LEGACY VILLAGE OF SALT RIVER

<p>Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses.</p><p><br></p><p><br></p><p>Findings:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed a manual thermometer in the Memory Care refrigerator reading at 50° instead of the required temperature of 41° F or below.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.</p>

<p>Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the sink in the Memory Care kitchen. The cabinet had a keyed locking mechanism; however, the lock was not currently locked, and the Compliance Officer was able to access the following:</p><p><br></p><p>-A bottle of "Soft Scrub";</p><p><br></p><p>-A can of "Febreeze" air mist;</p><p><br></p><p>-A bottle of "Result 100" Dish Machine Detergent; and</p><p><br></p><p>-A container of "McKesson" Instant Hand Sanitizing wipes.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.</p>

Based on record review, documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident, that covered how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a health and safety risk to residents, if the facility failed to have established policies and procedures, and employees were not instructed on managing a resident's aggressive behaviors, to ensure the safety of residents and others.

Findings include:

1. In record review, R2's medical record included the following documentation:
- "4/15/2024... Resident refused all morning medications... Has becoming more aggressive as time continues ... shouted at visitors and staff... swinged ... fist and shouted at med tech and used walker to hit med tech and other care staff..."
- "4/17/2024... Resident came out of room ... screaming ... Behavior escalated over time... refused... medication resident has grabbed 2 residents has scratched staff, try to hit staff with ... walker ... has been walking around yelling to anyone about how no one helps... family and wellness nurse has been notified."
- "4/17/2024... The nurse observed resident yelling at staff. Per staff, resident has been reaching out at other residents and hitting staff."
- "4/18/2024... Has been having behaviors, yelling, throwing things, hitting, using inappropriate language towards staff and residents..."

2. In documentation review, the Compliance Officer requested to review the facility's policy and procedures which covered how a caregiver will respond to a resident's sudden, intense, or out of control behavior. No policy was provided for review.

3. During an interview, E3, E4, and E5 reported the resident exhibited aggressive behaviors, and acknowledged the facility did not have a policy and procedure which included how a caregiver would respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Based on record review, documentation review and interview, the administrator failed to report an allegation of abuse according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.

Findings include:

1. A.R.S. \'a7 46-454(A) states: " A. A health professional, emergency medical technician, home health provider, hospital intern or resident, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the department of economic security or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit. The guardian or conservator of a vulnerable adult shall immediately report or cause reports to be made of such reasonable basis to the superior court and the adult protective services central intake unit. All of the above reports shall be made immediately by telephone or online.."

2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay."

3. In documentation review, the Department received a report which documented R2 grabbed a resident's arm, yelled and cussed during breakfast, behavior escalated, was trying to hit staff, was grabbing other residents' arms.

4. In record review, R2's record included documentation:
- "4/15/2024... Resident refused all morning medications... Has becoming more aggressive as time continues ... shouted at visitors and staff... swinged ... fist and shouted at med tech and used walker to hit med tech and other care staff..."
- "4/17/2024... Resident came out of room ... screaming ... Had a bout of loose stools... Behavior escalated over time... refused... medication resident has grabbed 2 residents has scratched staff, try to hit staff with ... walker ... has been walking around yelling to anyone about how no one helps... family and wellness nurse has been notified."
- "4/17/2024... The nurse observed resident yelling at staff. Per staff, resident has been reaching out at other residents and hitting staff."
- "4/18/2024... Has been having behaviors, yelling, throwing things, hitting, using inappropriate language towards staff and residents..."

5. During an interview, E6, E8, and E9 reported being present when R2 exhibited aggressive behavior towards staff and residents. E6 and E8 observed R2 pushed walker into staff and resident and grabbed a resident's arm. They reported resident threatening residents and staff with walker, had out of control behavior, and it was difficult to redirect or calm the resident so they called the resident's representative to come to the facility. They reported the representative is able to calm the resident.

6. During an interview, E1, E3, and E4 reported being unaware the resident's behavior posed a threat to other residents. E4 reported having directed the caregiver to call 911. E1 and E3 reported it wasn't necessary to call 911. E5, E7, and E8 reported the resident's behavior was out of control, aggressive, and threatening to other residents. No one reported the allegation to a peace officer or to the adult protective services central intake unit, as required.

Based on record review, documentation review, and interview, for three of six caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents.

Findings include:

1. In record review, the personnel records for E7 (hired as a caregiver on November 2, 2023), E8 (hired as a caregiver on February 6, 2023), and E11 (hired as a caregiver on February 2, 2024), did not include documentation the caregivers' skills and knowledge were verified.

2. In documentation review, the staffing schedule for April 2024, included documentation the caregivers worked shifts at the facility.

3. During an interview, E2, E3, and E4 acknowledged the personnel records for the caregivers did not include documentation of the verification of the caregivers' skills and knowledge, and acknowledged the documentation was required before a caregiver provided services for residents.

4. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 2, 2023, and the complaint investigation conducted on February 5, 2024, for which a plan of correction was submitted.

Based on record review, documentation review, and interview, for three of six caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff.

Findings include:

1. In record review, E5's personnel record (hired as a caregiver on October 9, 2023), did not include documentation of freedom from TB, and a TB screening and risk assessment. E6's record (hired as a caregiver on February 26, 2024), did not include documentation of a second negative TB test, and a screening and risk assessment. E7's record (hired on November 2, 2023), did not include documentation of freedom from TB, and a TB screening and risk assessment.

2. In documentation review, the staffing schedule for April 2024 included documentation the caregivers worked shifts at the facility.

3. During an interview, E2, E3, and E4 acknowledged the personnel records did not include documentation the caregivers provided evidence of freedom from TB, as required by R9-10-113.

Based on record review, documentation review, and interview, for two of six caregivers reviewed, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver was not oriented, as required.

Findings include:

1. In record review, the personnel records for E6 (hired as a caregiver on February 26, 2024), and E7 (hired as a caregiver (November 2, 2023) did not include documentation the caregivers received orientation.

2. In documentation review, the staffing schedule for April 2024 included documentation the caregivers worked shifts at the facility.

3. During an interview, E2, E2, and E4 acknowledged the personnel records for the caregivers did not include documentation the caregivers received orientation.

4. This is a repeat deficiency from the complaint investigation conducted on February 5, 2024, for which a plan of correction was submitted.

Based on record review, and interview, for three of six caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid training (FA) and cardiopulmonary resuscitation training (CPR) certification specific to adults which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have the required FA and CPR training.

Findings include:

1. In record review, E5's personnel record (hired as a caregiver on October 9th, 2023), did not include documentation of FA training and CPR certification.

2. In record review, E10's personnel record (hired as a caregiver on March 5, 2024), did not include documentation of FA training.

3. In record review, E11's personnel record (hired as a caregiver on February 2, 2024), did not include documentation of CPR training.

3. During an interview, the findings were reviewed with E2, E3, and E4, who acknowledged the caregivers did not provide the required documentation of current FA and CPR training.

Based on record review, documentation review, and interview, for two of two residents reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

A.R.S. \'a7 36-401.A.50. defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

A.R.S. \'a7 36-401.A.41. defines "Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

A.R.S. \'a7 36-401.A.16. defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. In record review, R1's medical record included a service plan dated March 20, 2024. The service plan did not include R1's level of care.

2. In record review, R2's medical record included a service plan dated January 10, 2024. The service plan did not include R2's level of care.

3. During an interview, the findings were reviewed with E2, E3, and E4, who acknowledged the residents' service plans did not include the resident's level of care. They reported R1 received personal care services and R2 receive directed care services.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the resident's MP or nurse did not acknowledge the services that were to be provided.

Findings include:

1. In record review, R1's medical record (received personal care and medication administration services) included a service plan dated March 20, 2024. The service plan was not signed and dated as reviewed by the resident or resident's representative.

2. In record review, R2's medical record (received directed care and medication administration services) included a service plan dated January 10, 2024. The service plan was not signed and dated as reviewed by the resident or resident's representative, the manager, and the MP or nurse.

3. During an interview, the findings were reviewed with E2, E3, and E4, who acknowledged the service plans were not signed and dated by the resident or resident's representative, the manager, and signed and dated as reviewed by the nurse or MP, as required.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures for medication services included procedures for assisting a resident in procuring medication. The deficient practice posed a health and safety risk if the facility did not have procedures to ensure a resident's prescribed medications were available for administration, and a resident did not received medication as ordered.

Findings include:

1. In documentation review, the compliance officer requested to review the facility's medication policies and procedures for procuring medication for residents. No policy was provided for review.

2. In record review, R2's medical record included an order for Clonidine medication, one tablet by mouth twice a day. The medication administration record indicated R2 did not receive the medication on April 1 through April 17 , 2024, twice daily, as ordered.

3. During an interview, E4 and E8 reported the Facility did not have the medication available for administration to R2, on April 1 through April 17, 2024. E2, E3, and E4 acknowledged the facility did not have policies and procedures for assisting a resident in procuring medication, and acknowledged a policy was required.

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure medications were administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medications in compliance with a medication order, and a resident did not receive medication as ordered.

Findings include:

1. In record review, R2's medical record included an order for Clonidine medication, one tablet by mouth twice a day. The medication administration record indicated R2 did not receive the medication on April 1 through April 17, 2024, twice daily, as ordered.

2. During an interview, E4 and E8 reported the Facility did not have the medication available for administration to R2 on April 1 through April 17, 2024.

3. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 2, 2023, and the complaint investigation conducted on February 5, 2024, for which a plan of correction was submitted.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. In documentation review, the facility did not have documentation of a fall prevention and fall recovery training program.

2. In record review, the personnel records for E4, E5, E6, E7, and E8, did not include documention staff received training on fall prevention and fall recovery.

3. During an interview, E2 acknowledged the facility had not developed and implemented a fall prevention and fall recovery training program for all staff.

4. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 2, 2023.

Based on documentation review, record review, and interview, for two of six residents reviewed, who suffered an incident, the manager failed to implement the facility's incident reporting policy. The deficient practice posed a risk to the health and safety of residents if incident reporting policies and procedures were not implemented, and documentation of incident reports did not include all relevant information, notifications, and actions implemented to prevent recurrence.

Findings include:

1. In documentation review, a review of facility policies and procedures revealed a policy titled, "Incident/Unusual Occurrence Reporting," documented, "All Incident Reports must be completed at the time of the occurrence for all unusual occurrences involving residents.... must be filled out completely and accurately and must not contain opinions or conclusions... must consist only of facts, direct observations, and witness statements. The following is a list of common incidents requiring completion of an Incident Report... Fall... Vomiting, Diarrhea, Constipation, Illness, Resident confused or combative, Unusual behavior... Bruises... Head Injury, Cuts... Skin tears... Medication incident... Other. Person who discovered or witnessed incident will complete an Incident Report...The Wellness Nurse completes the bottom portion identifying possible cause of the incident and develops and implements an action plan....

2. In documentation review, the Department received a report which indicated R4 received two Flu vaccinations from the facility. Documentation indicated R4 received a Flu vaccination on October 13, 2023, and a second Flu vaccination on October 18, 2024.

3. In record review, R4's medical record (received directed care and medication administration services) did not include documentation of the duplicate vaccination, and did not include documentation of an incident report (IR), per the facility's policy.

4. In documentation review, the Department received a report which indicated R1 had vomited and passed away from aspirating on vomit.

5. During an interview, E3 reported [E3] observed R1 appeared unwell, "... looked very pale, requested [R1] be sent to the hospital... 911 called, notified son..." E3 said an IR was not completed by E3, because E3 was on the way out the door... assumed med techs did the IR.

6. In record review, R1's record did not include documentation of an incident report related to 911 call for R1, and transfer to hospital. However, E2 reported an IR was located in a pile of papers, and provided an IR (dated the day of the resident death) that indicated R1 was sent to the hospital three days prior, and three days later the facility was notified of R1's passing. The facility did not have documentation an incident report was completed when R1 was observed to be unwell, 911 was called, and R1 was sent to the hospital.

7. During an interview, E1, E2, and E3 acknowledged an IR was not available for review for the incidents noted in the above paragraphs.

Based on record review, and interview, the administrator failed to report and document an alleged incident of abuse according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.

Findings include:

1. A.R.S. \'a7 46-454(A) states: " A. A health professional, emergency medical technician, home health provider, hospital intern or resident, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the department of economic security or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit. The guardian or conservator of a vulnerable adult shall immediately report or cause reports to be made of such reasonable basis to the superior court and the adult protective services central intake unit. All of the above reports shall be made immediately by telephone or online.."

2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay."

3. In documentation review, the Department received a report from O1, which documented, "... Unknown exact date of incident. Resident [R5] stated a caregiver inappropriately touched R5, in a sexual manner. R5 was unable to tell when the incident happened. "We began an investigation on 6/18/23. The caregiver in question was suspended pending investigation. I notified the Regional Director of Operations on 6/18/23."

3. In record review, R5's medical record (received directed care services) did not include documentation of the alleged abuse, the facility's investigation, and the required reporting per A.R.S. \'a7 46-454.

4. During an interview, E9 reported [E9] heard about the alleged incident from other care staff at the facility. E2 reported no documentation of the incident was available for review. E1 and E2 reported the facility had a recent change in management, O1 no longer was employed by the facility, and the facility did not have documentation showing the incident was reported, and investigated, as required.

Based on documentation review, record review and interview, for two resident deaths, the manager failed to provide written notification to the Department of a resident's death, which was unexpected according to A.R.S. \'a7 11-593.

Findings include:

1. In documentation review, the Compliance Officer inquired on the deaths of R1 and R7, and was provided documentation of the recent deaths of R1 and R7.

2. In documentation review, a review of Department records revealed the Department was not notified of the deaths of R1 and R7.

3. During an interview, with E2 and E3, it was reported the resident deaths were not expected. R1 appeared unwell and was sent to the hospital where R1 passed away. R7 was found unresponsive in R7's room, and was deceased. E2 reported R1's death wasn't reported because R1 was not at the facility when R1 passed away. R7's death was reported to Adult Protective Services; however, was not reported to the Department.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for a quality management (QM) program were documented and implemented. The deficient practice posed a risk as a quality management program documents and tracks the necessary information required to effectively evaluate and manage services provided.

Findings include:

1. In documentation review, the facility did not have a documented QM program available for review.

2. In documentation review, a review of QM reports revealed a report was documented on April 26, 2023, and the next QM report was documented on January 14, 2024. The reports did not indicate the facility had reviewed and evaluated incidents.

3. During an interview, E1 acknowledged the facility QM program was unavailable for review, and QM reports were not consistently documented.

Based on record review, and interview, for five of six caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, and according to policies and procedures. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident.

Findings include:

1. In record review, the personnel records for E4 (hired as a caregiver on October 26, 2023), E6 (hired as a caregiver on January 4, 2024), E7 (hired as a caregiver on October 1, 2023), E8 (hired as a caregiver on March 16, 2022), and E9 (hired as a caregiver on October 17, 2023) did not include documentation of the verification the caregiver's skills and knowledge.

2. During an interview, E1 acknowledged the personnel records for E4, E6, E7, E8, and E9, did not include documentation of the verification of skills and knowledge.

3. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 2, 2023.

Based on record review, and interview, for four of six caregivers reviewed, the manager failed to ensure that before providing assisted living services, a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver did not receive the required orientation.

Findings include:

1. In record review, the personnel records for E4 (hired as a caregiver on October 26, 2023), E6 (hired as a caregiver on January 4, 2024), E7 (hired as a caregiver on October 1, 2023), and E9 (hired as a caregiver on October 17, 2023) did not include documentation the caregivers received orientation.

2. During an interview, the findings were reviewed E1, who acknowledged the personnel records did not include documentation the caregivers received orientation.

Based on record review and interview, for one of six residents reviewed, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation, signed and dated by a Physician, Registered nurse practitioner, Registered nurse, or Physician Assistant, which included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. The deficient practice posed a safety risk, if residents were not appropriately assessed on acceptance.

Findings include:

1. In record review, R7's medical record (received directed care services) did not include the required documentation, signed and dated by a Physician, Registered Nurse Practitioner, Registered Nurse or Physician's Assistant, which included whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on the resident's date of acceptance, this documentation was required.

2. During an interview, E2 acknowledged R7's record did not include the signed and dated documentation to indicate whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review, and interview, for one of six residents reviewed, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months. The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services, and a caregiver was not aware of the services to be provided for a resident.

Findings include:

1. In record review, R5's medical record (received directed care services) included a service plan dated May 18, 2023. The service plan was not signed and dated by the resident's representative or the manager. The record did not include an updated service plan every three months, as required.

2. During an interview, E2 reported an updated service plan for R5 was unable to be located, and acknowledged a service plan was required to be reviewed and updated at least once every three months for a resident who received directed care services.

Based on record review, and interview, for one of seven residents reviewed, the manager failed to ensure a medical record was maintained for each 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, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 12-2297(A)(1) 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: 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.

1. In record review, the Compliance Officer requested to review the medical records for seven residents, including R3; however, no medical record was provided for R3.

2. During an interview, E1 and E2 acknowledged the facility was unable to locate R3's medical record. It was reported R3's residency was terminated less than six years ago.

Based on record review and interview, for three of six residents reviewed, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of the pneumonia vaccination. The deficient practice posed a health and safety risk if a resident or representative did not have knowledge of the availability of the vaccination.

The statute reads: A.R.S. \'a7 36-406(1)(d). Powers and duties of the department

In addition to its other powers and duties: 1. The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director.

Findings include:

1. In record review, the medical records for R1, R5, and R6 did not include documentation of notification of the resident or representative of the availability of the vaccination for pneumonia. Based on the residents' acceptance dates, this documentation was required.

2. During an interview, E1 and E2 acknowledged the residents' records did not include documentation the pneumonia vaccination was made available to the residents.

Based on record review and interview, for one of six residents reviewed, the manager failed to ensure a resident's written service plan included strategies to ensure the resident's personal safety. The deficient practice posed a risk if employees were unable to ensure the health and safety of a resident with a history of multiple falls.

Findings include:

1. In record review, R5's medical record included documentation R5 had a fall on July 10, 2023, October 10, 2023, October 17, 2023, November 10, 2023, November 13, 2023, and December 10, 2023.

2. In record review, R5's service plan, dated May 18, 2023 (received directed care services) included documentation R5 had diagnoses of Prostate cancer, frailty, visual hallucinations, had visual limitations, Glaucoma, Cataracts, muscle weakness, was dependent for mobility, ambulation, transferring, dressing, and personal hygiene. R1 had a "History of Falls... Fell in the last 30 days... Fall risk precautions..." The service plan did not include strategies to ensure the resident's personal safety.

3. During an interview, the findings were reviewed E2, who acknowledged R5's service plan did not include strategies to ensure the resident's personal safety.

Based on record review, and interview, for one of four residents reviewed, the manager failed to ensure medications were administered in compliance with a medication order. The deficient practice posed a health and safety risk if the facility did not administer medications in compliance with a medication order, and a resident did not receive the required medication.

Findings include:

1. In record review, R5's medical record included medication orders for Dorzolamide Opth Solution, instill 1 drop in left eye twice daily, Quetiapine 25mg, take 1 tab by mouth every night at bedtime, Mirtazapine 15 mg, take 1 tab by mouth every night at bedtime.

2. In record review, R5's medication administration record (MAR) included documentation R5 did not receive the medications, as ordered:
- R5 did not receive the Dorzolamide medication on December 17, 202 PM, December 25, 2024 AM through December 29, 2024, AM. The MAR notes documented, "New order, awaiting pharmacy deliver."
- R5 did not received the Quetiapine and Mirtazapine medication on December 15 - 17 2023. The MAR notes documented the meds were on cycle fill and the facility ran out.

3. During an interview, E2 did not know why R5's medications were unavailable, but reported it was possibly due to pharmacy hours, due to the pharmacy being out of State. E1 and E2 acknowledged R5's medications were not available to be administered in compliance with the medication orders.

4. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on June 2, 2023.

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 available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "PERSONNEL REQUIREMENTS & STAFFING POLICY: Ongoing Training". The policy stated "POLICY: ALL employees will complete ongoing training every 12 months based on level of care provided by the facility. The manager will offer updates on suggested topics by recruiting outside sources such as consultants, home health, or hospice groups to assist in training staff. PROCEDURE Fiver hours of annual ongoing training requirements are mandatory for nurses and care staff each year..." However, evidence of a fall prevention and fall recovery training program was not available for review.

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

3. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

4. A review of E5's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

5. A review of E7's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

6. A review of E8's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

7. A review of E9's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

8. In a joint interview, E1 reported to have a fall prevention and fall recovery training program, including initial training and continued competency training. However, E1 and E2 could not locate the documentation. E1 reported E3, E4, E5, E7, E8, and E9 completed fall prevention and fall recovery training, however, E1 could not locate the documentation. E1 and E2 acknowledged documentation of a training program for all staff regarding fall prevention and fall recovery was not available for review.

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 documentation of verification of skills and knowledge was not available for review.

2. A review of E4's personnel record revealed documentation of verification of skills and knowledge was not available for review.

3. A review of E5's personnel record revealed documentation of verification of skills and knowledge was not available for review.

4. A review of E7's personnel record revealed documentation of verification of skills and knowledge was not available for review.

5. A review of E8's personnel record revealed documentation of verification of skills and knowledge was not available for review.

6. A review of E9's personnel record revealed documentation of verification of skills and knowledge was not available for review.

7. A review of E3's personnel record revealed documentation of completed orientation specific to the duties to be performed by E3 was not available for review.

8. A review of E4's personnel record revealed documentation of completed orientation specific to the duties to be performed by E4 was not available for review.

9. A review of E5's personnel record revealed documentation of completed orientation specific to the duties to be performed by E5 was not available for review.

10. A review of E8's personnel record revealed documentation of completed orientation specific to the duties to be performed by E8 was not available for review.

11. A review of E9's personnel record revealed documentation of completed orientation specific to the duties to be performed by E9 was not available for review.

12. A review of E7's personnel record revealed documentation of cardiopulmonary resuscitation (CPR) and first aid training for E7 was not available for review.

13. A review of E9's personnel record revealed documentation of CPR and first aid training for E9 was not available for review.

14. A review of R5's medical record revealed a document titled "Orders of Care-Application for Residency" dated September 29, 2022 The document stated "This person has received a recent TB test: Yes..." However evidence of freedom of infectious tuberculosis (TB) as specified in R9-10-113 was not available for review.

15. A review of R7's medical record revealed an activities of daily living (ADL) document for May 2023. The document stated "Dressing: Dressing-Assist Caregiver will stand by resident as they dress and undress for safety Ted hose on in AM and off in PM". The document contained caregiver initials indicating the service was provided on May 1-12, 2023 and May 14-17, 2023 at 8:00 AM and 8:00 PM. However, documentation indicating R7 received the aforementioned service on May 13, 2023 was not available for review.

16. A review of the facility's policies and procedures revealed a policy titled "MEDICATION MANAGEMENT POLICY: MEDICATIONS ADMINISTRATION". However, the policy did not cover the documentation of a resident's refusal to take prescribed medication in the resident's medical record.

17. A review of facility documentation revealed an incident report dated November 5, 2022. The document stated "Resident was @ lunch and was falling asleep at the table. I asked [R1] if [R1] was ok. [R1] stated that [R1] was ok and went back to eating. I than [sic] noticied [sic] that [R1] was asleep again and when I tried to wake [R1] [R1] wasn't responsive and we could not wake [R1]. So we transferred [R1] to a wheelchair and took [R1] to [R1] room to preform [sic] vitals and called 911. Another med tech that was in training had said to another med tech that [E8] thought [E8] had given the resident another residents meds at the AM pass. Hospital was notified of meds that were given to [R1] mistakenly." Additionally, the document stated "Was physician notified? Yes...No...If yes, who:" However, the aforementioned section was left blank, and documentation of immediate notification of the resident's PCP was not available for review.

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

19. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

20. A review of E5's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

21. A review of E7's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

22. A review of E8's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

23. A review of E9's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

24. In an interview, E1 acknowledged the aforementioned documentation was not provided within two hours after a Department request

This is a repeat citation from the previous on-site compliance inspection conducted on May 23, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for four of four caregivers and two of two assistant caregivers sampled. The deficient practice posed a risk if the caregivers and assistant caregivers were unable to meet a residents needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a document titled "Personnel Requirements & Staffing POLICY: Job Descriptions" The policy stated "POLICY: Legacy will have established job descriptions for the care staff, nurses and Manager who have direct responsibility of the resident's care...Managers (Executive Director) Nurse and Caregivers, will have established job descriptions that address the following expectations: 1. Specific skills and knowledge to provide expected services." However, the policy did not indicate the skills and knowledge required for caregivers or assistant caregivers. 2. A review of the facility's policies and procedures revealed a document titled "Personnel Requirements & Staffing POLICY: Assistant Caregiver Employment Requirements" The policy stated "POLICY: It is currently Legacy Village of Salt River's practice to not hire Assistant Caregivers." However, the policy did not indicate the skills and knowledge required for assistant caregivers.

3. A review of E3's personnel record revealed documentation of verification of skills and knowledge was not available for review.

4. A review of E4's personnel record revealed documentation of verification of skills and knowledge was not available for review.

5. A review of E5's personnel record revealed documentation of verification of skills and knowledge was not available for review.

6. A review of E7's personnel record revealed documentation of verification of skills and knowledge was not available for review.

7. A review of E8's personnel record revealed documentation of verification of skills and knowledge was not available for review.

9. A review of E9's personnel record revealed documentation of verification of skills and knowledge was not available for review.

10. In a joint interview, E1 reported E3's, E4's, E5's, E7's, E8's, and E9's skills and knowledge were verified, however, E1 could not locate the documentation. E1 and E2 acknowledged E3's, E4's, E5's, E7's, E8's, and E9's skills and knowledge were not documented before E3, E4, E5, E7, E8 and E9 provided physical health services, and according to policies and procedures.

Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for five of eight employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the personnel reord 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.) R9-10-101.137. 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 the facility's policies and procedures revealed a policy titled "PERSONNEL REQUIREMENTS POLICY: Employee/Volunteer Orientation" The policy stated "PROCEDURE: New Employee/Volunteer orientation will be completed within 10 days from start date..."

3. A review of E3's personnel record revealed documentation of completed orientation specific to the duties to be performed by E3 was not available for review.

4. A review of E4's personnel record revealed documentation of completed orientation specific to the duties to be performed by E4 was not available for review.

5. A review of E5's personnel record revealed documentation of completed orientation specific to the duties to be performed by E5 was not available for review.

6. A review of E8's personnel record revealed documentation of completed orientation specific to the duties to be performed by E8 was not available for review.

7. A review of E9's personnel record revealed documentation of completed orientation specific to the duties to be performed by E9 was not available for review.

8. In a joint interview, E1 reported orientation was provided to E3, E4, E5, E8, and E9, however, E1 could not locate the documentation. E1 and E2 acknowledged E3's, E4's, E5's, E8's, and E9's personnel records did not include documentation of orientation.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for two of two assistant caregivers sampled. The deficient practice posed a risk if E7 and E9 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel record did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "PERSONNEL REQUIREMENTS & STAFFING POLICY: Employee/Volunteer Orientation". The policy stated "PROCEDURE: New employee/volunteer orientation will be completed within 10 days from the start date and will include the following:...CPR current (adult) First aid training, current (adult)."

2. A review of E7's personnel record revealed documentation of CPR and first aid training for E7 was not available for review.

3. A review of E9's personnel record revealed documentation of CPR and first aid training for E9 was not available for review.

4. In a joint interview, E1 reported E7 has CPR and first aid training, however, E1 could not locate the documentation. E1 reported to be unsure if E9 had CPR and first aid training. E1 and E2 acknowledged documentation of E7's and E9's CPR and first aid training was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of eight residents sampled. The deficient practice posed a risk as the services provided were unable to be verified, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R7's medical record revealed a service plan for personal care services. The service plan stated "DRESSING Assist: Caregiver will stand by resident as they dress and undress for safety Dressing Care Assistance: Ted hose on in AM and off in PM Usual time up in morning...2 Times/Day..."

2. A review of R7's medical record revealed an activities of daily living (ADL) document for May 2023. The document stated "Dressing: Dressing-Assist Caregiver will stand by resident as they dress and undress for safety Ted hose on in AM and off in PM". The document contained caregiver initials indicating the service was provided on May 1-12, 2023 and May 14-17, 2023 at 8:00 AM and 8:00 PM. However, documentation indicating R7 received the aforementioned service on May 13, 2023 was not available for review.

3. In an interview, E2 reported R7 was admitted to the hospital for the remainder of the month. E2 reported to be unsure of why the aforementioned service was not documented on May 13, 2023. E2 acknowledged the aforementioned service was not documented in R7's as provided.

This is a repeat citation from the previous on-site compliance inspection conducted on May 23, 2022.

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 Department documentation revealed AL11712 was authorized to provide directed care services.

2. A review of the facility's policies and procedures revealed a policy titled "DIRECTED CARE SERVICES POLICY: Residents that Wander". The policy stated: "Doors will be locked per fire code, alarm/bell or device will be in use to warn staff that doors are opened."

3. During the environmental inspection of the facility, the Compliance Officer observed a door leading out to an outside courtyard area in the memory care section of the facility. The Compliance Officer observed the outside area allowed residents to be a least 30 feet away from the facility. The Compliance Officer observed the outside area contained a locked door. However, the door leading to the outside area did not control or alert employees of egress when the door leading out to the courtyard was opened.

4. In a joint interview, E1 and E2 acknowledged the door leading to the outside area did not control or alert employees of the egress of a resident.

Based on documentation review and interview, the manager failed to implement policies and procedures for medication administration to cover the documentation of a resident's refusal to take prescribed medication in the resident's medical record. The deficient practice posed a risk as 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 the facility's policies and procedures revealed a policy titled "MEDICATION MANAGEMENT POLICY: MEDICATIONS ADMINISTRATION". However, the policy did not cover the documentation of a resident's refusal to take prescribed medication in the resident's medical record.

2. In a joint interview, E1 and E2 acknowledged the facility's medication policies and procedures did not cover documentation of a resident's refusal to take prescribed medication in the resident's medical record.

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

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "MEDICATION MANAGEMENT MEDICATION ADMINISTRATION". The policy stated "4. The five-step review (following the 5 rights) of the label on the medication must be completed each time a med pass is made."

2. A review of the facility's policies and procedures revealed a policy titled "MEDICATION MANAGEMENT POLICY: The Five (5) Rights." The policy stated "POLICY: Staff will use the five rights when administering medications. The five-step review (following the 5 rights) of the label on the medication must be completed each time a med pass is made..."

3. A review of facility documentation revealed an incident report dated November 5, 2022. The document stated: "Resident was @ lunch and was falling asleep at the table. I asked [R1] if [R1] was ok. [R1] stated that [R1] was ok and went back to eating. I than [sic] noticied [sic] that [R1] was asleep again and when I tried to wake [R1] [R1] wasn't responsive and we could not wake [R1]. So we transferred [R1] to a wheelchair and took [R1] to [R1] room to preform [sic] vitals and called 911. Another med tech that was in training had said to another med tech that [E8] thought [E8] had given the resident another residents meds at the AM pass. Hospital was notified of meds that were given to [R1] mistakenly."

4. A review of R3's medical record revealed a medication order dated May 17, 2023 for "Folic acid 1 mg (milligram) tablet 1 tablet orally once a day 30 day(s)".

5. A review of R3's medical record revealed a medication administration record (MAR) for June 2023. The MAR revealed "Folic acid tab 1 mg" with a caregiver's initials on June 1-2, 2023. The initials contained a circle around the initials. A legend key on the back of R3's MAR stated "Expections for [R3] Date/time 1-Jun-2023 7:25 AM Medication/treatment FOLIC ACID TAB 1 MG Reason: NEW ORDER AWAITING PHARMACY DELIVERY...Date/time 2-Jun-2023 8:09 AM Medication/treatment FOLIC ACID TAB 1 MG Reason: NEW ORDER AWAITING PHARMACY DELIVERY".

6. A review of R3's medications revealed "Folic acid 1 mg tablet" was not available for review.

7. In a joint interview, E1 and E2 reported E8 accidentally administered R9's medications to R1. E2 reported to be unsure if R3 was administered "Folic acid 1 mg tablet". E1 and E2 acknowledged R1 and R3 were not administered medications in compliance with medication orders.

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, the caregiver or assistant caregiver immediately notified the resident's primary care provider (PCP), for one accident, emergency, or injury resulting in the resident needing medical services. The deficient practice posed a risk as 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 facility documentation revealed an incident report dated November 5, 2022. The document stated "Resident was @ lunch and was falling asleep at the table. I asked [R1] if [R1] was ok. [R1] stated that [R1] was ok and went back to eating. I than [sic] noticied [sic] that [R1] was asleep again and when I tried to wake [R1] [R1] wasn't responsive and we could not wake [R1]. So we transferred [R1] to a wheelchair and took [R1] to [R1] room to preform [sic] vitals and called 911. Another med tech that was in training had said to another med tech that [E8] thought [E8] had given the resident another residents meds at the AM pass. Hospital was notified of meds that were given to [R1] mistakenly." Additionally, the document stated "Was physician notified? Yes...No...If yes, who:" However, the aforementioned section was left blank, and documentation of immediate notification of the resident's PCP was not available for review.

2. In a joint interview, E1 and E2 acknowledged documentation of the caregiver immediately notifying R1's primary care provider (PCP), for an accident, emergency, or injury resulting in the resident needing medical services was not available for review.

Based on documentation review, record 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 assistance caregiver documented the action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a risk as 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 facility documentation revealed an incident report dated November 5, 2022. The document stated "Resident was @ lunch and was falling asleep at the table. I asked [R1] if [R1] was ok. [R1] stated that [R1] was ok and went back to eating. I than [sic] noticied [sic] that [R1] was asleep again and when I tried to wake [R1] [R1] wasn't responsive and we could not wake [R1]. So we transferred [R1] to a wheelchair and took [R1] to [R1] room to preform [sic] vitals and called 911. Another med tech that was in training had said to another med tech that [E8] thought [E8] had given the resident another residents meds at the AM pass. Hospital was notified of meds that were given to [R1] mistakenly." However, the report did not include action(s) taken to prevent the accident, emergency, or injury from occurring in the future.

2. In a joint interview, E1 reported the facility retrained staff on the "five rights" of medication administration, and the residents have a photo on their medication administration records as a fail-safe. E1 reported E8 no longer works at the facility. E1 and E2 acknowledged actions taken to prevent the accident, emergency, or injury from occurring in the future were not documented.