KOZY GARDENS ASSISTED LIVING LLC

<p>Based on documentation review, observation, and interview, the governing authority failed to ensure that the Department was notified when there was a change in the manager. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. A review of Department documentation revealed E4 was listed as the facility manager. </p><p><br></p><p><br></p><p>2. During an inspection of the facility, the Compliance Officer observed E1’s manager's certificate posted within the facility, with an effective date of November 1, 2024.</p><p><br></p><p><br></p><p>3. In an interview, the findings were reviewed with E1, and E1 reported E1 became the manager on November 1, 2024 and thought the notification was made to the Department.</p>

<p>Based on record review and interview, the manager failed to ensure a personnel record for each employee included evidence of documentation outlined in R9-10-806(C)(1)(a-c) as required.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of E3’s personnel record revealed documentation of the following items was unavailable for review:</p><p><br></p><p><br></p><p>-documentation of E2’s skills and knowledge;</p><p>-current Cardiopulmonary resuscitation (CPR) training; and</p><p>-current First aid training.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 reported the documents exist; however, E1 was unable to locate them during the inspection.</p><p><br></p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged E2’s personnel record did not contain documentation of E2’s documented skills and knowledge, CPR training, and first aid training.</p>

Based on record review and interview, the manager failed to ensure a resident had a written service plan that was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition.

Findings include:

1. A review of R1's medical record revealed an initial service plan for directed care services, initiated on November 23, 2023. The service plan detailed limited assistance for fall risk. It stated R1 was independently mobile with the assistance of a walker.

2. A review of facility documentation revealed R1 was transported to the hospital after a syncope episode and resulted in a pacemaker being implanted on December 15, 2023.

3. A review of facility documentation revealed R1 suffered falls on December 27, 2023 and January 3, 2024. A review of the incident reports from December 27, 2023, revealed "Manager's Action Taken to Correct and/or Prevent Reoccurrence: - Requested home health to provide a walker to help keep resident stable due to his change in condition - Instructed staff to provide assistance to resident during movement until he is steady on his feet again - Check blood pressure twice a day before giving blood pressure medications".

3. A review of R1's medical record revealed no service plan update dated within 14 calendar days after R1's significant change in physical condition.

4. In an interview, E1 acknowledged R1's service plan was not updated within 14 calendar days after a significant change of condition.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager.

Findings include:

1. A review of Department documentation revealed E4 was no longer the licensed manager effective February 28, 2023.

2. In an interview, E1 reported E3 became the new manager on March 1, 2023.

3. A review of Department documentation revealed no evidence to indicate the governing authority notified the Department when there was a change in the manager.

4. In an interview, E1 acknowledged the facility did not notify the Department of a change in the facility's manager in March 2023.