LAKE VIEW TERRACE MEMORY CARE RESIDENCE

Based on documentation review, record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of seven residents reviewed. The deficient practice posed a potential TB exposure risk to residents.

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. Review of R1's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R1's acceptance date, this documentation was required.

3. Review of R2's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R2's acceptance date, this documentation was required.

4. Review of R3's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R3's acceptance date, this documentation was required.

5. Review of R6's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R6's acceptance date, this documentation was required.

6. Review of R7's medical record revealed no documentation of freedom from infectious TB was available for review. Based on R7's acceptance date, this documentation was required.

7. During an interview, E1 and E2 acknowledged documentation was not available showing R1, R2, R3, R6 and R7 had documentation of freedom from infectious TB as specified in R9-10-113.

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 intermittent nursing services or restraints, for six of seven residents reviewed. 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 no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R1's acceptance date, this documentation was required.

2. Review of R2's medical record revealed no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R2's acceptance date, this documentation was required.

3. Review of R3's medical record revealed no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R3's acceptance date, this documentation was required.

4. Review of R5's medical record revealed no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R5's acceptance date, this documentation was required.

5. Review of R6's medical record revealed no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R6's acceptance date, this documentation was required.

6. Review of R7's medical record revealed no documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints. Based on R7's acceptance date, this documentation was required.

7. In an interview, E1 and E2 acknowledged R1, R2, R3, R5, R6, and R7 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required intermittent nursing services or restraints.

Based on record review and interview, the manager failed to ensure a documented residency agreement was available for six of seven residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. Review of R1's medical record revealed no residency agreement. Based on R1's acceptance date, this documentation was required.

2. Review of R2's medical record revealed no residency agreement. Based on R2's acceptance date, this documentation was required.

3. Review of R3's medical record revealed no residency agreement. Based on R3's acceptance date, this documentation was required.

4. Review of R5's medical record revealed no residency agreement. Based on R5's acceptance date, this documentation was required.

5. Review of R6's medical record revealed no residency agreement. Based on R6's acceptance date, this documentation was required.

6. Review of R7's medical record revealed no residency agreement. Based on R7's acceptance date, this documentation was required.

7. In an interview, E1 and E2 acknowledged documentation was not available showing a documented residency agreement for R1, R2, R3, R5, R6, and R7.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of two residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. Review of R5's medical record revealed a written service plan for directed care service dated September 27, 2023, and a current written service plan for directed care services dated July 2, 2024. However, service plans updated at least every once every three months before the current service plan were not available for review.

2. In an interview, E1 and E2 acknowledged R5 received directed care services and the service plan was not updated at least once every three months.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided.

Findings include:

1. Review of R4's medical record revealed the most recent written service plan for directed care services dated January 28, 2024. However, this service plan did not include a signature and date from the resident or representative.

2. Review of R5's medical record revealed the most recent written service plan for directed care services dated July 2, 2024. However, this service plan did not include a signature and date from the resident or representative.

3. In an interview, E1 and E2 acknowledged R4's and R5's service plans did not include a signature and date from the resident or representative.

This is a repeat deficiency from the complaint investigation conducted February 22, 2024.

Based on record review and interview, the manager failed to ensure a written service plan was available, for three of seven residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive.

Findings include:

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

2. A review of R6's medical record revealed a written service plan was not available for review. Based on R6's date of acceptance, a service plan was required.

3. A review of R7's medical record revealed a written service plan was not available for review. Based on R7's date of acceptance, a service plan was required.

4. In an interview, E1 acknowledged that R2's, R6's, and R7's medical records did not contain a written service plan.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency, for two of four terminated residents sampled.

Findings include:

1. A review of R1's medical record revealed R1's date of termination of residency was not available for review.

2. In an interview, E1 reported R1 was no longer a resident at this facility.

3. A review of R5's medical record revealed R5's date of termination of residency was not available for review.

4. In an interview, E1 reported R5 was no longer a resident at this facility.

5. In an interview, E1 and E2 acknowledged that R1's and R5's termination dates were not included in the medical record.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one 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. Review of R1's medical record revealed a current written service plan dated June 25, 2024. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a document titled "Physician's Orders" which contained a list of medications, however, this document was not signed by a prescribing provider. R1's medical record contained no other documentation of signed written or verbal medication orders.

3. Review of R1's July 2024 medication administration record (MAR) indicated the following:
-Atorvastatin 40 mg tab was administered once a day July 1st-7th;
-Carbidopa/Levo 25-100mg tab was administered four times a day July 1st-7th;
-Donepezil 5 mg tab was administered once a day July 1st-7th;
-Finasteride 5mg tab was administered once a day July 1st-7th; and
-Fluvoxamine 50 mg tab was administered once a day July 1st-7th.

4. In an interview, E1 acknowledged the medications were not administered in compliance with an available medication order.

This is a repeat deficiency from the on-site compliance inspection conducted on January 31, 2024.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver had the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. The deficient practice posed a health and safety risk to R1 as necessary medication services were not provided.

Findings include:

1. A review of R1's medical record revealed R1 was receiving directed care services. In addition, R1 was receiving hospice services from Hospice Compassus until March 31, 2024.

2. A review of R1's medical record revealed R1's medication orders were discontinued by Hospice Compassus on April 1st, 2024 and no current medication orders were available.

3. A review of R1's medical record revealed medication administration records (MAR) dated April 2024 and May 2024. The MAR's indicated the medications were discontinued and were waiting for a new order from a new medical practitioner. The MAR's included the following medication:
- "Hydromorphone HCL 1 MG/1 ML LIQD - Take 0.5 ML (0.5 MG) by mouth 2 times daily for pain."
- "Acetaminophen 325 MG TAB - Take 2 Tablets (650MG) by mouth every 6 hours as needed for pain or fever over a 100."
- "Lorazepam 0.5MG TAB - Take 1 Tablet by mouth every 6 hours as needed for anxiety."

4. In an interview, O1 reported E2 contacted O1 regarding filling out documentation for a new medical practitioner and requested O1 to drop off the completed documentation at the facility after Hospice Compassus ended services on March 31, 2024. O1 reported to have dropped off the documentation with the front desk a few days later. However, O1 reported R1 was not seen by the new medical practitioner since Hospice Compassus ended services and R1 was not administered any medication from April 01, 2024 to May 17, 2024. In addition, O1 reported O1 was informed by a caregiver that R1 had been in pain and crying during the night. O1 reported the facility failed to notify O1 that the new medical practitioner had not seen R1 since Hospice Compassus ended services and R1 was not administered any medication.

5. In an interview, E1 reported the facility documented that R1's medications were not provided from April 01, 2024 to May 17, 2024 and the facility made multiple attempts to contact the pharmacy for refills, however, caregivers failed to follow up with R1's new medical practitioner to obtain new medication orders and notify O1. In addition E1, reported caregivers did not notify E1 about R1 not having medications.

6. A review of Department documents revealed an incident that occurred on May 17, 2024. R1 was needing emergency medical services and was transported to the emergency room. R1 was released on May 18, 2024 around 3:30 AM and the emergency room doctor provided a medication order for antibiotics to be picked up from the pharmacy. However, the facility failed to administer the medication for R1 and was unaware about the prescription provided by the emergency room doctor.

7. In an interview, O1 reported the medication prescribed from the emergency room doctor was not administered to R1 and the facility was unaware that the medication was not administered to R1 until O1 questioned the facility about the medication on May 20, 2024.

8. In an interview, E1 acknowledged the lack of current medication orders and the facility's failure to ensure R1 received the prescribed medication demonstrated the assigned caregivers did not possess the necessary qualifications, skills, and knowledge to properly meet R1's medication needs.

Based on interview and documentation review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the names of individuals who observed the accident, emergency, or injury, for one of two applicable residents. The deficient practice posed a potential risk of re-injury.

Findings include:

1. In an interview, E1 reported R1 had an accident, emergency, or injury on March 3, 2024, that resulted in R1 needing medical services.

2. A review of facility documentation revealed an incident report for the aforementioned incident. However, the report did not include the name(s) of any individual(s) who observed the accident, emergency, or injury.

3. In an interview, E1 acknowledged the report did not include the name(s) of any individual(s) who observed the accident, emergency, or injury. E1 stated, "We just had this discussion this morning."

This is a repeat/uncorrected citation from the complaint and compliance inspection conducted on January 31, 2024.

Based on interview and documentation review, the manager of an assisted living center failed to maintain a copy of the document provided to the emergency responder which included the items listed in Arizona Revised Statutes (A.R.S.) \'a7 36-420.04(A)(1) through (9), for one of one applicable resident sampled.

Findings include:

1. In an interview, E1 stated the facility sent R1 to the hospital on February 16, 2024, for "shallow breathing."

2. A review of facility documentation revealed a "Incident Report and Investigation Worksheet" for R1 dated February 16, 2024. The report stated, "Resident was not responding verbally. [R]esident was breathing, mouth was open." The report stated facility "Called 911." However, the review revealed no documentation in compliance with A.R.S. \'a7 36-420.04(A)(1) through (9) and this statute.

3. In an interview, E1 reported E1 was familiar with this statute. E1 reported the facility had standardized forms for the information in A.R.S. \'a7 36-420.04(A)(1) through (9). When the Compliance Officer requested documentation of compliance with this statute, E1 reported E1 could not locate the documentation. E2 reported E2 gave emergency personnel the required document but did not make a copy (as required by this statute).

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A) and (C), for two of four personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution.

Findings include:

1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work."

2. A.R.S. \'a7 36-411(C)(1) and (2) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card."

3. A review of E3's personnel record revealed E3 was hired as an assistant caregiver. The review revealed a photocopy of E3's fingerprint clearance card. However, the review revealed no documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2).

4. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E3's fingerprint clearance card was valid.

5. In an interview, when the Compliance Officer asked if the governing authority made documented, good faith efforts to verify the status of E3's fingerprint clearance card upon hire or any time thereafter, E1 reported being unsure. E1 reported the verification would have taken place before E1 was hired.

6. A review of E4's personnel record revealed E4 was hired as an assistant caregiver more than 20 days before the date of the inspection. The review revealed a filled but undated "APPLICATION FOR FINGERPRINT CLEARANCE CARD (non-IVP)." The review further revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(1) and (2).

7. A review of the DPS fingerprint clearance card verification website revealed no application for a fingerprint clearance card for E4.

8. In an interview, E1 acknowledged E4 worked at the facility without a fingerprint clearance card.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of one caregivers sampled. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E2's personnel record revealed E2 was hired as a caregiver/medication technician. The review revealed a photocopy of E2's previous first aid and CPR training certification dated as expired on October 7, 2023. The review revealed no current documentation of first aid and CPR training certification.

2. In an interview, E1 acknowledged E2 did not have CPR and first aid training for a time. E1 reported E2 took and passed a re-certification course on November 16, 2023, but did not have the certification card in E2's personnel record at the time of the inspection. E1 acknowledged E2 worked at the facility for more than one month without CPR and first aid training.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident or resident's representative, for four of four residents sampled.

Findings include:

1. A review of R1's, R2's, R3's, and R4's medical records revealed current service plans. However, the service plans were not signed and dated by the respective residents or residents' representatives.

2. In an interview, E1 acknowledged the aforementioned service plans were not signed and dated by all required parties.

Based on interview, documentation review, and record review, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of four residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information.

Findings include:

1. In an interview, E1 stated the facility sent R1 to the hospital on the evening of February 16, 2024, and R1 was still out of the facility at the time of the inspection.

2. A review of facility documentation revealed a "Incident Report and Investigation Worksheet" for R1 dated February 16, 2024. The report stated, "Resident was not responding verbally. [R]esident was breathing, mouth was open." The report stated the facility "Called 911."

3. A review of R1's medical record revealed a current service plan. The service plan indicated R1 required assistance with daily services including dressing, grooming, and frequent checks at night. The review revealed documentation of assisted living services provided to R1 in February 2024. However, even though R1 was not at the facility, the document indicated the following:
-R1 was provided services during the 6:00 AM to 2:00 PM shift on February 17-22, 2024;
-R1 was provided services during the 2:00 PM to 10:00 PM shift on February 18 and 21, 2024; and
-R1 was provided services during the 10:00 PM to 6:00 AM shift on February 17 and 20-21, 2024.

4. In an interview, E1 acknowledged facility personnel signed off on providing R1 services when R1 was not at the facility.

Based on documentation review, observation, 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 if the source of a potential food borne illness could not be identified.

Findings include:

1. A review of facility documentation revealed a posted menu for the date of the inspection. The menu listed "Frosted Zucchini Bar[s]" among other items.

2. During the environmental inspection of the facility, at approximately 12:15 PM, the Compliance Officer observed residents eating lunch. The Compliance Officer did not observe frosted zucchini bars.

3. In an interview, a resident reported being served chocolate cake instead of zucchini bars.

4. In a separate interview, the facility's chef confirmed chocolate cake was served instead of zucchini bars. The chef reported not having zucchini.

Based on interview and documentation review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future, for one of four residents sampled.

Findings include:

1. In an interview, E1 stated the facility sent R1 to the hospital on February 16, 2024, for "shallow breathing."

2. A review of facility documentation revealed a "Incident Report and Investigation Worksheet" for R1 dated February 16, 2024. The report stated, "Resident was not responding verbally. [R]esident was breathing, mouth was open." The report stated facility "Called 911." However, the document did not include any action taken to prevent the accident, emergency, or injury from occurring in the future.

3. In an interview, E1 acknowledged the aforementioned incident report did not include any action taken to prevent the accident, emergency, or injury from occurring in the future.

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for six of six staff members sampled. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently.

Findings include:

1. A review of facility documentation revealed the curriculum for the facility's fall prevention training program. However, the training program did not cover fall recovery.

2. A review of the personnel records of E1, E3, E4, E6, and E7 revealed documentation of fall prevention training. However, the review revealed no documentation of fall recovery training.

3. In an interview, E1 acknowledged the facility's training curriculum for fall prevention and fall recovery did not cover fall recovery.

4. A review of E5's personnel record revealed no documentation of fall prevention and fall recovery training.

5. In an interview, E1 reported there was no documentation of fall prevention and fall recovery training available for review for E5.

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

Based on documentation review and interview, the governing authority failed to designate a manager in writing. The deficient practice posed a risk as the assisted living facility did not have a manager for approximately 10 days.

Findings include:

1. A review of Department documentation revealed an email from the facility's previous manager. In the email, the previous manager reported no longer being the manager effective September 15, 2023. The review further revealed an email from E1. In the email, E1 reported being the manager effective September 25, 2023. The review further revealed a "Service Request Detail" document dated October 4, 2023, sent to the Compliance Officer by a representative of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). The document stated, "Notice of Facility Appointment - Start/End...ALM Start date 9-27-23."

2. In an interview, E1 reported E1 was the manager effective September 25, 2023. E1 confirmed the facility did not have a manager for approximately 10 days between September 15-25, 2023.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1)-(2), for two of six personnel members sampled. The deficient practice posed a risk if a personnel member was unqualified to work in a residential care institution.

Findings include:

1. A.R.S. \'a7 36-411(C)(1)-(2) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card."

2. A review of the personnel records of E5 and E6 revealed E5 was hired as a caregiver/medication technician and E6 was hired as an assistant caregiver. The review revealed applications for employment indicating both E5 and E6 had previous employment as well as photocopies of E5's and E6's fingerprint clearance cards. However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2).

3. A review of the Department of Public Safety fingerprint clearance card verification website revealed E5's and E6's fingerprint clearance cards were valid.

4. In an interview, E1 acknowledged the requirements in A.R.S. \'a7 36-411(C)(1)-(2) were not met for E5 and E6.

This is a repeat citation from the previous compliance inspection conducted on May 4, 2022.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident to cover recordkeeping.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Staffing Policy" dated January 9, 2018. The policy and procedure covered staffing but did not cover recordkeeping. The review revealed no policy and procedure covering recordkeeping.

2. In an interview, the Compliance Officer asked for the facility's policy and procedure on recordkeeping. E1 reported not knowing whether the facility had one but would contact "corporate" and ask there.

3. In the exit interview, E1 reported E1 had not heard back from "corporate" about a policy covering recordkeeping.

Based on documentation review, interview, and record review, 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 and according to policies and procedures, for two of five caregivers and assistant caregivers sampled. The deficient practice posed a risk if a caregiver or an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed no policy and procedure covering how the facility would verify and document a caregiver's or assistant caregiver's skills and knowledge.

2. In an interview, E1 acknowledged the facility did not have a policy and procedure covering how the facility would verify and document a caregiver's or assistant caregiver's skills and knowledge.

3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in January 2023 and moved into the role of caregiver/medication technician in late December 2023. The review revealed E4's skills and knowledge as an assistant caregiver were verified and documented before E4 provided services as an assistant caregiver. However, the review revealed no documentation E4's skills and knowledge as a caregiver were verified and documented before E4 provided services as a caregiver.

4. A review of E6's personnel record revealed E6 was hired as an assistant caregiver in January 2024. However, the review revealed no documentation demonstrating E6's skills and knowledge were verified and documented before E6 provided services as an assistant caregiver.

5. A review of facility documentation revealed two personnel schedules dated December 2023 and January 2024. The schedules revealed E4 provided physical health services as a caregiver in late December 2023 and on a regular basis in January 2024. The schedules revealed E6 provided physical health services as an assistant caregiver on a regular basis in January 2024.

6. In an interview, E1 acknowledged E4's skills and knowledge as a caregiver were not verified and documented, and E6's skills and knowledge as an assistant caregiver were not verified and documented.

Technical assistance was provided on this rule during the complaint inspection conducted on July 19, 2022.

Based on documentation review, interview, and record review, the manager failed to ensure the assisted living facility had a manager, caregivers and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services, behavioral care, and ancillary services in the assisted living facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk if a caregiver or an assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs and as the assisted living facility did not have a manager for approximately 10 days.

Findings include:

1. A review of Department documentation revealed an email from the facility's previous manager. In the email, the previous manager reported no longer being the manager effective September 15, 2023. The review further revealed an email from E1. In the email, E1 reported being the manager effective September 25, 2023. The review further revealed a "Service Request Detail" document dated October 4, 2023, sent to the Compliance Officer by a representative of the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). The document stated, "Notice of Facility Appointment - Start/End...ALM Start date 9-27-23."

2. In an interview, E1 reported E1 was the manager effective September 25, 2023. E1 confirmed the facility did not have a manager for approximately 10 days between September 15-25, 2023.

3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver in January 2023 and moved into the role of caregiver/medication technician in late December 2023. The review revealed E4's skills and knowledge as an assistant caregiver were verified and documented before E4 provided services as an assistant caregiver. However, the review revealed no documentation E4's skills and knowledge as a caregiver were verified and documented before E4 provided services as a caregiver.

4. A review of E6's personnel record revealed E6 was hired as an assistant caregiver in January 2024. However, the review revealed no documentation demonstrating E6's skills and knowledge were verified and documented before E6 provided services as an assistant caregiver.

5. A review of facility documentation revealed two personnel schedules dated December 2023 and January 2024. The schedules revealed E4 provided physical health services as a caregiver in late December 2023 and on a regular basis in January 2024. The schedules revealed E6 provided physical health services as an assistant caregiver on a regular basis in January 2024.

6. In an interview, E1 acknowledged E4's skills and knowledge as a caregiver were not verified and documented, and E6's skills and knowledge as an assistant caregiver were not verified and documented.

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

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of six personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. A.A.C. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."

2. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. A review of the personnel records for E3 and E5 revealed the following:
-E3 was hired as a caregiver in July 2023;
-A tuberculin skin test (TST) for E3 dated as administered on July 10, 2023, but never read;
-No second-step TST for E3;
-E5 was hired as a caregiver/medication technician in December 2023 and terminated E5's employment in January 2024;
-A TST for E5 dated as administered on December 4, 2023, but never read; and
-No second-step TST for E5.

4. A review of facility documentation revealed two personnel schedules dated July 2023 and December 2023. The schedules revealed E3 and E5 first worked providing physical health services in July 2023 and December 2023, respectively, without evidence of freedom from infectious TB.

5. In an interview, E1 acknowledged E3 and E5 did not provide evidence of freedom from infectious TB before providing services at or on behalf of the assisted living facility or as specified in A.A.C. R9-10-113.

Technical assistance was provided on this rule during the compliance inspection conducted on May 4, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed by the caregiver or assistant caregiver before providing assisted living services to a resident, for three of five caregivers or assistant caregivers sampled. The deficient practice posed a risk if a caregiver or an assistant caregivers was unable to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, "Staffing Policy" dated January 9, 2018. The policy and procedure stated, "Staff (including contract staff) members receive orientation and training to meet each state's specific requirements prior to providing direct resident contact."

2. A review of E3's personnel record revealed E3 was hired as a caregiver in July 2023. The review revealed a "GENERAL ORIENTATION FOR NEW EMPLOYEES" form with E3's name, the topics to be covered during orientation, the method of the instruction, and places for the instructor to sign and date after orientation on a certain topic was completed. However, the form was not filled out. The review revealed no other orientation documentation for E3.

3. A review of the personnel records of E5 and E6 revealed E5 was hired as a caregiver in December 2023 (and terminated E5's employment in January 2024) and E6 was hired as an assistant caregiver in January 2024. However, the review revealed no documentation of E5's or E6's completed orientation.

4. A review of facility documentation revealed a series of personnel schedules dated between July 2023 and January 2024. The schedules revealed the following:
-E3 provided physical health services on a regular basis between July 2023 and January 2024;
-E5 provided physical health services on a regular basis in December 2023 and January 2024; and
-E6 provided physical health services during multiple shifts in January 2024.

5. In an interview, E1 acknowledged E3, E5, and E6 did not complete orientation before providing assisted living services.

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

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Medication Availability" dated June 8, 2017. The policy and procedure stated, "It is expected that medications will be given and documented as ordered. This is required by law and is a community expectation."

2. In an interview, E1 reported all residents received medication administration.

3. A review of R1's medical record revealed a current service plan indicating R1 required medication administration services. The review revealed a medication order for "DULOXETINE" daily dated December 12, 2023, as well as a medication administration record (MAR) dated January 2024. The MAR indicated R1 did not receive "DULOXETINE" on January 21-24, 2024, with the reason indicated as "WAITING FOR PHARMACY TO DELIVER."

4. A review of R2's medical record revealed a current service plan indicating R2 required medication administration services. The review revealed a medication order for "alendronate" once weekly and "fluticasone" daily dated December 15, 2023, as well as a MAR dated January 2024. The MAR indicated R2 did not receive "alendronate" on January 5 and 12, 2024, with the reason indicated as "WAITING FOR PHARMACY TO DELIVER" the medication. The MAR further indicated R2 did not receive "fluticasone" on January 1-9, 2024, with the reason indicated as either "WAITING FOR FAMILY TO DELIVER MEDICATIONS," "WAITING FOR PHARMACY TO DELIVER", or the "Med not in house."

5. A review of R5's medical record revealed a current service plan indicating R5 required medication administration services. The review revealed a medication order for "AMIODARONE" twice daily and "ELIQUIS" twice daily dated December 12, 2023, as well as a MAR dated January 2024. The MAR indicated R5 did not receive the first dose of "AMIODARONE" on January 25-26, 2024, or the first dose of "ELIQUIS" on January 25, 2024, with the reason indicated as "WAITING FOR PHARMACY TO DELIVER."

6. In an interview, E1 reported the aforementioned medications were not administered as ordered, as they were not available at the facility.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, for two of eight applicable residents sampled. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay."

2. A review of R4's medical record revealed an incident report dated November 4, 2023. The document indicated the facility "Called 911" and R4 was "Sent to Emergency Room." The document included a place to document the "Physician name," "date," "time," and the manner of contact. However, the items were left blank.

3. A review of R6's medical record revealed an incident report dated December 20, 2023. The document indicated the incident occurred at 5:15 PM and R6 was "Sent to Emergency Room." However, the document revealed R6's primary care provider was not notified until 7:56 PM, more than two and a half hours after the incident occurred.

4. In an interview, E1 acknowledged the manager failed to immediately notify the residents' primary care providers.

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

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented all items required by this rule, for seven of eight applicable residents sampled. The deficient practice posed a potential risk of re-injury.

Findings include:

1. A review of the medical records of R4, R6, R7, R8, R9, R10, and R11, revealed seven incident reports dated between November 4, 2023, and January 7, 2024. Each of the incident reports stated the facility "Called 911," the resident was "Sent to Emergency Room," or both. Three of the incident reports did not include the name(s) of individual(s) who observed the accident, emergency, or injury and six of the incident reports did not include any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. In an interview, E1 acknowledged the manager failed to document all items required by this rule.