ORANGE GARDEN ASSISTED LIVING LLC

Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to initiate an investigation and document the information required in Arizona Administrative Code (A.A.C.) R9-10-803(J)(5)(a-d), within five working days. The deficient practice posed a risk to the physical health and safety of residents.

Findings include:

1. A review of facility documentation revealed a document dated August 31, 2023. The document reflected Arizona Adult Protective Services (APS) completed an investigation regarding allegations of neglect regarding R4.

2. A review of Department documentation revealed a document titled "Intake Information" dated January 8, 2024. The intake contained allegations of neglect regarding R3.

3. In an interview, E1 reported APS visited the facility to investigate allegations of neglect regarding R3. E1 reported being unaware of all of the allegations associated with the report, and reported the case with APS was closed.

4. In an interview, E1 acknowledged internal investigations of the allegations of neglect of R3 and R4 were not initiated and information required in A.A.C. R9-10-803(J)(5)(a-d) was not documented within five working days.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to ensure the safety of a resident who may wander. The deficient practice posed a risk if facility staff were unaware of the whereabouts of a resident.

Findings include:

1. A review of Department documentation revealed AL11714 was licensed to provide directed care services.

2. A review of facility policies and procedures revealed a policy on wandering. The policy reflected "Facility will do routine checks and document to verify location in facility."

3. A review of facility documentation revealed no documentation to reflect routine checks were conducted and documented.

4. In an interview, E1 reviewed and acknowledged the facility's wandering policy was not implemented.

Based on observation, documentation review, and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk of not meeting residents' dietary needs.

Findings include:

1. During the environmental inspection of the facility conducted on May 8, 2024, at approximately 10:15 AM, the Compliance Officer observed residents being served hamburgers, french fries, and water for lunch.

2. A review of the facility's menu dated May 8, 2024 revealed "Chicken stir fry with vegtable and rice, fruit juice, soda, or ice tea, and ice cream" was scheduled to be served for lunch, and "Egg salad sandwich with lettuce, pickle salad, ice cream and fruit juice or milk or coffee" was scheduled to be served for dinner.

3. In an interview, E4 reported the residents would be served bologna sandwich, egg salad and water, orange juice, or coffee for dinner.

4. At approximately 4:45 PM, the Compliance Officer observed E4 preparing bologna sandwiches for dinner.

5. In an interview, E1 acknowledged meals were not served according to the posted menu.

Based on observation, documentation review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager.

Findings include:

1. A review of Department documentation revealed O1 was no longer the manager of AL11714 on April 1, 2023.

2. The Compliance Officer observed E1's license, issued by the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), posted on the premises.

3. A review of E1's (hired in 2023) personnel record revealed E1 was hired as the licensed manager. However, documentation the Department was notified when there was a change in the manager was not available for review.

4. In an interview, E3 acknowledged the governing authority did not notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. The deficient practice posed a risk if there was not sufficient staff with the qualifications, experience, skills, and knowledge necessary to meet the needs of the residents.

Findings include:

1. A review of R3's medical record, contained an incident report dated May 7, 2022. The document stated, "Resident found on floor...resident slide [R3's]self on floor...resident wants us to put back on floor...refused to go to the hospital..stated ok and no injury sustained...action taken: check resident every two to three hours". There was no documentation of resident checks in R3's record.

2. An incident report dated May 8, 2022 stated "resident found on floor...called 911 and resident pronounced death".

3. In an interview, E2 and E3 acknowledged there was no documentation of resident checks in R3's record. E2 reported R3 was checked on.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed documentation stating R1 required continuous medical services with a note underneath the corresponding area that read "feeding liquid food and medication".

2. During an interview, E2 and E3 acknowledged R1's record contained documentation of continuous medical services required. E3 indicated the form was filled out incorrectly.

This is a repeat deficiency from the last compliance inspection conducted on May 11, 2022.

Based on record review and interview, the manager failed to ensure an assistant caregiver was only assigned to provide the assisted living services the assistant caregiver had the documented skills and knowledge to perform, for one of four caregiver sampled. The deficient practice posed a risk if the caregivers were unable or to meet a resident's needs.

Findings include:

1. A review of R1's medical record revealed a service plan dated June 14, 2023. The service plan revealed R1 required g-tube feeding four times a day with flushing of g-tube with water before and after feeding.

2. In an interview, E3 reported E2 was trained on g-tube feeding from E3 on March 15, 2023, and provided the Compliance Officer with a form titled "Employee Certification that had the area checked for "Feeding tube care/feeding pump". However, E3 was not a licensed medical person. The there was no further documented evidence of tube feed training for review.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. Review of R1's medical record revealed a current written service plan for personal care services dated June 14, 2023. This service plan stated "Tube feeding...flush g-tube with 60cc of water before feeding and 30 cc after feeding". However, documentation was not available indicating this service was provided.

2. During an interview, E2 and E3 acknowledged R1's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.

Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage, and was safe for human consumption.

Findings include:

1. During an environmental inspection, the Compliance Officer observed the refrigerator located on the patio had spoiled tomatoes with black spots, mold and indentation.

2. In an interview, E2 reported the food in the extra refrigerator is for resident consumption. E2 acknowledged the spoiled food.

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

Findings include:

1. The Compliance Officer observed the following materials in an unlocked shed located in the backyard:
- gallon container of Pinesol;
- canister of Raid;
- Clorox.

2. In an interview, E2 acknowledged the poisonous or toxic materials were not maintained in a locked area and were accessible to residents.