EAST VALLEY MANSION ASSISTED LIVING

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident.

Findings include:

1. A review of R2's medical record revealed a written service plan for directed care services dated September 11, 2023. However, a service plan after September 11, 2023 was not available for review.

2. In an interview, E1 and E2 acknowledged R2 received directed care services and the service plan was not updated at least once every three months.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident sampled. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R2's medical record revealed no documentation that showed the flu and pneumonia vaccinations were received or refused. Based on R2's acceptance date, this documentation was required.

3. In an interview, E1 and E2 acknowledged R2's medical record did not include current documentation that showed the flu and pneumonia vaccinations were received or refused.

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 sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of a resident.

Findings include:

1. A review of R1's medical record revealed a current written service plan for personal care services dated October 22, 2024. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

2. In an interview, E1 and E2 acknowledged R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included: strategies to ensure a resident's personal safety; documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service, for one of one sampled residents receiving directed care services. The deficient practice posed a health risk to the resident.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated September 11, 2023 that stated R2 required directed care services. This service plan revealed no documentation of strategies to ensure personal safety, and documentation of the resident's weight. R2's medical record contained no documentation from a medical practitioner stating that weighing the resident was contraindicated. There was no documentation regarding coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

4. During an interview, E1 and E2 acknowledged R2's service plan did not include documentation of all the requirements for a resident receiving directed care services.

Based on observation, documentation review, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closed, or self-contained unit. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During an environmental inspection of the facility with E2, the Compliance Officer observed a file cabinet that contained five residents' medication boxes. The cabinet was equipped with a locking mechanism, however, the cabinet was not locked.

2. During the environmental inspection of the facility, the Compliance Officer observed the caregivers were not accessing the medications at the time of arrival.

3. In an interview, E2 acknowledged medications were stored in an unlocked manner and accessible to residents.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials.

Findings include:

1. During the environmental inspection of the facility with E2, the Compliance Officer observed an unlocked cabinet in the kitchen near the sink that contained the following:
-Hot Shot Flying Insect Killer;
-Easy-Off oven cleaner;
-Cascade dishwashing detergent;
-Raid insect killer;
-Clorox disinfecting wipes; and
-two cans of Glade Odor Eliminating aerosol

2. During the environmental inspection of the facility with E2, the Compliance Officer observed an unlocked cabinet in a resident's bedroom that contained the following:
-Lysol disinfecting wipes;
-Lysol toilet bowl cleaner; and
-Glade Odor Eliminating air spray

3. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a document labeled "Fall prevention and recovery training programs." The document stated "All employees will have an initial training on fall prevention and recovery. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files."

2. A review of E2's personnel record revealed documented fall prevention and recovery training dated March 2022. However, E2's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program.

3. A review of E4's personnel record revealed documented fall prevention and recovery training dated March 2022. However, E4's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program.

3. In an interview, E1 and E5 acknowledged the facility's fall prevention and fall recovery program was not administered according to the documented program requirements.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

Findings include:

1. A review of facility documentation revealed a policy and procedure manual labeled "East Valley Mansion Assisted Living LLC." The documentation indicated the most recent review date was February 3, 2020.

2. In a interview, E3 acknowledged the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

Based on observation, interview, record review, and documentation review, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver.

Findings include:

1. The Compliance Officer arrived on site at approximately 10:00 AM. Upon arrival, the Compliance Officer observed E2 and E3 present, with eight residents on the premises. The Compliance Officer observed E5 arrived to the facility at approximately 10:45 AM, and E1 arrived at the facility at approximately 11:00 AM. The Compliance Officer observed E2 and E3 interacting with residents on the premises prior to the arrival of E5 and E1, socializing with residents in the living room and assisting residents with eating.

2. During the environmental inspection of the facility with E2, the Compliance Officer requested E2 to unlock the caregiver room. E2 reported E4 had the keys to the room. The Compliance Officer did not observe E4 on the premises until approximately 11:15 AM, when E4 unlocked the room.

3. In an interview, E4 reported being a live-in caregiver, and stated E4 was in a different part of the house when the Compliance Officer arrived and began the inspection.

4. A review of E2's personnel record revealed a signed job description labeled "Caregiver" dated July 16, 2023. However, E2's personnel record did not contain documentation of completion of an approved caregiver training program.

5. A review of E3's personnel record revealed a signed job description labeled "Caregiver" dated September 5, 2020. However, E3's personnel record did not contain documentation of completion of an approved caregiver training program.

6. In an interview, E1 reported E2 and E3 were assistant caregivers.

7. In an interview, E4 reported E4 was a certified caregiver. E4 stated E4 was in the back of the home in the casita area, and not in view of E2 and E3, while the Compliance Officer conducted the environmental inspection of the facility. E1, E4, and E5 acknowledged E2 and E3 interacted with residents without the supervision of a manager or caregiver during the inspection.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for four of four caregivers or assistant caregivers sampled.

Findings include:

1. A review of facility policies and procedures dated February 2, 2020 revealed a section labeled "Staffing documentation and recordkeeping." The policy stated "1. A facility manager shall ensure that a file is maintained on the premises for each employee containing the following: i. The individuals qualifications, including skills and knowledge applicable to the individuals job duties..."

2. During the environmental inspection of the facility, the Compliance Officer observed E2 and E3 interacting with the residents and assisting residents with eating lunch. The Compliance Office also observed E4 assisting a resident in a wheelchair from the living room to the dining room table.

3. A review of E1's, E2's, E3's, and E4's personnel records revealed no documentation to indicate E1's, E2's, E3's, or E4's skills and knowledge were verified before E1, E2, E3, and E4 provided physical health services at the facility.

4. In an interview, E1 and E5 acknowledged E1's, E2's, E3's, and E4's personnel records did not contain documented verification of E1's, E2's, E3's, and E4's skills and knowledge.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services to a resident. 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 the facility's policies and procedures revealed a policy titled "cardiopulmonary resuscitation and First aid requirements." The policy stated: "Each manager, caregiver, and other applicable employees shall...Obtain and maintain current CPR and first aid..."

2. A review of E4's personnel record revealed E4 worked as a caregiver. E4's personnel record revealed a CPR and first aid card dated September 4, 2021 with an expiration date of September 4, 2023. E4's personnel record did not contain documentation of current CPR and first aid training certification.

3. A review of facility documentation revealed a staffing schedule dated September 2023. The schedule indicated E4 was scheduled to work at the facility on September 1-17, 2023.

4. In an interview, E1 and E5 acknowledged E4's personnel record did not contain documentation of current CPR and first aid training certification.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was prepared at least one week in advance, posted in a location easily seen by the residents, updated as necessary to reflect substitutions, and maintained for at least 12 months after the last scheduled activity.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer did not observe a posted calendar of planned activities.

2. In an interview, E1 reported there was no calendar of planned activities. E1 and E5 acknowledged the manager failed to ensure a calendar of planned activities was prepared at least one week in advance, posted in a location easily seen by the residents, updated as necessary to reflect substitutions, and maintained for at least 12 months after the last scheduled activity.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:

1. A review of facility documentation revealed a policy and procedure manual, dated February 3, 2020. The manual included several policies and procedures for medication administration, including "Medication Administration Authorization," and "Medication Statement." However, there was no documentation to indicate the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

2. In an interview, E1 and E5 acknowledged the policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served.

Findings include:

1. During the enviromental inspection of the facility, the Compliance Officer observed a conspicuously-posted food menu dated August 2023. No additional food menu was available for review.

2. In an interview, E1 and E5 acknowledged the manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served.

Based on observation and interview, the manager failed to ensure each sleeping area not furnished by a resident had a bed frame, for one of eight total residents.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R3's bedroom. The bedroom contained a bed consisting of a box spring foundation and a mattress. However, the bed did not have a frame.

2. In an interview, E2 reported R3's family did not want R3 to have a bed frame because R3 would fall out of bed. E1 and E5 acknowledged the manager failed to ensure each sleeping area not furnished by a resident had a bed frame.