous employment check for the caregivers listed and notate it on their applications. Which are attached. We are also completing an audit on current employees to perform any additional employment checks that were missing or that were not performed correctly.

Permanent Solution:

In order to better complete the task of employment verification I have updated our application to include the code stating the need for employment verification and I have added a section after each work history for that verification to be performed and written. See attached application. This is the application we will use going forward for all future staff and it must be completed prior to starting employment. There is also a notice to future employees that any gaps of employment larger than 6 months will require more information and possibly a new application for fingerprint clearance card.

Person Responsible:

Taylor Jackson, Facility Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R3’s medical record revealed a service plan which indicated R3 received directed care services, including medication administration. R2’s medical record contained a medication order for “Macrobid 100 MG CAPSULE Take 1 Capsule every 12 hours by oral route for 7 days.” R3’s medical record also contained a discontinue order for “nitrofurantoin macrocrystaL 50 mg capsule Take 1 capsule(s) twice a day by oral route for 7 days.” Both orders were written on February 10, 2025. 2. Further review of R2’s medical record revealed a Medication Administration Record (MAR) for the month of March 2025, which included sections for documenting the administration “NITROFUANTOIN MCR 50 MG Take 1 capsule by mouth once daily for UTI." The record reflected Nitrofurantoin was administered daily for the entire month of March. Evidence of documentation of administration of Macrobid was unavailable for review. 3. In an interview, E1 agreed R1 had not been administered medication in compliance with a medical order.

Temporary Solution:

In response to this deficiency, we performed a medication reconciliation for the resident listed in the deficiency to ensure that our medication list is now accurate and current and had him sign it. Which I will attach for your review.

Permanent Solution:

I updated our entire medication policies and added a medication order audit section to better address verifying orders and communicating with the physician more frequently to verify our orders are correct. As well as I included the language of R9-10-816.B.3.b. under our medication administration section. We then had our nurse review and sign off on our policies, which are now implemented

Person Responsible:

Taylor Jackson, Facility Manager

Facility Information

Inspection History

INSP-0115529

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible: