BROOKDALE NORTH GLENDALE

Based on record review and interview, the manager failed to ensure a personnel record for two of four employees sampled included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C), to include verification of the current status of the employee's fingerprint clearance card.

Findings include:

A.R.S. \'a7 36-411
C. Owners shall make documented, good faith efforts to:
2. Verify the current status of a person's fingerprint clearance card.

1. Review of E1's and E4's personnel records revealed no documentation to demonstrate the verification of the current status of the employees' fingerprint clearance cards at their respective dates of hire.

2. Review of the Arizona Department of Public Safety Fingerprint Clearance Status website revealed E1 and E4 currently had valid fingerprint clearance cards.

3. In an interview, E1 acknowledged the documentation of compliance with A.R.S. \'a7 36-411(C) was missing.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of one discharge residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R3's medical record revealed a service plan for directed care services (dated in July 2023). The service plan stated the following service was to be provided to R3:
-"Preferred AM Care Time: Between 7 a.m. and 8 a.m.;"
-"Assist resident using the bathroom schedule: approximately every two to four hours during the day and as needed during the night."

2. A review of R3's medical record revealed activities of daily living (ADL) sheets for July 2023, August 2023, and September 2023. The ADL sheet stated "Signature indicates all ADL's have been completed in accordance to resident service plan." However, no initials were documented on the following dates and the following shifts:
-July 3, 2023, Days shift;
-July 7-8, 2023, Days shift;
-July 24, 2023, Days shift;
-July 31, 2023, Days shift;
-August 18, 2023, Days shift;
-August 21, 2023, Days shift;
-September 14-15, 2023, Evening shift; and
-September 16, 2023, Evening and Nights shift.

3. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees 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. The facility was licensed at the directed care level.

2. During a facility tour with E1 and E7, the Compliance Officers observed the back door leading to a gated courtyard. The door did not have a device to alert employees of the egress of a resident from the facility and was unlocked.

3. During an interview, E7 reported the facility locks the door if the external temperature is above 95 degrees, so did not think the facility needed a device to alert employees of the egress of a resident from the facility.

4. In an interview, E1 reported the facility has never had an alarm on that door and acknowledged residents access to an outside area did not alert the employees of the egress of a resident.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver immediately notified the resident's primary care provider.

Findings include:

R9-10-101.110. "Immediate" means without delay.

1. A review of facility documentation revealed a document titled "Completed AZ ALZ/DC Incident Report" (dated May 18, 2023 at approximately 7:20AM) for R3. The incident report stated " ... Fall, Unwitnessed ... Head Injury ... Injury with ER Treatment. ... Resident was sent to [hospital] ER per ... POA request." The report documented R3's primary care provider was notified at 9:00AM.

2. In an interview, E1 acknowledged a caregiver or assistant caregiver did not immediately notify the resident's primary care provider.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future.

Findings include:

1. A review of facility documentation revealed a document titled "Completed AZ ALZ/DC Incident Report" (dated May 18, 2023 at approximately 7:20AM) for R3. The incident report stated " ... Fall, Unwitnessed ... Head Injury ... Injury with ER Treatment. ... Resident was sent to [hospital] ER per ... POA request." However, documentation of actions taken to prevent the accident, emergency, or injury from occurring in the future was not available for review.

2. In an interview, E1 acknowledged a caregiver or assistant caregiver did not document any action taken to prevent the accident, emergency, or injury from occurring in the future.

Based on observation and interview, the manager failed to ensure a bathroom in two of two residential units sampled contained a window that opened or another means of ventilation.

Findings include:

1. During a tour of the facility, the Compliance Officers observed the bathrooms in R1's and R2's residential units did not contain windows that opened.

2. During a tour of the facility, the Compliance Officers observed ventilation fans in the bathrooms in R1's and R2's residential units. However, the fans were not in working order.

3. In an interview, E5 reported the belt for the ventilation fans in that section of the facility was broken and needed to be replaced.

4. In an interview, E1 acknowledged the bathrooms in the residential units did not contain a means of ventilation at the time of inspection.