HACIENDA AT THE CANYON

Based on documentation review, observation, and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the assisted living facility's caregivers.

Findings:

1. A review of department documentation revealed the facility made a self-report on May 22, 2024. The reported stated "On May 8, 2024 the community received 180 tablets 6 individual cards, or Hydrocodone 10-325mg tablets. During the morning narcotic count on May 17, 2024, 2 associates notice 1 full card of Hydrocodone 10-325mg tablets missing from the narcotic box.. was in a locked medication cart, total missing equals 30 tablets. Community is doing currently an investigation, regarding missing Narcotics".

2. E1 started an investigation. E1 and E2 reported E4 and E5 were put on administrative leave until the investigation was completed. E6 had been terminated due to not starting the investigation as soon as the incident was reported to E6. The incident was reported to Adult Protective Services (APS) and the Pima County Sheriff's Department.

3. E1 and E2 reported the facility was unable to determine who was responsible for the missing 30 Hydrocodone tablets belonging to R1.

4. In an interview, E1 and E2 acknowledged R1's medication was missing.

Based on documentation review, observation, and interview, the manager failed to establish, document, and implement policies and procedures for all required procedures in R9-10-816(F)(3).

Findings include:

1. A review of policies and procedures revealed the following "Controlled Substances Count Policy". The policy states " A. Policy Statement: It is the policy of Watermark Retirement Communities, LLC (WRC) and its affiliates to account for all Scheduled II-IV Medications at the end of each shift and to promptly investigate discrepancies in controlled substance counts. B. Procedure: I. All Scheduled Medications II-IV (Controlled substances) must be under double lock. II. The assigned medication-distributing associate is ultimately responsible for the security of controlled substances assigned residents during his/her shift unless properly relieved by another associate authorized to administer controlled substances. If relieved for any reason during the shift, a controlled substance count will be performed and properly documented by the outgoing associate and the associate assuming responsibility for the controlled substances".

2. A review of department documentation revealed the following "05/08/2024 community received 180 tablets-6 individual cards, or Hydrocodone 10-325mg tablets. During the morning narcotic count on 5?17/2024, 2 associates noticed 1 full card of Hydrocodone 10-325mg tablets missing from the narcotic box. The box was in a locked medication cart, total missing equals 30 tablets. Community is doing an investigation, regarding missing Narcotics". The narcotics belonged to R1.

3. A review of documentation provided by E1 revealed the following "DRC and ED made aware of the missing narcotics from 5/17/2024, suspensions of the 2 caregivers and the nurse done on 5/20; Investigation started with interview of suspended employees as well as additional caregivers that worked in assisted living; internal investigation concluded that company policy was not being followed regarding proper counting of narcotics; as a results nurse was terminated and the 2 suspended caregivers were given final written warnings; training with the assistance from Pharmacy on counting narcotics was given to suspended caregivers before returning to work on the floor; training for all other caregivers working in AL; Missing narcotic was never located.

4. In an interview, E1 and E2 acknowledged their policies and procedures on narcotic counting were not implemented by caregivers.

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

Findings include:

1. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in March 2024.

2. A review of E4's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The document stated " Standard - First-Aid". The course was taken on October 23, 2023.

3. An online search of the National CPR Foundation revealed this is an online course. No hands-on CPR training is included.

4. A review of the facility's policies and procedures titled "Cardiopulmonary Resuscitation (CPR) Policy". This document stated "... B. 1. Nurses and other care staff are educated to initiate CPE, as recommended by the American Heart Association (AHA)" .... XII. Certification is only obtained by attending a course offered through a certifying agency such as the American Red Cross, the American Heart Association or an associate employed at the community that is a current certified instructor through one of these agencies", and "Associate & Volunteer Training and Personnel Files Arizona Only". ..3. Documentation of: Prior to delivery of care to the residents the Business Office Manager will verity current training in First Aid through accredited vendor and will verify current training in CPR specific to adults from one of the following organizations: American Red Cross, American Heart Association or National Safety Council (with hands on demonstration of techniques)".

5. In an interview, E1 and E8 reported being unaware the National CPR Foundation was an online CPR course that did not include hands on demonstration of techniques. E1 and E8 acknowledged E4 did not have current documentation on hands-on CPR training before providing assisted living services.

Based on record 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 licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On April 18, 2023, the Compliance Officer requested the following documents during the on-site inspection:

- Documentation of E5, and E6's first aid documentation;
- The following documentation from E1's personnel record:
- The individual's starting date of employment;
- The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
- The individual's completed orientation and in-service education required by policies and procedures;
- Cardiopulmonary resuscitation training; and
- First aid training.

2. In an interview, E1, and E8 acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request.

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for two of four sampled caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E5's personnel record revealed E5 was hired as a caregiver in January 2023.

2. A review of E5's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection.

3. A review of staff schedules revealed R5 was scheduled to work April 15, 16, 17, and 18, 2023, at 6:00 a.m. to 2:30 p.m.

4. A review of E6's personnel record revealed E6 was hired as a caregiver in February 2023.

5. A review of E6's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection.

6. A review of staff schedules revealed R6 was scheduled to work April 16, 17, and 18, 2023 at 6:00 a.m. to 2:30 p.m.

7. A review of a policy's and procedures revealed a policy titled "Associate & Volunteer Training and Personnel Files AZ Only" This document stated ...."B. Procedures: Each file will contain the following: .... Prior to delivery of care to the residents the Business Office Manager will verify current training in First Aid through an accredited vendor .... American Red Cross, American Heart Association or National Safety Council. .... The Business Office Manager will maintain copies of current First Aid and CPR training in the employment files".

8. In an interview, E1, and E8 acknowledged E5's and E6's personnel records did not include documentation of first aid training.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained, for one of seven personnel records reviewed.

Findings include:

1. The Compliance Officer observed E1 was the manager of the facility.

2. The Compliance Officer requested to review E1's personnel record.

3. A review of E1's personnel record revealed the following was missing:

- The individual's starting date of employment;
- The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
- The individual's completed orientation and in-service education required by policies and procedures;
- Cardiopulmonary resuscitation training; and
- First aid training.

4. A review of the facility's policy and procedure revealed a policy titled, "Associate & Volunteer Training and Personnel Files AZ Only" This document stated ...."B. Procedures: Each file will contain the following: ....Freedom from pulmonary tuberculosis, ... First Aid through an accredited vendor and will verify current training in CPR specific to adults from one of the following organizations; 1) American Red Cross, 2) American Heart Association or 3) National Safety Council. .... The Business Office Manager will maintain copies of current First Aid and CPR training in the employment files. ....Employee qualifications as required for the position, .... Employee orientation will include 3-4 hours of training on the following topics within the first week of employment (WRC-HR-I197 "MANGO" Mandatory Orientation Guide".

5. In an interview, E1, and E8 acknowledged E1's personnel file was incomplete.

Based on observation and interview, the manager failed to ensure the swimming pool was locked when the swimming pool was not in use.

Findings Include:

1. During a tour of the facility the Compliance Officer observed when exiting the women's bathroom/dressing room that led into the outdoor pool area, the door was unlocked, and the swimming pool was not in use. The Compliance Officer reentered the bathroom area and observed on the back of the entrance to the bathroom/dressing room the door had a pad lock at the top that had been left unlocked.

2. During a tour of the facility the Compliance Officer observed when exiting the men's bathroom/dressing room that led into the outdoor pool area, the door was unlocked, and the swimming pool was not in use. The Compliance Officer reentered the bathroom area and observed on the back of the entrance to the bathroom/dressing room the door had a pad lock at the top that had been left unlocked.

3. In an interview, E1 acknowledged both the men's and women's bathroom/dressing room doors had been left unlocked while the swimming pool was not in use.

Based on observation and interview, the manager failed to ensure pool safety requirements were conspicuously posted in the swimming pool area.

Findings include:

1. During the facility tour, the Compliance Officer observed the facility had a swimming pool in their courtyard. However, pool safety requirements were not conspicuously posted in the swimming pool area.

2. During an interview, E1 acknowledged the pool safety requirements were not conspicuously posted in the swimming pool area.