SOUTHWEST COMFORT CARE, LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident to cover methods by which the assisted living facility 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 facility was authorized to provide. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees..

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Whereabouts of Residents" dated January 16, 2024. However, the policy and procedure was not based on the level of assisted living services provided to the residents.

2. In an interview, E2 acknowledged the policy and procedure was not based on the level of assisted living services provided to the residents.

This is an uncorrected citation from the complaint inspection conducted on February 8, 2024.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan.

Findings include:

1. A review of R1's medical record revealed a service plan dated July 10, 2024, and a second service plan dated October 10, 2024. Both service plans indicated R1 was to receive a shower two times per week. The review further revealed documentation of assisted living services (ADLs) provided to R1 in October 2024. The ADLs revealed R1 received a shower on October 2, 2024, and R1 did not receive a shower on any other day in October 2024.

2. In an interview, E3 stated, "[R1] showers [R1's] self." When the Compliance Officer asked if R1 received only one shower from facility personnel in October 2024, E3 stated, "Yes."

This is an uncorrected citation from the complaint inspection conducted on February 8, 2024.

Based on documentation review, observation, and interview, the manager failed to ensure 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 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 egress of a resident 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 Officers observed sliding glass doors in each of the three bedrooms with direct access to the outdoors. The Compliance Officers observed two of the doors did not have alerts or controls installed. The Compliance Officers observed the third door did not have a control installed but did have an alert installed. However, upon opening each of the three doors, the Compliance Officers heard no alert.

3. In a series of interviews, E4 stated, "It 's not working" when referring to the installed alert in one of the three bedrooms. E4 reported alerts were installed on all exterior doors after the last inspection but the residents pulled them off. E2 stated, "I know these doors are very important."

This is an uncorrected citation from the complaint inspection conducted on February 8, 2024, and a repeat citation from the compliance inspection conducted on May 15, 2023.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R1's medical record revealed a current service plan which indicated R1 was to receive medication administration. The review revealed a medication order for "WIXELA INHUB FLUTICASONE PROIONATE [ sic ] AND SALMETEROL INHALATION POWDER 100/50 72.5 MCG PO BID" dated September 5, 2024. The review further revealed a medication administration record (MAR) dated October 2024 which indicated R1 received Wixela on October 1, 2024, and R1 did not receive Wixela on any other day in October 2024.

2. The Compliance Officers observed R1's Wixela.

3. In an interview, E4 reported believing R1's Wixela was on an "as needed" basis. E4 reported R1's physician wanted to discontinue the medication but had not done so as of the time of the inspection. When the Compliance Officer asked if R1 received R1's Wixela after October 1, 2024, E4 stated, "No."

4. A review of R2's medical record revealed a current service plan which indicated R2 was to receive medication administration. The review revealed a MAR dated October 2024 which indicated R2 received medication administration on October 4-14, 2024. However, the review revealed no medication orders for any of the 11 administered medications.

5. In an interview, E4 confirmed R2 received medication administration. E4 acknowledged R2 did not have medication orders.

6. In a separate interview conducted at approximately 1:00 PM, E3 stated, "Some of [the residents] have not taken [the residents'] morning meds yet." E3 stated R1 and R3 were supposed to have taken medications "before breakfast" and on "empty stomach."

This is an uncorrected citation from the complaint inspection conducted on February 8, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "MEDICATIONS SERVICES" dated January 16, 2024. The policy stated, "The caregiver will initial in the MAR for the date and time the medication was given to the resident and the medication taken." The policy and procedure continued: "Medication administration records will be filled by the authorized personnel that are doing medication administration and/or assisting in self-medication administration only after observing the resident taking the medication. Time and date will be recorded as well as the initials of the person that administered the medication."

2. A review of R2's medical record revealed a medication administration record (MAR) dated October 2024. The MAR revealed no medication was documented as administered the morning of the inspection, October 15, 2024.

3. In an interview, E3 and E4 reported R2 had received R2's medication the morning of the inspection but it had not been documented.

4. A review of R7's medical record revealed a MAR dated October 2024 which indicated R7 received R7's Tuesday, Thursday, and Saturday lunchtime medications at 12:00 PM. The review further revealed R7 received insulin on October 16, 2024, one day in the future.

5. In an interview, E3 reported R7 was not at the facility on Tuesdays, Thursdays, and Saturdays at 12:00 PM due to regularly scheduled medical appointments. E3 reported E3 gave R7 the Tuesday, Thursday, and Saturday lunchtime medications at 2:30 PM when R7 arrived back at the facility. E3 reported E3 documented the administration at 12:00 PM on those days instead of at 2:30 PM when the medications were actually administered. Regarding documenting the administration of R7's insulin in the future, E3 stated, "I just made a mistake."

This is an uncorrected citation from the complaint inspection conducted on February 8, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to cover methods by which the assisted living facility 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 facility was authorized to provide. The deficient practice posed a risk as the facility was unaware of the whereabouts of a resident for more than one month.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Whereabouts of Residents" dated January 16, 2024. The policy and procedure was not based on the level of assisted living services provided to the residents. The policy and procedure stated: "A. Wandering or eloping residents who have left the facility without required supervision; should do the following to ensure the continued safety of a resident who may wander...6. Contact hospitals, shelters, jails and bus stations during the search to assist in locating the resident."

2. In an interview, E3 reported R3 left the facility on January 2, 2024, and never came back.

3. A review of R3's medical record revealed "CAREGIVER NOTES" dated January 2, 2024. The notes revealed the following:
-R3 requested to go to the Veterans Affairs Medical Center (VA) to pick up R3's car;
-R3 and the "main caregiver" (no name given) got into a disagreement regarding whether R3 should drive where R3 was "screaming and [scaring] the resident[s]";
-The "main caregiver" drove R3 to the VA;
-R3 and the "main caregiver" drove back to the facility in separate vehicles; and
-Several hours after returning to the facility, R3 told facility personnel R3 was leaving and would return, left R3's phone number, and left the facility in R3's car.

4. A review of facility documentation revealed an incident report for R3 dated January 2, 2024, at 5:45 PM. The incident report stated: "[R3] came back to Southwest [Comfort Care, LLC], but left after [a] few minutes. [R3] said [R3] will come back tomorrow, if [R3 doesn't] come back we can call [R3's] cell phone...We talked to [R3] to make sure [R3] will come back, [R3] said [R3] will, [R3] just need to pay [R3's] rental (room) and will be back."

5. In an interview, E3 reported E3 called E1, R3, the police, and the VA shortly after R3 left. E3 reported E3 did not call hospitals (other than the VA), shelters, jails, or bus stations as required per policy and procedure. E3 reported E3 did not know where R3 was at the time of the inspection, more than one month after the elopement.

6. In a telephonic interview, E1 reported E1 called the police, the referral agency that referred R3 to the facility, and the VA shortly after E1 was notified of R3's absence. E1 reported E1 did not call hospitals (other than the VA), shelters, jails, or bus stations as required per policy and procedure. E1 reported E1 did not know where R3 was at the time of the isnpection, more than one month after the elopement. The Compliance Officer requested E1 contact hospitals other than the VA, shelters, jails, and bus stations as required per policy and procedure, as well as the police to follow up on the original report.

7. In a text message received on February 8, 2024, at 7:50 PM, E1 stated, "I got a hold of [R3]. [R3] is living in a trailer in [city]...[R3] said [R3] is fine and will call me if [R3] ever needs anything."

Based on observation, documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee or volunteer, for four of four employees or volunteers sampled. The deficient practice posed a risk as required information could not be verified.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed several time cards in a holder on the wall in the office.

2. A review of facility documentation revealed the time cards belonged to E5, E6, E7, and E9. The timecards revealed the following:
-E5 worked on February 1 and 5-7, 2024;
-E6 worked on February 4, 2024;
-E7 worked on February 3, 2024; and
-E9 worked on January 12, 2024.

The review further revealed a personnel schedule dated February 2024. The schedule revealed E5 worked on February 1, and 5-7, 2024, and E6 worked on February 4, 2024. The schedules did not include E7 and E9.

3. In an interview, E3 reported E5 was a caregiver and E6 and E7 were volunteers. E3 reported E9 no longer worked at the facility.

4. A review of facility personnel records revealed no personnel records for E5, E6, E7, and E9.

5. In an interview, E3 stated, "[E6 and E7] just started" and "We're training [E6 and E7]." E3 acknowledged the facility did not have personnel records for E5, E6, E7, and E9 available for review at the time of the inspection.

Based on observation, record review and interview, the manager accepted and retained an individual whose primary condition for which the individual needed assisted living services was a behavioral health issue, for one of one applicable resident. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R1 walking around the house without assistance.

2. A review of R1's medical record revealed a current service plan. The plan stated "[R1's] Medical/Behavioral Hx" included "Psychotic disorder." The service plan revealed R1 did not receive assistance with bathing, oral care, shaving, dressing, toileting, ambulation, or transferring. The review revealed a "MENTAL HEALTH DISCHARGE NOTE" from the Phoenix Veterans Affairs Medical Center (VA). The note included a reminder for R1 to attend a "post hospital psychiatry appointment" as well as information regarding the purposes of R1's medication, including "TO STABILIZE MOOD," "FOR PSYCHOTIC DISORDER," and "FOR...INSOMNIA [and] ANXIETY."

3. In an interview, R1 reported R1 did not need assisted living services. R1 reported R1 heard about this facility from a friend and needed a place to live after leaving the VA. In a later interview when the Compliance Officer asked if facility personnel combed R1's hair, R1 stated, "No. I don't want people touching me."

4. In a separate interview, when the Compliance Officer asked if facility personnel combed R1's hair daily, E3 stated, "No. [R1] doesn't want to be touched." E3 reported R1 only received medication services and did not receive any other physical health services.

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

Findings include:

1. A review of R1's medical record revealed a service plan dated December 10, 2023. The service plan indicated R1 was to receive hair care daily in the form of "Comb Hair."

2. In an interview, when the Compliance Officer asked if facility personnel combed R1's hair daily, R1 stated, "No. I don't want people touching me."

3. In a separate interview, when the Compliance Officer asked if facility personnel combed R1's hair daily, E3 stated, "No. [R1] doesn't want to be touched."

Based on documentation review, observation, and interview, the manager failed to ensure 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 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 egress of a resident 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 sliding glass doors in each of the three bedrooms with direct access to the outdoors. The Compliance Officer observed two of the doors did not have alerts or controls installed. The Compliance Officer observed the third door had half of the alert installed, but did not have the accompanying magnet, rendering the alert inoperable. Upon opening each of the three doors, the Compliance Officer heard no alert.

3. In an interview, when the Compliance Officer asked if the doors alerted caregivers, E3 stated, "No."

This is a repeat citation from the compliance inspection conducted on May 15, 2023.

Based on observation, interview, and record review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R1 hand a small cup to one of the caregivers. As R1 was handing over the small cup, R1 stated, "Last night I fell asleep and didn't get to take these."

2. The Compliance Officer observed the cup contained medication. The Compliance Officer also observed R1's medication bottles. A comparison between the small cup and R1's medication bottles revealed the small cup contained one 100 mg (milligrams) capsule of "Benzonatate," one 5 mg tablet of "Fluphenazine Hydrochloride," and one 50 mg tablet of "Hydroxyzine Hydrochloride."

3. A review of R1's medical record revealed a current service plan which indicated R1 was to receive medication administration. The review revealed a medication order for "Benzonatate 100 MG...1 capsule as needed Orally Three times a day" dated February 5, 2024, and a medication order for "Fluphenazine HCL 5 mg po tid" and "Hydroxyzine HCL 50 mg po tid PRN" dated November 17, 2023.

4. A review of R1's medical record revealed a medication administration record dated February 2024. However, the two "as needed" medications nor the scheduled medication were documented as administered the night before the inspection or the day of the inspection.

5. In an interview, E3 reported the medication in the small cup was R1's lunchtime medication, not R1's nighttime medication from the night before the inspection. E3 acknowledged R1 did not receive R1's medication in compliance with a medication order.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for nine of nine total residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "MEDICATIONS SERVICES" dated January 16, 2024. The policy stated: "Medication administration records will be filled by the authorized personnel that are doing medication administration and/or assisting in self-medication administration only after observing the resident taking the medication. Time and date will be recorded as well as the initials of the person that administered the medication."

2. A review of resident medical records revealed medication administration records (MARs) for all nine residents dated February 2024. The review revealed some scheduled medication was not documented as administered on February 7, 2024, and most scheduled medication was not documented as administered on February 8, 2024. Apart from two medications for R9 signed as administered by E4 on February 1, 2024, all other instances of medication administration (at 6:00 AM, 7:00 AM, 8:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 5:00 PM, 7:00 PM, and 8:00 PM) were signed by E3 from February 1-8, 2024.

3. A review of facility documentation revealed a personnel schedule dated February 2024. The schedule revealed E3 worked from 7:00 AM to 7:00 PM on February 1-8, 2024. Therefore, the schedule indicated E3 could not have administered medication at 6:00 AM or 8:00 PM.

4. In an interview, E4 reported having administered medication to R1 on February 7, 2024. When the Compliance Officer asked why E3 signed the MAR if E4 administered the medication, E3 reported it was E3's standard practice to sign the MAR when E3 placed the medication in the cup and placed the cup in the medication cabinet. E3 reported another caregiver then removed the prepared cup from the medication cabinet and administered the medication at a later time.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not provided during the inspection, and the licensee did not provided the documentation within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "A.R.S. 36-420. A.R.S. 36-420.01." dated October 1, 2021. The policy stated "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." However, the policy did not include initial training and continued competency training in fall prevention and fall recovery.

2. A review of E3's personnel record revealed no documentation of initial training or continued competency training in fall prevention and fall recovery available for review.

3. In a telephonic interview, E1 reported E3 did not complete fall prevention and fall recovery training. E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review, documentation review, and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of E3's personnel record revealed no documentation of E3's qualifications, including skills and knowledge applicable to E3's job duties, available for review.

2. A review of E3's personnel record revealed no documentation of E3's completed orientation available for review.

3. A review of R1's medical record revealed an undated document titled "PRE-ADMISSION DETERMINATION". The document stated "This facility does not accept residents who require the following: Please circle all that applies...Continuous medical services-hospital yes...no...Continuous nursing services- rehab/nursing homes...restraints (physical or medical) Intermittent nursing services (hospice, home health, PT, etc...) yes...no..." However, the document was blank, and R1's medical record did not contain documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant.

4. A review of R2's medical record revealed R2's signed residency agreement and any amendment per R9-10-811
(C)(9), medication orders per R9-10-811(C)(12), and documentation of medication administered to the resident per R9-10-811(C)(13). However, the medical record did not contain the following:
-Resident information to include the resident's name, and the resident's date of birth;
-The names, addresses, and telephone numbers of the resident's primary care provider, other persons, such as a home health agency or hospice service agency, involved in the care of the resident, and an individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency;
-If applicable, the name and contact information of the resident's representative and the document signed by the resident consenting for the resident's representative to act on the resident's behalf, or if the resident's representative had a health care power of attorney established under A.R.S. \'a7 36-3221 or a mental health care power of attorney executed under A.R.S. \'a7 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or was a legal guardian, a copy of the court order establishing guardianship;
-The date of acceptance;
-Documentation of the resident's needs required in R9-10-807(B);
-Documentation of general consent and informed consent, if applicable;
-Documentation of freedom from infectious tuberculosis as required in R9-10-807(A);
-A copy of the resident's health care directive, if applicable;
-The resident's signed residency agreement and any amendments;
-The resident's service plan and updates;
-If applicable, documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;
-If applicable, documentation of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident;
-Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d);
-Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B);
-If a resident is receiving behavioral care, documentation of the determination in R9-10-812(3);
-If applicable, for a resident who is unable to direct self-care, the information required in R9-10-815(F);
-Documentation of any significant change in a resident's behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident's changing needs; and
-Documentation of the notification required in R9-10-803(G) if the resident is incapable of handling financial affairs.

5. A review of the facility's policies and procedures revealed a policy titled "A.R.S. 36-420. A.R.S. 36-420.01." dated October 1, 2021. The policy stated "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." However, the policy did not include initial training and continued competency training in fall prevention and fall recovery.

6. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

7. In an telephonic interview, E1 acknowledged documentation indicating compliance with the aforementioned requirements was not provided within two hours after a Department request

This is a repeat citation from the complaint inspection conducted on October 19, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of four personnel sampled. The deficient practice posed a risk if E3 was not qualified to provide the required services to residents, and the Department was provided false and misleading information.

Findings include:

1. A review of E3's personnel record revealed a caregiver training certificate from Assisted Living Training School (ALTP-0010) dated February 26, 2022.

2. A review of the NCIA Board website revealed the following information: "Verification of training certificate after August 2, 2013 can be checked at the following website: https://az.tmuniverse.com."

3. A review of "https://az.tmuniverse.com" revealed no evidence to indicate E3 completed a caregiver training program.

4. In an interview, E3 reported to be a volunteer. E3 reported E3 did not complete a caregiver training program. The Compliance Officer showed E3 the caregiver certificate, and E3 reported E3 did not complete the caregiver training program listed on the certificate.

5. In a telephonic interview, E1 reported E3 worked as an assistant caregiver. E1 reported E1 did not review E3's personnel file. E1 reported E1 did not know how the caregiver certificate was obtained, or why the caregiver certificate was in E3's file. E1 acknowledged the caregiver certificate was not valid.

Based on record review, documentation review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of four personnel records sampled. The deficient practice posed a risk if E3 was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel records did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-806(A)(4)(a) states: "A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services..."

2. A review of E3's personnel record revealed no documentation of E3's qualifications, including skills and knowledge applicable to E3's job duties, was available for review.

3. A review of the facility's policies and procedures revealed an undated policy titled "VERIFYING CAREGIVER'S SKILLS AND KNOWLEDGE." The policy stated "PROCEDURES: 1. All staff need to be trained and their skills and knowledge verified prior to staff providing assistance with new equipment or procedures."

4. In a telephonic interview, E1 reported to have skills and knowledge documentation for E3, however, the documentation was not in E3's personnel record. E1 acknowledged documentation of E3's verified skills and knowledge was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of four personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the personnel record did not include the documentation during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-101(153) states "Orientation" means: "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution."

2. A review of E3's personnel record revealed no documentation of E3's completed orientation available for review.

3. A review of the facility's policies and procedures revealed an undated policy titled "ORIENTATION, IN-SERVICE TRAININGS FOR EMPLOYEES." The policy stated "POLICY: The Manager (or designee) is responsible for the training and orientation of all employees to enable them to perform the responsibilities of their jobs in an effective and efficient manner."

4. In a telephonic interview, E1 reported E3 was hired as an assistant caregiver. E1 reported E3 had completed orientation, however, the documentation was not in E3's personnel record. E1 acknowledged documentation of E3's completed orientation was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed an undated document titled "PRE-ADMISSION DETERMINATION". The document stated "This facility does not accept residents who require the following: Please circle all that applies...Continuous medical services-hospital yes...no...Continuous nursing services- rehab/nursing homes...restraints (physical or medical) Intermittent nursing services (hospice, home health, PT, etc...) yes...no..." However, the document was blank, and R1's medical record did not contain documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant.

2. In a telephonic interview, E1 acknowledged R1 did not submit documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated an signed by a physician, registered nurse practitioner, registered nurse or physician assistant.

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. The deficient practice posed a risk as there was no service plan to direct the services to be provided to a resident, The deficient practice posed a risk if the facility was unable to meet a resident's needs, the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R2's medical record revealed a written service plan was not available for review. Based on R2's date of acceptance, this documentation was required.

2. In an interview, E1 acknowledged a service plan for R2 was not completed within 14 calendar days after R2's date of acceptance.

Based on observation, record review and interview, the manager failed to ensure a resident's medical record contained the information required in Arizona Administrative Code (A.A.C.) R9-10-811(C)(1)-(24), for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not provided during the inspection, and was not provided to the Department within two hours after a Department request.

Findings include:

1. A review of R2's medical record revealed R2's signed residency agreement and any amendment per A.A.C. R9-10-811(C)(9), medication orders per A.A.C. R9-10-811(C)(12), and documentation of medication administered to the resident per A.A.C. R9-10-811(C)(13). However, the medical record did not contain the following:
-Resident information to include the resident's name, and the resident's date of birth;
-The names, addresses, and telephone numbers of the resident's primary care provider, other persons, such as a home health agency or hospice service agency, involved in the care of the resident, and an individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency;
-If applicable, the name and contact information of the resident's representative and the document signed by the resident consenting for the resident's representative to act on the resident's behalf, or if the resident's representative had a health care power of attorney established under Arizona Revised Statutes (A.R.S.) \'a7 36-3221 or a mental health care power of attorney executed under A.R.S. \'a7 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or was a legal guardian, a copy of the court order establishing guardianship;
-The date of acceptance;
-Documentation of the resident's needs required in A.A.C. R9-10-807(B);
-Documentation of general consent and informed consent, if applicable;
-Documentation of freedom from infectious tuberculosis as required in A.A.C. R9-10-807(A);
-A copy of the resident's health care directive, if applicable;
-The resident's signed residency agreement and any amendments;
-The resident's service plan and updates;
-If applicable, documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;
-If applicable, documentation of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident;
-Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d);
-Documentation of the resident's orientation to exits from the assisted living facility required in A.A.C. R9-10-818(B);
-If a resident is receiving behavioral care, documentation of the determination in A.A.C. R9-10-812(3);
-If applicable, for a resident who is unable to direct self-care, the information required in A.A.C. R9-10-815(F);
-Documentation of any significant change in a resident's behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident's changing needs; and
-Documentation of the notification required in A.A.C. R9-10-803(G) if the resident is incapable of handling financial affairs.

2. In a telephonic interview, E1 reported E1 is waiting for documents from R2's hospice care provider. E1 acknowledged R2's medical record did not contain the applicable information required in A.A.C. R9-10-811(C)(1)-(24).

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does 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. The deficient practice posed a risk if the facility was unaware of a resident's general or specific whereabouts.

Findings include:

1. A review of the facility's policies and procedures revealed an undated policy titled "WANDERING/ELOPEMENT". The policy stated "...5. Exit doors in the facility that are not wired for the wanderguard system may be equipped with delayed eggress with an alarm that will sound if a resident exits through the door..."

2. A review of Department documentation revealed AL11681 was authorized to provide directed care services.

3. During the environmental inspection of the facility, the Compliance Officer observed R2's bedroom contained a door leading out to the back yard. The Compliance Officer observed the outside area, in the back yard, allowed residents to be a least 30 feet away from the facility. The Compliance Officer observed the outside area contained two locked gates. The door leading to the outside area contain an alarm, however, the alarm was switched to "off" and did not control or alert employees of egress when the door leading out to the back yard was opened.

4. During the environmental inspection of the facility, the Compliance Officer observed a back door leading out to the back yard from the kitchen area. The Compliance Officer observed the outside area, in the back yard, allowed residents to be a least 30 feet away from the facility. The Compliance Officer observed the outside area contained two locked gates. The door leading to the outside area contain an alarm, however, the alarm was switched to "off" and did not control or alert employees of egress when the door leading out to the back yard was opened.

5. In a telephonic interview, E1 acknowledged the doors leading to the outside area did not control or alert employees of the egress of a resident.