ALOHA ASSISTED LIVING LLC

Based on documentation review, and interview, a manager failed to implement policies and procedures to protect the health and safety of a resident that covered methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center is authorized to provide.

Findings Include:

1. A review of facility documentation revealed a policy titled "Wandering Policy." The policy states "Residents who wander place their health and safety at risk if they should leave and get lost. All personnel will make every attempt to keep residents from wandering away from the facility by: Following the steps outlined in this procedure. ...10. If a resident does wander from the facility and is not located immediately the following measures will be taken....B. notify local law enforcement of the lost resident....D. Provide sufficient personnel to search the neighborhood door to door resolution.

2. A review of facility documentation incident report dated October 11, 2024 at 7:00 PM. The incident report revealed [...R1 stepped out of the home to walk around the neighborhood around 7:00 PM and R1 was not able to find their way back to the facility. The facility called the police station and patrol cars to go look for R1, R1 was located on Mckellips Rd and was returned back to the facility at 10:00 PM.] A review of incident report revealed another incident report dated October 12, 2024 at 6:30 PM. The incident report revealed [...R1 left the facility at 5:11 PM and came back after 30 minutes. R1 then left the facility again at 6:30 PM saying R1 needed to go to the barber shop and R1 did not return to the facility, the facility reported R1 missing to the police station. R1 was found on almost on the freeway and was returned to the 9:10 PM.] The facility documentation incident report does not indicate if the staff at the facility went door to door to locate R1.

3. In an interview, E1 and E5 reported facility staff allowed R1 to leave the facility unsupervised twice. E1 and E5 acknowledge the facility did not report the missing resident to law enforcement immediately and did not provide sufficient personnel to search the neighborhood door to door resolution. E1 and E5 reported R1 had issues with leaving the other facility they were at and R1 was place at this current facility.

Based on documentation review, observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as E4 was not qualified to provide the required services unsupervised.

Findings include:

1. Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(49) states "[s]upervision" means "directly overseeing and inspecting the act of accomplishing a function or activity."

2. During the environmental inspection of the facility, the Compliance Officers observed E4 working at the facility and providing direct services to R4 without being under the direct supervision of a caregiver or manager.

3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver. There was no documentation in E4's personnel record to indicate E4 completed an approved caregiver training program.

4. In an interview, E1 and E5 acknowledged E4 was an assistant caregiver and E4 provided services to residents without being under the direct supervision of a caregiver or manager.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for one former resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for the sampled resident.

Findings include:

1. A.R.S. \'a7 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider."

2. The Compliance Officer requested R1's record for review. However, R1's medical record was not provided.

3. In an interview, E1 and E4 reported R1's medical record was unavailable for review at the time of the survey.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented for ensuring the safety of a resident who may wander.

Findings Include:

1. A review of facility documentation revealed a policy titled "Wandering Policy." The policy states "Residents who wander place their health and safety at risk if they should leave and get lost. All personnel will make every attempt to keep residents from wandering away from the facility by: Following the steps outlined in this procedure. ...10. If a resident does wander from the facility and is not located immediately the following measures will be taken....B. notify local law enforcement of the lost resident....D. Provide sufficient personnel to search the neighborhood door to door resolution.

2. A review of facility documentation incident report dated October 11, 2024 at 7:00 PM. The incident report revealed [...R1 stepped out of the home to walk around the neighborhood around 7:00 PM and R1 was not able to find their way back to the facility. The facility called the police station and patrol cars to go look for R1, R1 was located on Mckellips Rd and was returned back to the facility at 10:00 PM.] A review of incident report revealed another incident report dated October 12, 2024 at 6:30 PM. The incident report revealed [...R1 left the facility at 5:11 PM and came back after 30 minutes. R1 then left the facility again at 6:30 PM saying R1 needed to go to the barber shop and R1 did not return to the facility, the facility reported R1 missing to the police station. R1 was found on almost on the freeway and was returned to the 9:10 PM.] The facility documentation incident report does not indicate if the staff at the facility when door to door to located R1.

3. In an interview, E1 and E5 reported facility staff allowed R1 to leave the facility unsupervised twice. E1 and E5 acknowledge the facility did not report the missing resident to law enforcement immediately and did not provide sufficient personnel to search the neighborhood door to door resolution. E1 and E5 reported R1 had issues with leaving the other facility they were at and R1 was place at this current facility.

Based on record review and interview, the manager failed to ensure a written service plan for a resident receiving directed care services was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services.

Findings include:

1. A review of R1's medical record revealed a written service plan for directed care services, dated March 11, 2023. However, a more recent service plan was not available for review.

2. In a joint interview, E2 and E3 acknowledged R1's service plan was not reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of two residents sampled.

Findings include:

1. A review of R1's medical record revealed a written service plan for directed care services, dated March 11, 2023. The service plan included a section titled "BATHING," which indicated R1 was to receive assistance with "Shower: 3X per week, Wash hair: 3X week."

2. Further review of R1's medical record revealed documents titled "Activities of Daily Living" (ADL) for June 2023. A column on the left side of R1's June ADL stated, "Shower per week: 2x, Hair was [sic] per week: 1x, Full assistance." The document revealed R1 received assistance with showering on June 1-3, 8, 15, 21, 24, and 29, 2023. The document indicated R1 received assistance with hair washing on June 1, 8, 15, 21, 24, and 29, 2023. However, documentation showing R1 received assistance with "Shower" and "Wash hair" three times per week as specified in R1's service plan was not available for review.

3. In an interview, E3 reported R1 often refused assistance with showering. E3 reported R1 received assistance with showering at least once a week, and R1's hair was usually washed when R1 was showered. E3 acknowledged R1 was not provided with services as specified in R1's service plan.

4. A review of R2's medical record revealed a written service plan for personal care services, dated March 30, 2023. The service plan included a section titled "BATHING," which indicated R1 was to receive assistance with "Shower: 3X per week, Wash hair: 3X per week."

5. Further review of R2's medical record revealed documents titled "Activities of Daily Living" (ADL) for June 2023. A column on the left side of R2's June ADL stated, "Shower per week: 2x, Hair was [sic] per week: 2x, assistance." The document revealed R2 received assistance with showering and washing hair on June 1, 6, 8, 17, 22, 24, 27, and 30, 2023. However, documentation showing R2 received assistance with "Shower" and "Wash hair" three times per week as specified in R2's service plan was not available for review.

6. In an interview, E3 reported R2 received assistance showering twice per week. E3 reported R2 received assistance washing R2's hair each time R2 was showered. E3 acknowledged R2 was not provided with services as specified in R2's service plan.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled.

Findings include:

1. A review of R1's medical record revealed a written service plan was not available for review. Based on R1's date of acceptance, this documentation was required.

2. In an interview, E1 acknowledged a service plan had not yet been completed for R1. E1 acknowledged a written service plan was not completed within 14 calendar days of R1's date of acceptance.

Based on documentation review, observation, and interview, the manager of an assisted living facility authorized to provide directed care services failed to implement policies and procedures to ensure the safety of a resident who may wander.

Findings include:

1. A review of Department documentation revealed AL11576 was authorized to provide directed care services.

2. A review of the facility's policies and procedures revealed a policy titled "Wandering Policy". The policy stated: "Residents who wander place their health and safety at risk if they should leave the facility and get lost. All personnel will make every attempt to keep residents from wandering away from the facility by following the steps outlined in this procedure...4. Ensure the security of locks on all exits of the building always [sic]. 5. Ensure any alarms used on doors and/or windows are operational at the start of each shift..."

3. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the dining area out to the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the back yard allowed residents to be at least 30 feet away from the facility. The Compliance Officer also observed an unlocked gate in the back yard which opened to an alleyway, which led to a church parking lot. The church parking lot was bordered by busy roads on the South and West sides.

4. In an interview, E2 reported R1 has attempted to leave the facility and return to R1's previous residence multiple times since arriving at the facility. E2 reported on one occasion, E2 finished using the bathroom and came out to find R1 had wandered out of the facility, but E2 was able to quickly locate R1. E2 reported the alert mechanism on the door into the back yard stopped working the morning of the inspection. E2 reported E2 was not aware the gate in the back yard needed to be locked.

5. In an interview, E1 acknowledged policies and procedures were not implemented to ensure the safety of a resident who may wander.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the 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, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from the dining area out to the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the back yard allowed residents to be at least 30 feet away from the facility. The Compliance Officer also observed an unlocked gate in the back yard which opened to an alleyway, which led to a church parking lot. The church parking lot was bordered by busy roads on the South and West sides.

3. In an interview, E1 acknowledged the device to alert employees of the egress of a resident from the facility to the outside area through the back door was not in working order. E1 also acknowledged the gate in the facility's back yard did not control or alert employees of the egress of a resident from the facility. E1 acknowledged the back door and back yard gate were not controlled and did not alert employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure policies and procedures covering termination of residency, including termination initiated by the manager of an assisted living facility, were implemented.

Findings include:

1. A review of facility policies and procedures revealed a policy titled, "Termination of Residency" which stated, "The manager may terminate residency of residents as follows...2. With 14 calendar days written notice of termination of residency. A. For non-payment of fees, charges, or deposits..."

2. In an email received by the Department on December 21, 2022, E1 provided documentation of the written termination notice sent to R1's power of attorney (POA). The email stated, "In keeping with Mercy Care we are herby [sic] submitting to you a notice of 14 day termination of residency. We have been consistently unable to collect rents until after the 10th of the month. Mercy Care makes it very clear that rents not paid by the 10th of each month are eligible for a 14 day termination of residency. You have 14 days to find a new place of residence. We expect the room to be vacated by 9/24/2022." The email was sent to R1's power of attorney on September 12, 2022 at 11:02 AM, and therefore did not provide the resident the 14 calendar days required by the facility's policies and procedures on termination of residency. The email notice only allowed 12 calendar days for the resident to vacate the room.

3. In an interview, E1 reported R1's residency was terminated for consistent non-payment of fees. E1 reported R1's POA was given a verbal 14 day termination notice on September 10, 2022. However, E1 acknowledged the facility's written notice did not provide R1 with 14 calendar days to vacate the facility, as was required by facility policies and procedures covering termination of residency initiated by the manager of an assisted living facility.

Based on record review and interview, the manager failed to provide a 14-calendar-day written notice of termination of residency when terminating a resident for nonpayment of fees, charges, or deposit, for one of one discharged residents sampled.

Findings include:

1. A review of facility policies and procedures revealed a policy titled, "Termination of Residency" which stated, "The manager may terminate residency of residents as follows...2. With 14 calendar days written notice of termination of residency. A. For non-payment of fees, charges, or deposits..."

2. In an email received by the Department on December 21, 2022, E1 provided documentation of the written termination notice sent to R1's power of attorney (POA). The email stated, "In keeping with Mercy Care we are herby [sic] submitting to you a notice of 14 day termination of residency. We have been consistently unable to collect rents until after the 10th of the month. Mercy Care makes it very clear that rents not paid by the 10th of each month are eligible for a 14 day termination of residency. You have 14 days to find a new place of residence. We expect the room to be vacated by 9/24/2022." The email was sent to R1's power of attorney on September 12, 2022 at 11:02 AM, and therefore did not provide the resident the 14 calendar days required by the facility's policies and procedures on termination of residency. The email notice only allowed 12 calendar days for the resident to vacate the room.

3. In an interview, E1 reported R1's residency was terminated for consistent non-payment of fees. E1 reported R1's POA was given a verbal 14 day termination notice on September 10, 2022. However, E1 acknowledged the facility's written notice did not provide R1 with 14 calendar days to vacate the facility.

Based on documentation review and interview, the manager failed to ensure the written notice of termination of residency in subsection (G) included the policy for refunding fees, charges, or deposits, the deposition of a resident's fees, charges, and deposits; and contact information for the State Long-Term Care Ombudsman.

Findings include:

1. In an email received by the Department on December 21, 2022, E1 provided documentation of the written termination notice sent to R1's power of attorney (POA) on September 12, 2022 at 11:02 AM. The email stated, "In keeping with Mercy Care we are herby [sic] submitting to you a notice of 14 day termination of residency. We have been consistently unable to collect rents until after the 10th of the month. Mercy Care makes it very clear that rents not paid by the 10th of each month are eligible for a 14 day termination of residency. You have 14 days to find a new place of residence. We expect the room to be vacated by 9/24/2022." However, the email did not include the following information:
-The policy for refunding fees, charges, or deposits;
-The deposition of a resident's fees, charges, and deposits; and
-Contact information for the State Long-Term Care Ombudsman.

2. In an interview, E1 reported the email was the only written notice provided to R1's POA regarding R1's termination of residency. E1 reported R1 and R1's POA were already given the above information when R1 moved in and was not aware the information had to be included in written termination notices. E1 acknowledged the manager failed to ensure the written notice of termination of residency in subsection (G) included the policy for refunding fees, charges, or deposits, the deposition of a resident's fees, charges, and deposits; and contact information for the State Long-Term Care Ombudsman.

Based on record review and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of two residents sampled.

Findings include:

1. A review of R2's medical record revealed a signed medication order, dated August 10, 2022, for "Bumetanide 1 mg (milligram) p.o. QD." Further review of R2's medical record revealed an "encounter note", electronically signed by a medical practitioner on November 23, 2022. The note stated, "Continues to have [condition] so will increase Bumex from 1mg to 2mg."

2. A review of R2's medical record revealed a medication administration record (MAR) for December 2022. The entry for Bumetanide on the MAR was changed with pen several times. The initial text on the MAR stated, "Bumetanide 1 MG Take 1 Tab PO Twice Daily With Breakfast and Dinner." However, "1 mg" was crossed out with black pen, and "2 mg" was written instead, and "and Dinner" was also crossed out with black pen. On the side of the MAR were two notes written in pen stating "Changed to 3 MG 12/2/22" and "Changed to 4 MG 12/10/22." R2's MAR indicated R2 was administered Bumetanide at 8:00 AM from December 1-9, 2022, and at 8:00 AM and 2:00 PM from December 10-21, 2022.

3. In an interview, E1 reported the dosage for R2's Bumetanide was increased from 2 MG to 3 MG on December 2, 2022. E1 further reported the dosage was increased again to 4 MG on December 10, 2022, with 2 MG administered at 8:00 AM and 2 MG administered at 2:00 PM. E1 reported E1 believed medication change orders existed for these dosage increases, but acknowledged the orders were not available for review and the medication was not administered in compliance with the most recent documented medication order available.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the residents medical record, for two of two residents sampled.

Findings include:

1. A review of facility policies and procedures revealed a policy titled "Medication Refusal" which stated, "Medication refused by resident or medication not given for other reasons will be circled and initialed in the MAR by trained caregiver. Reasons for not giving medication will be documented in the MAR ..."

2. A review of R1's medical record revealed a medication order dated May 25, 2022 for the following:
"-Senna-Plus 8.6 MG (milligrams) - Take 2 Tabs PO every night at bedtime;
-Trazadone 50 MG - Take 1 Tab PO at bedtime;
-Hydroxyzine 10 MG - Take 1 Tab PO 3x daily;
-Terazosin 1 MG - Take 1 cap PO once daily;
-Eliquis 5 MG - Give 1 Tab PO twice daily;
-Gabapentin 300 MG - Take 1 Capsule by mouth twice daily;
-Hydralazine 25 MG - Give 1 Tab PO Q 8 HRS, hold if SBP 130 or below;
-Irbesartan 300 MG - Take one tablet by mouth once daily, hold if SBP