MIRABELLA AT ASU

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one 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. A review of R1's medical record revealed a service plan (dated August 20, 2024) that indicated R1 would receive the following services:
- Night checks, 2-3 times per night;
- Maximum assistance with activities;
- Maximum assistance with eating, with each meal;
- Maximum assistance with ambulation;
- Moderate assistance with bed mobility;
- Maximum assistance with compression stockings;
- Maximum assistance with dressing;
- Maximum assistance with oral care;
- Maximum assistance with toileting; and
- Maximum assistance with incontinence.

2. A review of R1's activities of daily living (ADL) documentation, for the month of August 2024, revealed missing documentation of night checks on the following dates:
- August 10, 2024;
- August 13, 2024;
- August 18, 2024; and
- August 23, 2024.

3. A review of R1's ADL documentation, for the months of August and September 2024, revealed missing documentation of activities assistance on the following dates:
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 21, 2024;
- August 30, 2024;
- September 2, 2024; and
- September 3, 2024.

4. A review of R1's activities of daily living (ADL) documentation, for the month of August 2024, revealed missing documentation of eating assistance on the following dates:
- August 2, 2024, at 6:00 PM;
- August 8, 2024, at 1:00 PM and 6:00 PM;
- August 9, 2024, at 9:00 AM, 1:00 PM, and 6:00 PM;
- August 16, 2024, at 1:00 PM and 6:00 PM;
- August 21, 2024, at 9:00 AM, 1:00 PM, and 6:00 PM;
- August 22, 2024, at 6:00 PM;
- August 30, 2024, at 6:00 PM;
- September 2, 2024, at 1:00 PM and 6:00 PM; and
- September 4, 2024, at 9:00 AM, 1:00 PM, and 6:00 PM.

5. A review of R1's ADL documentation, for the month of August 2024, revealed missing documentation of ambulation assistance on the following dates:
- August 4, 2024;
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 18, 2024;
- August 21, 2024;
- August 23, 2024;
- August 29, 2024; and
- August 30, 2024.

6. A review of R1's ADL documentation, for the month of August 2024, revealed missing documentation of bed mobility assistance on the following dates:
- August 4, 2024;
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 18, 2024;
- August 21, 2024;
- August 23, 2024;
- August 29, 2024; and
- August 30, 2024.

7. A review of R1's ADL documentation, for the months of August and September 2024, revealed missing documentation of compression stockings assistance on the following dates:
- August 4, 2024;
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 21, 2024;
- August 23, 2024;
- August 30, 2024;
- September 2, 2024; and
- September 4, 2024.

8. A review of R1's ADL documentation, for the months of August and September 2024, revealed missing documentation of dressing assistance on the following dates:
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 21, 2024;
- August 23, 2024;
- August 30, 2024;
- September 2, 2024; and
- September 4, 2024.

9. A review of R1's ADL documentation, for the months of August and September 2024, revealed missing documentation of oral care assistance on the following dates:
- August 4, 2024;
- August 8, 2024;
- August 9, 2024;
- August 16, 2024;
- August 21, 2024;
- August 23, 2024;
- August 30, 2024;
- September 2, 2024; and
- September 4, 2024.

10. A review of R1's ADL documentation, for the month of August 2024, revealed missing documentation of toileting assistance on the following dates:
- August 2, 2024, at 4:00 PM;
- August 4, 2024, at 12:00 PM and 4:00 PM;
- August 8, 2024 at 4:00 PM;
- August 9, 2024, at 8:00 AM, 12:00 PM, and 4:00 PM;
- August 12, 2024, at 4:00 AM;
- August 16, 2024, at 4:00 PM;
- August 21, 2024, at 8:00 AM, 12:00 PM, and 4:00 PM; and
- August 30, 2024 at 4:00 PM.

11. A review of R1's ADL documentation, for the month of August 2024, revealed missing documentation of incontinence care on the following dates:
- August 4, 2024;
- August 8, 2024;
- August 9, 2024;
- August 12, 2024;
- August 15, 2024;
- August 16, 2024;
- August 21, 2024;
- August 23, 2024; and
- August 30, 2024.

12. In an interview, E1 reported R1 received all aforementioned services in the months of August and September 2024. However, documentation of the services provided were not available for Compliance Officer review. E1 acknowledged a caregiver failed to document the services provided in R1's medical record.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2)(b)(iii) for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. R9-10-814(B)(2)(b)(iii) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..."

2. A review of R1's service plan (dated August 20, 2024) revealed R1 received directed care services, and was confined to a bed or chair.

3. A review of R1's medical record did not include documentation of the determination required.

4. In an interview, E1 acknowledged R1's medical record did not include the required determination per R9-10-814(B)(2)(b)(iii).

Based on record review and interview, the manager failed to ensure resident records contained evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113 for two of two residents sampled. The deficient practice posed a 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. A review of R1's medical record revealed no documentation of a tuberculosis screening test at the time of the inspection. Based on R1's acceptance date, this documentation was required.

3. A review of R2's medical record revealed no documentation of a tuberculosis screening test at the time of the inspection. Based on R2's acceptance date, this documentation was required.

4. In an interview, E1 acknowledged R1's and R2's medical records did not contain evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113.

Technical assistance was provided on the Rule during the compliance inspection conducted August 16, 2022.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the identification of residents needing assistance for evacuation and the identification of residents who were not evacuated. The deficient practice posed a risk if employees were unable to implement the evacuation plan.

Findings include:

1. A review of Department documentation revealed the facility was licensed for directed level of care.

2. A review of the evacuation drill documentation revealed evacuation drills conducted October 18, 2023 and May 8, 2024. However, documentation of the identification of the residents needing assistance and the identification of residents who were not evacuated was not available.

3. In an interview, E4 reported not all the residents participated in the evacuation drill dated May 8, 2024.

4. In an interview, E1 and E4 acknowledged the evacuation drills did not include the identification of residents needing assistance for evacuation and the identification of residents who were not evacuated.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employees to have a valid fingerprint clearance card or fingerprint clearance card application within 20 working days of hire for two of six sampled personnel records reviewed, which posted a safety risk.

Findings include:

1. Review of randomly selected personnel records found that E5's personnel record, who was hired on December 15, 2022, contained no documentation of a fingerprint clearance card nor fingerprint clearance card application. There was no documentation that E5 had a fingerprint clearance card that was verified with the Department of Public Safety (DPS) or DPS website at the time of hire nor anytime since. E5 was hired as a maintenance Technician. Part of E5's responsibilities is going in and out of residents' units as needed for repairs.

2. Review of E6's personnel record, who was hired on November 28, 2022, contained no documentation of a fingerprint clearance card nor fingerprint clearance card application. There was no documentation that E6 had a fingerprint clearance card that was verified with the Department of Public Safety (DPS) or DPS website at the time of hire nor anytime since. E6 was hired as a housekeeper. Part of E6's responsibilities is cleaning residents' units.

3. During an interview, E1 acknowledged there was no documentation from the DPS website nor any other documented evidence that these two sampled employees had a fingerprint clearance card that was valid.

Based on record review and interview, the manager failed to ensure that one of four sampled personnel records reviewed, that before providing assisted living services to a resident, a manager provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification, which posed a health and safety risk to a resident.

Findings include:

1. Review of randomly selected personnel records revealed that E1's record contained documentation of completing the required first aid and CPR training, however, this certification had expired in July 2023. E1 was hired as a manager.

2. During an interview, E1 acknowledged E1's first aid and CPR training had expired in July of 2023; E1 was a manager.