BROOKDALE TANQUE VERDE

Based on 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 and cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four 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 the facility's policy and procedures for Cardiopulmonary Resuscitation (CPR), and First Aid Training revealed "Cardiopulmonary Resuscitation (CPR) and First Aid Training are required for Arizona nurses, caregivers, managers or volunteers who provides direct care to residents".

2. A review of E3's personnel record revealed E3 was hired as a caregiver in January 2024.

3. A review of E3'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.

4. A review of staff schedules from June 2024 until September 2024, revealed R3 was scheduled to work the 2:00 pm to 10:00 pm shift every Wednesday, Thursday, Friday, Saturday and Sunday.

No other documentation was provided while Compliance Officer was on-site.

5. In an interview, E1 acknowledged that E3's BLS card did not include first aid.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, for one of four sampled residents.

Findings include:

1. A review of R2's medical record revealed R2 was receiving services at the directed care level.

2. A review of R2's medical record revealed a service plan dated August 22, 2024, for directed care services. However, the service plan was not signed and dated by R2's representative.

3. In an interview, E1 acknowledged the service plan for R2 had not been signed and dated by the residents representative when the plan was updated as required.

Based on record review, documentation review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of the license issued by the Department revealed the facility was licensed at the directed care level.

2. During the environmental inspection the Compliance Officer observed when exiting from the hallway into the courtyard no alarm sounded to alert employees of a resident's egress. The Compliance Officer observed a total of three doors exiting into the courtyard all three doors when opened did not alert employees of a resident's egress.

3. During an interview, E1, acknowledged the doors did not alert employees of a resident's egress.

Based on documentation review, and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months and includes all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted.

Findings include:

1. A review of the facility's documentation revealed an evacuation drills for employees and residents were conducted on January 26, 2024, and on July 30, 2024. However no documentation was available for review that included all individuals on the premises, and no documentation provided that included a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident.

2. In an interview, E1 acknowledged no documentation was available for review that included all individuals on the premises, and no documentation provided that included a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident.

Technical assistance was provided during the on-site compliance inspection conducted on August 1, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when initially developed and when updated, for two of four residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated May 15, 2023, for personnel care services. However, the service plan was not signed and dated by R1 or R1's representative.

2. A review of documentation revealed on May 17, 2023, a letter was emailed to O2 R1's representative along with R1's service plan asking to please sign the document. However, the document had not been signed on August 1, 2023, while the Compliance Officer reviewed the service plan. No other documentation was provided to show a good faith attempted was made to get the document signed.

3. A review of R2's medical record revealed a service plan dated March 1, 2023, for directed care services. However, the service plan was not signed and dated by the manager.

4. In an interview, E1 acknowledged the service plans provided for R1 and R2 had not been signed and dated by R1's representative, and R2's service plan had not been signed and dated by the manager.

Based on documentation review, and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

Findings include:

A.A.C. R9-10-818.A.3. states, "A manager shall ensure that documentation of the disaster plan review required in subsection (A)(2) includes:

a. The date and time of the disaster plan review;
b. The name of each employee or volunteer participating
in the disaster plan review;
c. A critique of the disaster plan review; and
d. If applicable, recommendations for improvement"

1. A review of facility documentation revealed no evidence of an annual disaster plan review.

2. In an interview, E1 acknowledged an annual disaster plan review was not available for review.