THE GARDENS AT BLENMAN ELM

Based on documentation review, record review, and interview, the assisted living center failed to maintain a copy of the documentation provided to an emergency responder, for one of one sampled residents for whom an emergency responder had been contacted.

Findings include:

1. A review of R1's medical record revealed an incident report dated November 2, 2024. The incident report stated, "We found [R1] in bed struggling to breathe, move, or respond. Took vitals and tilted bed to help [R1] breathe. Continued to monitor and [R1's responsible party] came in and we agreed to call 911 due to oxygen being 86%."

2. A review of R1's medical record revealed R1 was hospitalized from November 2, 2024 until November 8, 2024.

3. A review of R1's medical record revealed a copy of any documentation given to the emergency responder on November 2, 2024 was not available for review.

4. In an interview, E1 acknowledged a copy of the documentation given to the emergency responder on November 2, 2024 for R1 was not provided for review.

Based on record review and interview, the manager failed to ensure, for one of one sampled resident receiving home health services, care instructions were documented in the resident's service plan.

Findings include:

1. A review of R1's medical record revealed a service plan, dated November 2, 2024, for directed care services. The service plan stated, "[R1] has several wounds on both right and left lower limbs upon admission and requires a pain pill to be administered prior to wound care twice a week." However, the service plan did not include any wound care instructions.

2. A review of R1's medical record revealed documentation of home health care instructions were not available for review.

3. During the on-site inspection, E1 contacted R1's home health agency and received a progress note dated November 15, 2024. This progress note stated, "The patient..seen today for multiple wounds in bilateral lower extremities that seconds to bullous lesions for almost 3 months and have since ruptured resulting in open wounds....Clean wound with NS or soapless cleanser and pat dry.: W#1,5,6: Clean wound with NS or wound cleanser, Pat dry, Apply Xeroform in the wound bed, cover with gauze and secure with tape. F/U with [wound care] provider every week. [wound care] provider to visit once weekly. HH to visit 2x-3x a week for dressing changes. PRN if soiled...Offload the wound and reposition per facility/agency protocol Q2 hrs and prn. Continue to monitor for symptoms and signs of infection and for worsening wound characteristics."

4. In an interview, E1 acknowledged R1's service plan did not include the care instructions provided to the facility by R2's home health agency.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-7), for two of two directed care residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan, dated November 2, 2024, for directed care services. However, the service plan did not include the following:
- Skin maintenance to prevent and treat bruises, injuries, pressure sores and infections per R9-10-814(F)(1);
- Offering sufficient fluids to maintain hydration per R9-10-814(F)(2);
- Cognitive stimulation and activities to maximize functioning;
- Documentation of the resident's weight; and
- Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

2. A review of R2's medical record revealed a service plan, dated November 20, 2024, for directed care services. However, the service plan did not include the following:
- Skin maintenance to prevent and treat bruises, injuries, pressure sores and infections per R9-10-814(F)(1);
- Cognitive stimulation and activities to maximize functioning;
- Documentation of the resident's weight; and
- Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

3. In an interview, E1 acknowledged the service plans provided for R1 and R2 had not included all of the requirements found in R9-10-815(C)(1-7).

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration.

Findings include:

1. A review of R1's medical record revealed a service plan, updated November 2, 2024, for directed care services including medication administration.

2. A review of R1's medical record revealed a prescription, dated November 7, 2024, which stated, "O2 (DME) Start Date: Nov 7, 2024, Length of need: Lifetime (99 months), Oxygen delivery method: Nasal Cannula...Oxygen flow rate (LPM): 2, Oxygen use: Continuous."

3. A review of R1's medical record revealed an electronic Medication Administration Record (eMAR) dated November, 2024. However, the eMAR did not document the administration of oxygen to R1 as ordered.

4. A review of R1's medical record revealed documentation of the administration of oxygen to R1, since November 7, 2024, was not available for review.

5. In an interview, E1 acknowledged the eMAR provided for R1 did not accurately document the medications administered to R1.

Based on record review and interview, the manager failed to ensure a resident was provided a diet that met the resident's nutritional needs as specified in the resident's service plan, for two of two sampled residents.

Findings include:

1. A review of R1's, and R2's service plans revealed a diet was not specified, to include a regular diet as applicable.

2. In an interview, E1 acknowledged the provided service plans did not specify the diet which would be provided to each resident to meet their nutritional needs.

Based on record review, documentation review, and interview, for two of three personnel records sampled, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services. The deficient practice posed a health and safety risk to residents, if a caregiver or assistant caregiver did not have the documented skills and knowledge to provide care and services for a resident.

Findings include:

1. A review of E2's personnel record revealed E2 was hired as an assistant caregiver in September of 2023.

2. A review of facility documentation revealed a policy and procedure titled, "Assistant Caregiver Job Descriptions, Duties, and Qualifications" (reviewed December 25, 2022). The job description stated, "Demonstrates the qualifications, skills, and knowledge required to provide assisted living services and/or behavioral care to a population of adults with various levels of physical, functional, and cognitive needs; (Please see Skill Verification Checklist completed by assistant caregiver, manager and or trainer)"

3. A review of E2's personnel record revealed the required skill verification checklist was not available for review.

4. A review of E3's personnel record revealed E3 was hired as a caregiver in August of 2023.

5. A review of facility documentation revealed a policy and procedure titled, "Caregiver Job Descriptions, Duties, and Qualifications" (reviewed December 25, 2022). The job description stated, "Demonstrates the qualifications, skills, and knowledge required to provide assisted living services and/or behavioral care to a population of adults with various levels of physical, functional, and cognitive needs; (Please see Skill Verification Checklist completed by caregiver, manager and or trainer)"

6. A review of E3's personnel record revealed a skill verification checklist titled, "Employee Skills and Knowledge Record." However, the checklist had only been completed by E3 and had not been completed or signed by the, "manager and or trainer," as required.

7. In an interview, E1 acknowledged the personnel records provided for E2 and E3 had not included documentation of verification and documentation of each employee's skills and knowledge according to the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three employees sampled.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."

3. A review of E2's personnel record revealed an assessment of risks of prior exposure to infection tuberculosis and a determination if E2 had signs or symptoms of tuberculosis was not available for review. Additionally, the second-step Mantoux skin test (TST) was administered one day after the first-step TST was determined to be negative, instead of one to three weeks later as recommended by the CDC.

4. A review of E3's personnel record revealed an assessment of risks of prior exposure to infection tuberculosis and a determination if E3 had signs or symptoms of tuberculosis was not available for review. Additionally, E3's second-step TST was located during the on-site inspection but was not present in E3's personnel record.

5. In an interview, E1 acknowledged E2 and E3 had not provided documentation of freedom from infectious TB as specified in R9-10-113.

Technical assistance for this rule was provided during the on-site compliance inspection conducted on November 14, 2023.

Based on record review, documentation review, and interview, the manager failed to ensure two of three personnel records sampled contained documentation indicating a caregiver or assistant caregiver received orientation before providing assisted living services to a resident.

Findings include:

1. A review of E2's personnel record revealed E2 was hired as an assistant caregiver in September of 2023.

2. A review of E2's personnel record revealed an orientation checklist. However, the checklist had not been filled out.

3. A review of E3's personnel record revealed E2 was hired as an caregiver in August of 2023.

4. A review of E3's personnel record revealed an orientation checklist. However, the checklist had not been filled out.

5. In an interview, E1 acknowledged the personnel records provided for E2 and E3 did not include documentation of orientation.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of two residents sampled.


Findings include:

1. A review of R2's medical record revealed a service plan, dated November 8, 2023, for personal care services. The service plan stated the following service would be provided to R2:
- "Diabetes: Blood Glucose Monitoring. Check blood sugars 2 x day. 1) Have [R2] wash hands prior to test 2) Caregiver to do finger stick using clean technique 3) Monitor each shift for symptoms, daily while awake, of low and high blood sugar: tiredness, weakness, headache, sweet smelling breath, sweating, shakiness, or slurred speech 4) If [R2] shows any of these symptoms, check blood sugar. If it is

Based on documentation review, record review, observation, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of CPR training, including a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of two sampled employees. The deficient practice posed a risk to the health and safety of residents if employees were unable to perform life saving measures in the event of an emergency.

Findings include:

1. A review of the facility's policies and procedures, reviewed December 25, 2022, revealed a policy titled, "CPR and First Aid Policy and Procedures," which stated, "This assisted living facility requires a caregiver who provides direct care to residents to obtain and provide documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration of the caregiver's ability to perform cardiopulmonary resuscitation from one of the following organizations: 1. American Red Cross, 2. American Heart Association, or 3. National Safety Council."... F... No on-line CPR training will be allowed."

2. A review of E2's personnel record revealed E2 had been hired as an assistant caregiver in November of 2022.

3. A review of the facility's policies and procedures revealed a job description titled, "Assistant Caregiver Job Descriptions, Duties, and Qualifications," which stated, "f. Has valid and current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, prior to providing personal or directed care services.

4. The Compliance Officer observed E2 providing personal care to residents throughout the on-site inspection.

5. A review of E2's personnel record revealed a CPR and First Aid certification, dated November 17, 2022, from "New Life CPR."

6. Online research revealed, "New Life CPR," is an on-line only training program which does not include a demonstration of the individuals ability to perform CPR and is not affiliated with American Heart Association, American Red Cross, or the National Safety Council.

7. In an interview, E1 acknowledged the facility's policies and procedures required assistant caregivers to have current and valid CPR training and acknowledged E2's CPR training was not from an authorized source and did not include a demonstration of the ability to perform CPR.

Based on observation, interview, and record review, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver.

Findings include:

1. Upon arriving at the facility, the Compliance Officer observed E2 and E4 were present at the facility.

2. A review of E2's personnel record revealed E2 was an assistant caregiver.

3. The Compliance Officer observed between approximately 11:15 a.m. until 12:15 p.m., E4 was in the kitchen preparing lunch while E2 answered call bells and provided personal care to multiple residents out of E4's supervision.

4. In an interview, E1 acknowledged E2 was an assistant caregiver and had not been directly supervised by E4 at all times while interacting with residents.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of the residents.

Findings include:

1. During a facility tour, the Compliance Officer observed a cabinet located in the laundry room had magnetic locks. However, all four magnetic locks had been switched off and the Compliance Officer was able to access the cabinet without a magnet. Inside the cabinet, the surveyor observed various toxic and poisonous cleaning chemicals such as, "CLR," "Pine-Sol," "Bar Keeper's Friend," "Comet with Bleach," "Bissel Pro Advanced Oxy spot and stain," and bleach.

2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.

This is a repeat deficiency from the on-site compliance inspections conducted on December 7, 2021 and December 15, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of facility documentation revealed a policy manual reviewed and approved on November 4, 2019. The policy manual included a policy titled, "Fall and Injury Policy and Procedure," which stated, "...all caregivers at the time of their employment will review the Fall and Injury Policy and Procedure before providing services to the residents."

2. A review of E2's personnel record revealed no current documentation of fall prevention and fall recovery training.

3. In an interview, E1 acknowledged the manager had not administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of two sampled residents.

Findings include:

1. A review of R2's medical record revealed a service plan dated November 14, 2022 for Directed Care Services. The service plan was originally marked as personal care, however, a line was struck through the box indicating personal care, the strike through was initialed, and the box indicating directed care was marked by hand. The service plan did not address any of the required items found in Arizona Administrative Code (A.A.C.) R9-10-815.C.3-7. for Directed Care services.

2. In an interview, E1 reported the service plan for R2 was not accurate and should not have been changed from personal care to directed care. E1 acknowledged the service plan for R2 did not include the accurate level of service R2 was expected to receive.

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 one of two sampled residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 14, 2022 for personal care services including medication administration. The service plan stated, "1) The assisted living facility maintains current orders for all medications & stores medications in accordance with their policies and procedures. 2) The amount, type and frequency of medication administration is recorded on the medication administration record. 3) Medications are ordered by care staff/manager from Pharmcare."

2. A review of R1's medical record revealed a list of medication orders dated October 24, 2022, which included, "Prilosec OTC Tablet, Delayed Release 20 mg (milligrams), (Omeprazole Magnesium), Give 1 tablet by mouth in the morning for indigestion, Start 05/10/2022."

3. A review of R1's medical record revealed a prescription dated October 25, 2022 for "Omeprazole 20 mg cap, 1 cap. PO 30 min before morning meal."

4. A review of R1's medical record revealed a medication administration record (MAR) dated November 2022. The MAR included documentation of all medications administered to R1 during the month of November 2022. However, the MAR did not include documentation of the administration of Prilosec (Omeprazole) to R1.

5. The Compliance Officer observed a medication cart containing R1's medications included a multi-dose package of "Omeprazole Cap 20 mg." The multi-dose package had been filled on December 5, 2022.

6. In an interview, E1 acknowledged "Omeprazole" was not administered to R1 as ordered in November 2022. E1 reported the pharmacy did not supply the medication until December 5, 2022.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.

Findings include:

1. The Compliance Officer observed the hot water temperature measured at 123.4 \'b0F in a private bathroom located in bedroom #9.

2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95 \'b0F and 120 \'b0F.

This is a repeat deficiency from the previous on-site compliance survey conducted on December 7, 2021.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area and inaccessible to residents.

Findings include:

1. During a facility tour, the Compliance Officer observed a cabinet located in the laundry room did not have a lock. Inside the cabinet, the surveyor observed a blue plastic tote containing a bottle of,"Great Value All Purpose Cleaner," a bottle of,"Great value Glass Cleaner," and a bottle of, "Lysol Advanced Power Clinging Gel."

2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.

This is a repeat deficiency from the previous on-site compliance inspection conducted on December 7, 2021.