ARIZUMA HORIZONS ASSISTED LIVING HOMES

Based on observation, interview, documentation review, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E5.

Findings include:

1. When the Compliance Officer arrived at the facility, E5 was observed at the facility.

2. In an interview, E1 reported E5 was hired as a housekeeper on November 8, 2023.

3. Review of the facility's policy and procedure manual revealed a policy titled "Environmental Services Personnel Qualifications" reviewed and signed by E1 September 30, 2022. This policy stated "...Employee requirements: 1. Full name and date of birth. 2. Current address and phone number. 3. Date of hire and the termination date at the end of employment. 4. Work experience and references..."

4. Review of the personnel records revealed no record for E5.

5. In an interview, E1 acknowledged a personnel record was not established for E5.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two 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 document titled "Activities of Daily Living Record" dated November 2023. This document revealed R1 was assisted with oral hygiene, bathing, toileting, incontinent care, and repositioning. However, documentation was not available indicating these services were provided November 8th - present.

2. Review of R2's medical record revealed a document titled "Activities of Daily Living Record" dated November 2023. This document revealed R2 was assisted with oral hygiene, bathing, toileting, incontinent care, and repositioning. However, documentation was not available indicating these services were provided November 6th - present.

3. In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated October 2, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated October 23, 2023. This medication order stated "Levothyroxine 88mcg 1 PO QD".

3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated "Levothyroxine 88mcg 1 PO QD" and indicated one tab was administered at 7:30am November 1st - 7th. However, did not include documentation the medication was administered at 7:30am November 8th - present.

4. During an observation of R1's medications, Levothyroxine 88mcg was observed.

5. Review of R2's medical record revealed a current written service plan dated October 2, 2023. This service plan indicated R2 received medication administration.

6. Review of R2's medical record revealed signed medication orders dated October 23, 2023. These medication orders stated the following:
"Trazodone 100mg 1 PO QHS"
"Escitalopram 10mg 1 PO QD"
"Haloperidol 1mg PO BID"

7. Review of R2's medical record revealed a November 2023 MAR. This MAR stated the following:
"Trazodone 100mg 1 PO QHS" However, did not include documentation the medication was administered at 8pm November 1st - present.
"Escitalopram 10mg 1 PO QD" and indicated one tab was administered at 8am November 1st - 5th. However, did not include documentation the medication was administered at 8am November 6th - present.
"Haloperidol 1mg PO BID" and indicated one tab was administered at 8am and 8pm November 1st - 5th. However, did not include documentation the medication was administered at 8am November 6th - present.

8. During an observation of R2's medications, Trazodone 100mg, Escitalopram 10mg, and Haloperidol 1mg were observed.

9. In an interview, E1 reported the medications were administered per the medication order and acknowledged R1's and R2's medical records did not include documentation the medications were administered on the above listed days.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed two bottles of Walgreens Severe Cold & Flu unlocked in the kitchen refrigerator.

2. During an observation, the caregivers were not accessing the medications at the time of arrival.

3. In an interview, E1 acknowledged medications were stored unlocked.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "Disaster plan, Relocation, Records, Medications, Food and Water." Documentation was available in the policy and procedure that showed the disaster plan was last reviewed September 30, 2022.

2. In an interview, E1 acknowledged the facility's disaster plan was not reviewed within the last 12 months.

Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted on each hallway of each floor of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed two interior hallways did not have a posted evacuation path.

2. In an interview, E1 acknowledged the evacuation path was not posted on each hallway of the assisted living facility.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed three rechargeable fire extinguishers. These fire extinguishers had a service tag attached dated September 2022.

2. In an interview, E1 acknowledged the rechargeable fire extinguishers were not serviced at least once every 12 months.

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

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed Lysol toilet bowl cleaner unlocked in the cabinet under a hall bathroom sink. This cabinet had a locking device, however the device was not locked. In addition, the Compliance Officer observed Lysol toilet bowl cleaner and Microban multipurpose cleaner unlocked in the cabinet under a hall bathroom sink. The cabinet had a locking device, however the device was not locked.

2. During an observation, the caregivers were not accessing the toxic materials at the time of arrival.

3. In an interview, E1 acknowledged toxic materials were stored unlocked.

Based on documentation review, record review and interview, the manager accepted and retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance when the resident is accepted by the assisted living facility the resident or resident's representative requires documentation the resident be accepted by or remain in the assisted living facility.

Findings include:

1. A review of the facility records revealed the facility is licensed for Directed level of care.

2. A review of R2's medical record revealed a personal care service plan dated December 14, 2022. The service plan identified R2 as "bedbound."

3. In an interview, E1 reported R2 was bedbound at admission. E1 reported the facility does require the resident or resident's representative to complete documentation approving a resident who is confined to a bed or chair because of an inability to ambulate even with assistance at admission. E1 acknowledged this document was not completed at admission for R2. E1 acknowledged the manager accepted and retained residents who were confined to a bed or chair because of an inability to ambulate even with assistance without documentation from resident or resident's representative that the resident can be accepted by or remain in the assisted living facility.