SUNCREEK SURPRISE LLC

Based on documentation review, record review, and interview, the manager failed to ensure a written service plan include the correct level of service the resident received for one of two residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A.R.S. \'a7 36-401.38 defines "Directed care services" as programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

2. Review of R2's medical record revealed a written service plan for personal care services dated March 16, 2023.

3. During an interview, E1 reported R2 was incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. E1 acknowledged R2 received directed care services and the service plan did not include the correct level of service.

Based on record review and interview, the manager failed to ensure a written service plan included the amount, type, and frequency of assisted living services provided for one of two residents reviewed. The deficient practice posed a risk if a resident's service plan did not include the services to be provided.

Findings include:

1. Review of R2's medical record revealed a written service plan dated March 16, 2023. This service plan indicated R2 was incontinent of bladder and bowel, however did not indicate the amount, type, and frequency of incontinence care provided to R2.

2. During an interview, E1 reported R2 was provided with incontinence care multiple times a day and acknowledged R2's service plan did not include the amount, type, and frequency of incontinence care provided to R2.

3. Technical assistance was provided on this Rule during the compliance inspection conducted June 20, 2022.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated March 16, 2023. This service plan stated "Wound: both heels acquired @ Banner on 3/6/23. Healed 4/20/2023". This service plan revealed no documentation of skin maintenance to prevent skin issues.

2. During an interview, E1 reported R2's wounds had healed, however acknowledged R2's service plan did not include skin maintenance to prevent skin issues.

3. Technical assistance was provided on this Rule during the compliance inspection conducted June 20, 2022.