BARTON HOUSE I

INSP-0124225

Complete

Date: 4/25/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-05-05

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 25, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-803.C.1.a-w. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers; b. Cover orientation and in-service education for employees and volunteers; c. Include how an employee may submit a complaint related to resident care; d. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11; e. Except as provided in subsection (M), cover cardiopulmonary resuscitation training for applicable employees and volunteers, including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training; f. Cover first aid training; g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual; h. Cover staffing and recordkeeping; i. Cover resident acceptance and resident rights; j. Cover termination of residency, including: i. Termination initiated by the manager of an assisted living facility, and ii. Termination initiated by a resident or the resident's representative; k. Cover the provision of assisted living services, including: i. Coordinating the provision of assisted living services, ii. Making vaccination for influenza and pneumonia available to residents according to A.R.S. § 36-406(1)(d), and iii. Obtaining resident preferences for food and the provision of assisted living services; l. Cover the provision of respite services or adult day health services, if applicable; m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide; n. Cover resident medical records, including electronic medical records; o. Cover personal funds accounts, if applicable; p. Cover specific steps for: i. A resident to file a complaint, and ii. The assisted living facility to respond to a resident's complaint; q. Cover health care directives; r. Cover assistance in the self-administration of medication, and medication administration; s. Cover food services; t. Cover contracted services; u. Cover equipment inspection and maintenance, if applicable; v. Cover infection control; and w. Cover a quality management program, including incident report and supporting documentation;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established and documented. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards, and the Department was unable to determine substantial compliance as the documentation was not available during the inspection. Findings include: 1. The facility's policies and procedures were not available for review. 2. In an interview, E1 reported not knowing where the policies and procedures were. E1 also noted that the facility had the policies and procedures when a compliance officer came to investigate a complaint early this year. E1 acknowledged that policy and procedures were not available for review.

Permanent Solution:

Executive Director educated on regulation on 4/25/25. Ensure copy of policy and procedure binder is readily available as needed. ED familiarized with location of policy and procedure binder and is available for review.

Person Responsible:

Executive Director or Designee

Deficiency #2

Rule/Regulation Violated:

R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three sampled personnel members. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2’s personnel record revealed that E2 was hired as a caregiver in March 2025. 2. A review of E2's personnel record revealed no documentation of first aid training and CPR training. 3. In an interview, E1 acknowledged that E2 had no documentation of CPR and first aid training.

Permanent Solution:

Executive Director and Business Office Manager educated on regulation on April 25th, 2025. All current employee files were audited for CPR/First Aid. Routine audits will be completed to ensure compliance.

Person Responsible:

Executive Director, Business Office Manager or Designee

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.5.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative;

Evidence/Findings:

Based on the record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or resident’s 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 to be provided. Findings include: 1. A review of R1's medical record revealed the most recent written service plan for Directed care services dated in February 2025. However, this service plan did not include a signature and date from the resident or the resident’s representative. 2. A review of R2's medical record revealed the most recent written service plan for Directed care services dated in April 2025. However, this service plan did not include a signature and date from the resident or the resident’s representative. 3. In an interview, E1 acknowledged that R1’s and R2's service plans did not include a signature and date from the resident or the resident’s representative.

Permanent Solution:

Executive Director and Resident Care Director educated on regulation requirements. Executive Director in contact with POA for R1 to obtain signature. R2 Service plan signed on 04/25/2025.
All current resident charts will be audited to ensure compliance by 05/09/2025.

Person Responsible:

Executive Director, Resident Care Director or Designee

Deficiency #4

Rule/Regulation Violated:

R9-10-818.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on the documentation review and interview, the manager failed to ensure the 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. A review of facility documentation revealed no documentation of a disaster plan review was available for the Compliance Officer review. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Permanent Solution:

Executive Director and Maintenance Director educated on regulation on 4/25/25. Disaster Plan reviewed and acknowledged on 4/25/25.

Person Responsible:

Executive Director, Maintenance Director or Designee

INSP-0061208

Complete

Date: 12/6/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-12-07

Summary:

The following deficiency was found during the on-site investigation of complaint AZ00203870 conducted on December 6, 2023:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

A.R.S.§ 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions
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.

Evidence/Findings:

Based on record review and interview, a residential care institution failed to ensure an employee had a valid fingerprint clearance card, for one of two caregivers sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population.

Findings include:

1. A review of E3's personnel record revealed a fingerprint clearance card with an expiration date of December 11, 2009.

2. In an interview, E1 reported believing E3 was "grandfathered" for E3's fingerprint clearance card since E3 had been working with the facility for approximately 15 years. The Compliance Officer informed E1 Arizona Revised Statutes (A.R.S.) \'a7 36-411 was changed in September 2022 to remove the stipulation E1 referred to. E3 reported being unaware of the change.

3. In an interview, E1 acknowledged E3 did not have a current, valid fingerprint clearance card.

Facility Information

Inspection History

INSP-0124225

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0061208

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0061206

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings: