EDEN ESTATES ASSISTED LIVING

INSP-0124390

Complete

Date: 4/10/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-04-22

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 10, 2025:

Deficiencies Found: 4

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 documentation review, 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 the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(1)(3) 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. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee.” 2. Review of E2’s personnel record revealed no documentation of good faith efforts to contact previous employers. 3. Review of E2’s personnel record revealed no documentation to verify that a potential employee was not on the adult protective services registry. Based on E2’s date of hire this was required. 4. Review of the facility’s April 2025 schedule showed E2 worked for twelve hours on April 7 and April 8th. 5. In an interview, E1 acknowledged E2’s personnel record did not include documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work. E1 also acknowledged E2’s personnel record did not include documentation of efforts to verify if the employee was on the adult protective services registry.

Temporary Solution:

In regard to the portion related to previous employer information or recommendations that may be relevant to a person's fitness to work in a residential care institution the following actions were taken: 1. Previous employer information was collected. 2. Julieta Gabi, Facility Manager, contacted the provided previous employers to verify work history and gather recommendations for E2's employment. Julieta received satisfactory responses from the past employers.

In regard to the portion related to verifying that the potential person is not on the Adult Protective Registry the following actions were taken: 1. Julieta Gabi, Facility Manager, verified on 4/12/2025 that E2 was not listed on the APS Registry. 2. I, Joshua Hull, then printed a copy of this for E2's employment file and attached a scanned copy to this POC.

Permanent Solution:

In regard to both verifying past employment references as well as verifying that a potential employee is not listed on the APS Registry the facility manager will complete both of these reviews prior to offering official employment.

Person Responsible:

Joshua Hull, Owner

Deficiency #2

Rule/Regulation Violated:

R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB), for one of two employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "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...2. Include: 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: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. Review of E2’s personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. In addition, no documentation of a risk assessment of prior exposure to infectious TB or a determination if E2 had signs or symptoms of TB. Based on E2's hire date, this documentation was required. 4. Review of the facility’s April 2025 schedule showed E2 worked for twelve hours on April 7 and April 8th. 5. In an interview, E1 acknowledged E2 was in the facility working on April 7, 2025 and April 8, 2025. 6. In an interview, E1 acknowledged E2’s personnel record did not include documentation of freedom from infectious TB as required in R9-10-113.

Temporary Solution:

Immediately following the compliance survey E2 scheduled a TB Screening, Risk Assessment, and a two step TB Skin test. In addition E2 was removed from the schedule until the two step process could be completed. Note: Attached includes the original TB test that was reviewed during the compliance review from 09/2024, as well as the results from the newly administered two step testing.

Permanent Solution:

Prior to a new employee beginning work within our facility a TB Screening, Risk Assessment, and Two-Step Skin test will be conducted and documented in the employee's file.

Person Responsible:

Joshua Hull, Owner

Deficiency #3

Rule/Regulation Violated:

R9-10-808.C.1.g. Service Plans 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 documented the services provided in the medical record, for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1’s medical record revealed a current service plan dated March 1, 2025. The following were a list of services R1 received: - Partial bath PRN- Dressing full assist- Grooming: Comb hair Daily- Nails- Clean and check with bed bath 2. Review of R1’s medical records revealed an Activities of Daily Living (ADL) log for the month of April 2025. The ADLs revealed no services were documented on the following days of April: 1st, 2nd, 3rd, 5th, 6th, 7th, 8th, 9th, and 10th. On April 4, 2025 the service that was documented was bathing. 3. Review of R2’s medical records revealed a current service plan dated February 1, 2025. The following were a list of services R2 received:- Bathing/ Hygiene: Shower 2x week- Brush teeth/ encourage oral care daily- Lotion skin after shower & PRN to maintain Moisture. 4. Review of R2’s medical records revealed ADL for the month of April 2025. The ADLs revealed the services listed above were not documented on the following days of April: 1st, 2nd, 4th, 5th, 6th, 7th, 8th, 9th, and 10th. On April 3, 2025 the service that was documented was Bathing. 5. In an interview, E1 reported E1 did not know ADLs were supposed to be documented. E1 also reported that services were provided. 6. In an interview, E1 and E3 acknowledged documentation was not available showing the services were provided.

Temporary Solution:

The staff on shift during the compliance survey immediately began documenting services identified in a resident's service plan in the residents EHR/MAR. Julieta Gabi, Facility Manager, also informed all staff not on shift at the time of this and instructed each staff member to review the resident's service plan and to begin documenting services.

Permanent Solution:

Services identified in a resident's service plan will be documented in the resident's EHR/MAR. Additionally, new employees will be trained on the electronic EHR/MAR that our facility utilizes on the proper way to document services provided.

Person Responsible:

Joshua Hull, Owner

Deficiency #4

Rule/Regulation Violated:

R9-10-819.A.11. Environmental Standards A. A manager shall ensure that: 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:

Based on documentation review, observation, and interview, the manager failed to ensure that poisonous and toxic materials were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Documentation review revealed that the facility was licensed for Directed Care. 2. The Compliance Officers observed ambulatory residents 3. During the facility tour with E1, the Compliance Officers observed the following poisonous or toxic materials in unlocked cabinets in the kitchen:· Great Value furniture polish and Clorox wipes· ReliOn sterile alcohol swabs· Scotchgard furniture protector 4. In an interview, E1 acknowledged that poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area and inaccessible to residents.

Temporary Solution:

Following the survey the hazardous materials that were identified were relocated to a secured location that was locked and inaccessible to our residents.

Permanent Solution:

Additional cabinets throughout the house are getting magnetic locks installed to allow for cleaning supplies to be stored securely while also allowing staff to access them in key locations throughout the home to retain a clean and sanitary facility.

Person Responsible:

Joshua Hull, Owner

Facility Information

Inspection History

INSP-0124390

Summary:

Deficiencies Found: 4

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:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0095655

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings: