HERITAGE OAKS ASSISTED LIVING LLC

INSP-0124567

Complete

Date: 4/14/2025 - 4/15/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-21

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00218652 conducted on April 14, 2025.

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. 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, baseline 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis (TB) infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E1’s and E4’s personnel records revealed annual training and education related to recognizing the signs and symptoms of TB, to include initial training per R9-10-113.A.1, was not available for review. 2. A review of R1’s medical record revealed documentation of baseline screening to include a risk assessment, symptom screening, and a negative TB test, dated within seven days after R1’s date of acceptance, was not available for review. 3. A review of R2’s medical record revealed a negative TB test dated 19 days prior to R2’s date of admission. However, documentation of a complete baseline screening to include a risk assessment and symptom screen were not available for review. 4. In an interview, E1 and E2 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f. Technical assistance was provided for this rule during the on-site compliance and complaint inspection conducted on January 3, 2024.

Temporary Solution:

Finding 1: By May 19, 2025, the Facility Manager will ensure that E1 and E4 complete an online TB training module (e.g., CDC’s TB 101 for Health Care Workers) focusing on recognizing TB signs and symptoms. Completion certificates will be printed and filed in their personnel records.
Finding 2: By May 19, 2025, the facility manager will coordinate with a licensed medical practitioner to complete R1’s baseline TB screening, including a risk assessment for prior exposure, symptom screening, and a TB test (e.g., tuberculin skin test or IGRA). Results will be documented in R1’s medical record.
Finding 3: By May 19, 2025, the facility manager will ensure R2 completes a risk assessment for prior TB exposure and a symptom screening by a licensed medical practitioner. Since the TB test is recent (within 90 days), no new test is required unless indicated. Results will be documented in R2’s medical record.

Permanent Solution:

Finding 1: By May 19, 2025, the facility will implement a comprehensive TB training program for all employees and volunteers. The program will include: Initial TB training within 7 days of hire, covering signs, symptoms, and infection control practices, using CDC or Arizona Department of Health Services (ADHS) materials. Annual refresher training scheduled via the facility’s HR calendar. Our initial orientation will include a segment on TB training.
Finding 2: By May 19, 2025, the facility will revise its admission policy to require complete baseline TB screening (risk assessment, symptom screening, and TB test) within 7 days after resident acceptance.
Finding 3: The permanent solution for Finding 2 (revised admission policy, staff training, and record review by May 19, 2025) will address this issue, ensuring all residents, including R2, have complete baseline TB screenings with risk assessment and symptom screening documented, regardless of prior test timing.

Person Responsible:

Reid Reilly, Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for four of four personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. § 36-411 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency 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. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459. D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service. E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked. F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card. G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety. H. For the purposes of this section: 1. "Direct supportive services": (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including: (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair. (ii) Assistance with self-administration of medication. (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room. (iv) Transportation services, including van services. (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution. 2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised. 3. "Home health services" has the same meaning prescribed in section 36-151." Findings include: 1. A review of E1’s personnel record revealed E1 had been hired in August of of 2020, and was a manager. 2. A review of E1's personnel record revealed documentation of an Adult Protective Services registry check was not available for review. 3. A review of E3's personnel record revealed E3 had been hired as an assistant caregiver in December of 2024. 4. A review of E3's personnel record revealed documented attempts to contact E3's prior employers was not available for review. 5. A review of E3's personnel record revealed documentation of an Adult Protective Services registry check was not available for review. 6. A review of E4’s personnel record revealed E4 had been hired as a caregiver in February of 2023. 7. A review of E4's personnel record revealed an employment record covering August of 2022 through E4's hire date. However, E4's fingerprint clearance card had been issued in 2018, leaving a more than six month period of time between 2018 and August of 2022 during which E4's employment record did not document E4 had been employed by any employer. 8. A review of E5’s personnel record revealed E5 had been hired as a caregiver in October of 2023. 9. A review of E5's personnel record revealed documentation of an Adult Protective Services registry check was not available for review. 10. In an interview, E1 and E2 acknowledged the personnel records provided for E1, E3, E4, and E5 did not include documentation of compliance with all sections of ARS § 36-411.

Temporary Solution:

Finding 1: By May 19, 2025, the Facility Manager will verify E1’s (and all others) status's on the APS registry via the Arizona Department of Economic Security’s online portal. The verification result will be documented in E1’s (and all others) personnel file with a dated printout or screenshot.
Finding 2: By May 19, 2025, the Facility Manager will contact E3’s prior employers to obtain information or recommendations relevant to E3’s fitness to work in an assisted living facility. Documentation of contact attempts (e.g., emails, call logs) and responses will be placed in E3’s personnel file.
Finding 3: E4 had a reported 6 month gap in employment history. Manager knows E4 filled out application incorrectly and that there was no gap in employment. Manager will have E4 redo application history to show the true reflection of no gap in employment history.

Permanent Solution:

Finding 1: By May 19, 2025, the facility will implement a policy requiring APS registry checks for all employees upon hire and by March 31 annually, per A.R.S. § 36-411.C.3-5.
Finding 2: Manager will make sure good-faith efforts to contact prior employers for all new hires.
Finding 3: Manager shall ensure employees fill out application history correctly in the future and if there are employment gaps to follow the rules of ensuring they reapply for the fingerprint clearance card. Turns out the employee had no lapse in employment. See updated form

Person Responsible:

Reid Reilly, Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the facility's license revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed an exit door from the kitchen had a door alarm magnet, but was missing the door alarm entirely. The Compliance Officer observed when the door was opened, an alarm did not sound. 3. During an environmental tour of the facility, the Compliance Officer observed an exit door from the living room had a door alarm, but was missing the magnet. The Compliance Officer observed when the door was opened, an alarm did not sound. 4. In an interview, E1 and E2 acknowledged the facility provided directed care services, and did not have a means to control or alert employees of the egress of a resident from the facility on all exits.

Temporary Solution:

Finding 1: After inspection, manager immediately purchased brand new door alarms and installed door alarms on the kitchen door to ensure compliance and safety.
Finding 2: After inspection, manager immediately purchased brand new door alarms and installed door alarms on the living room door to ensure compliance and safety.

Permanent Solution:

Finding 1: Manager will ensure there is always working door alarms on every egress door that is required to have one.
Finding 2: Manager will ensure there is always working door alarms on every egress door that is required to have one.

Person Responsible:

Reid Reilly, Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a mediation order, for one of two sampled residents. Findings include: <ol><li>A review of R2's medical record revealed a service plan, dated November 11, 2024, for personal care services including medication administration.</li><li>A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2025. For the medication, "Memantine HCI Oral Tablet 5 MG, Give 5 mg by mouth at bedtime for dementia," the MAR indicated the following:<ol><li>On March 20, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 21, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 22, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 23, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 24, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 25, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 26, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 27, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 28, 2025, the medication had not been administered due to, "Medication not Available";</li><li>On March 29, 2025, the medication had been marked as administered;</li><li>On March 30, 2025, the medication had not been administered due to, "Medication not Available"; and</li><li>On March 31, 2025, the medication had not been administered due to, "Medication not Available".</li></ol></li><li>A review of R2's medical record revealed an order from a medical practitioner ordering the medication to be held until filled, discontinued, or changed was not available for review.</li><li>A review of R2's medical record revealed a termination notice stating the facility was not able to meet R2's needs for ordered medication was not available for review.</li><li>In an interview, E1 acknowledged the medication had not been administered on March 29, 2025 as it was not yet available on that date.</li><li>In an interview, E1 and E2 acknowledged R2 had not been administered Memantine between March 20 and March 31 due to the medication not being available.</li></ol>

Temporary Solution:

Finding 1: By May 19, 2025, the Facility Manager will ensure R2’s Memantine HCl 5 mg is obtained from the pharmacy and administered as ordered by the medical practitioner. If the medication cannot be obtained immediately, the Facility Manager will contact R2’s prescribing practitioner by May 19, 2025, to obtain a temporary hold order or alternative instructions, which will be documented in R2’s medical record. The MAR for March 29, 2025, will be corrected to reflect non-administration with a note explaining the error. If the facility cannot meet R2’s medication needs, a termination notice will be issued to R2 or their representative by May 19, 2025, in accordance with Arizona regulations, and documented in R2’s record.

Permanent Solution:

Finding 1: Manager learned about a new way to do things during meeting with inspector and that is to obtain an order from the Dr. to hold the medication until received. This will ensure compliance and if the Dr does not approve the hold then we let the resident's family know and if they can't obtain it then we either pay for it or have the resident move out.

Person Responsible:

Reid Reilly, Manager

Deficiency #5

Rule/Regulation Violated:

A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of four personnel sampled. Findings include: 1. A review of E3's personnel record revealed documentation of completed initial training on fall prevention and fall recovery was not available for review.2. In an interview, E1 and E2 acknowledged the personnel record provided for E3’s had not included documentation of initial training in fall prevention and fall recovery training.

Temporary Solution:

Finding 1: By May 19, 2025, the Facility Manager will ensure E3 completes initial training on fall prevention and fall recovery using materials from the Arizona Falls Prevention Coalition or equivalent resources aligned with best practices. The training will cover identifying fall risks, prevention strategies, and safe fall recovery techniques. A completion certificate or signed training log will be placed in E3’s personnel file, documenting the date, content, and instructor.

Permanent Solution:

Finding 1: Manager will ensure that all employees moving forward receive an initial fall training and that all employees also partake in an annual fall training class.

Person Responsible:

Reid Reilly, Manager

INSP-0070561

Complete

Date: 1/30/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-02-06

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on January 30, 2023:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents.

Findings include:

1. A review of the facility's policy and procedure manual revealed a medication policy dated February 16, 2022. The medication policy stated, "The manager or designee will establish with resident &/or their representative at time of move-in, how medications will be procured to ensure medications are received in a timely & proper manner. If the resident's medications are not procured in a timely manner, the resident's physician will be notified to determine the best course of action. A note will be made in the resident's chart when a medication is not procured in a timely manner. The person responsible for procuring the medication will be routinely followed up with until medication is properly procured."

2. A review of R2's medical record revealed a service plan dated August 4, 2022 for personal care services including medication administration. The service plan stated, "Medications are ordered by care staff/manager from ______ [left blank]."

3. A review of facility documentation revealed a form titled, "Medication Refill Chart." The form included the date, resident, medication name, and date needed, and the initials of the staff making the entry. Each entry was crossed out with a second initial. The form included the following entries for R2:
-"12/18...Gas Relief [Simethicone], ASAP";
-"12/19...Simethicone 125 mg (milligrams), ASAP";
-"1/6/23...Famotidine 40 mg, ASAP";
-"1/14/23...Gas Relief 125 MG [Simethicone], ASAP";
-"1/14/23..Famotidine, ASAP";
-"1/15/23...Famotidine, ASAP";
-"1/15/23...Simethicone chew tab, ASAP"; and
-"1/23/23...Simethicone chew tab, ASAP."

4. In an interview, E3 reported the caregivers log the medication if they notice it needs to be refilled and after contacting the pharmacy or other appropriate person to request the refill, the entry is crossed out and initialed. E3 reported if the same medication is logged again that will alert staff to determine why the first refill request was not successful. E3 reported this may include contacting the prescriber, however, E3 reported specific documentation of contacting R2's physician regarding medication refills was not available for review.

5. A review of R2's medical record revealed list of medication orders dated October 24, 2022 which included the following:
-"Escitalopram Oxalate 20 mg Oral Tablet, Give 1 tab PO QD";
-"Simethicone Oral Tablet Chewable 125 MG, Give 1 tab PO to chew after each meal"; and
-"Famotidine 40 MG Oral Tablet, Give 1 tab PO QHS."

6. A review of R2's medical record revealed a medication administration record (MAR) dated December 2022. For the medication, "Escitalopram 20 MG, take 1 tab QD for mod," the MAR indicated the following:
-On December 26 through December 30, 2022, the medication was marked with the exception, "Not Available." However, log entries on the medication refill chart were not made for any of these missed doses; and
-On December 31, the medication was initialed at 8:00 PM as administered.

7. A review of R2's medical record revealed a MAR dated January 2023. For the medication, "Escitalopram 20 MG, take 1 tab QD for mod," the MAR indicated the following:
-On January 1, 2023, the medication was initialed at 8:00 PM as administered;
-On January 2-6, 2023, the medication was marked with the exception, "Not Available," however, log entries on the medication refill chart were not made for any of these missed doses;
-On January 7, 2023, the medication was initialed at 8:00 PM as administered; and
-On January 8-10, 2023, the medication was marked with the exception, "Not Available," however, log entries on the medication refill chart were not made for any of these missed doses.

8. In an interview, E1 acknowledged R2's "Escitalopram" was not available between December 26, 2022 and January 10, 2023 and was not administered on December 31, 2022, January 1, 2023, or January 7, 2023.

9. A review of R2's medical record revealed a MAR dated January 2023. For the medication, "Famotidine Oral Tablet 40 mg, Give 1 tab PO QHS," the MAR indicated the following:
-On January 6, 2023, the medication was marked with the exception, "Not Available";
-On January 7, 2023, the medication was initialed at 8:00 PM as administered;
-On January 8-10, 2023, the medication was marked with the exception, "Not Available," however, log entries on the medication refill chart were not made for any of these missed doses;
-On January 11, 2023, the medication was initialed at 8:00 PM as administered;
-On January 12-13, 2023, the medication was marked with the exception, "Not Available," however, log entries on the medication refill chart were not made for any of these missed doses;
-On January 14, 2023, the medication was marked with the exception, "Out";
-On January 15, 2023, the medication was initialed at 8:00 PM as administered; and
-On January 16-18, 2023, the medication was marked with the exception, "Not Available," however, log entries on the medication refill chart were not made for any of these missed doses.

10. In an interview, E1 acknowledged R2's "Famotidine" was not available between January 6-18, 2023 and was not administered on January 7, 11, or 15, 2023.

11. A review of R2's medical record revealed a MAR dated December 2022. For the medication, "Simethicone Oral Tablet Chewable 125 MG, Give 1 tab PO to chew after each meal," the MAR indicated the following:
-On December 18, 2023, at 5:30 PM, the medication was marked with the exception, "Awaiting Refill";
-On December 19, 2023, at 8:30 AM, the medication was marked with the exception, "Out of Stock";
-On December 19, 2023, at 12:30 PM, the medication was marked with the exception, "N/a";
-On December 19, 2023, at 5:30 PM and December 20, 2023 at 8:30 AM, the medication was marked with the exception, "Not Available";
-On December 20, 2023 at 12:30 PM, the medication was marked with the exception, "N/a", however, a log entry on the medication refill chart was not made at the time of this missed dose;
-On December 20, 2023 at 5:30 PM and December 21, 2023 at 8:30 AM, the medication was marked with the exception, "Not Available", however, log entries on the medication refill chart were not made for either of these missed doses; and
-On December 21, 2023 at 12:30 PM, the medication was marked with the exception, "Out of stock," however, a log entry on the medication refill chart was not made at the time of this missed dose.

12. A review of R2's medical record revealed a MAR dated January 2023. For the medication, "Simethicone Oral Tablet Chewable 125 MG, Give 1 tab PO to chew after each meal," the MAR indicated the following:
-On January 14, 2023, at 12:30 PM, the medication was marked with the exception, "Not Available";
-On January 14, 2023, at 5:30 PM, the medication was marked with the exception, "Out";
-On January 15, 2023, at 8:30 AM, the medication was initialed as administered;
-On January 15, 2023, at 12:30 PM, the medication was marked with the exception, "N/A";
-On January 15, 2023, at 5:30 PM, the medication was marked with the exception, "On order";
-On January 16, 2023, at 8:30 AM, the medication was initialed as administered;
-On January 16, 2023, at 12:30 PM, the medication was marked with the exception, "N/a," however, a log entry on the medication refill chart was not made at the time of this missed dose;
-On January 16, 2023, at 5:30 PM, the medication was marked with the exception, "Not Available," however, a log entry on the medication refill chart was not made at the time of this missed dose;
-On January 17, 2023, at 8:30 AM, the medication was initialed as administered;
-On January

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented.

Findings include:

1. A review of the facility work schedule revealed the facility operated on three shifts, however, the shift times were not discernable from the work schedule.

2. In an interview, E1 reported the day and swing shifts overlap considerably, and the overnight shift is from 10:00 PM to 6:00 AM. E1 reported the disaster drills are conducted during the overlap between the day and swing shift so both shifts are covered by a single drill.

3. A review of facility disaster drills revealed the following documentation:
-A document dated April 29, 2021 for the "AM + PM" shift. However, the time was written over, obscuring the original entry, and appeared to say either, "2:05 pm," or "4:05 pm";
-A document dated December 13, 2021 for the "AM + PM" shift. The drill documentation did not include the time of the drill;
-A document dated April 15, 2022 at 4:06 PM for the "PM" shift; however, more than three months had elapsed since the previous drill;
-A document dated September 8, 2022 at 3:30 PM for the "2nd" shift; however, more than three months had elapsed since the previous drill;
-A document dated December 2, 2022 at 2:00 PM for the "AM + PM" shift; and
-A document dated January 4, 2023 at 3:00 PM for the "2nd" shift.

4. In an interview, E1 acknowledged no drills were conducted on the overnight shift. E1 acknowledged disaster drills were not conducted and documented at least once every three months on each shift.

Technical assistance for this rule was provided during the on-site compliance inspection conducted on January 6, 2022.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of facility documentation revealed the following evacuation drills for employees and residents were completed during the previous twelve months:
-December 13, 2021 at 1:50 PM;
-August 24, 2022 at 9:00 AM (more than 6 months after the previous drill);
-September 8, 2022 at 3:30 PM; and
-January 5, 2023 at 4:00 PM.

2. In an interview, E1 acknowledged evacuation drills for employees and residents were not conducted at least once every six months.

Technical assistance for this rule was provided during the on-site compliance inspection conducted on January 6, 2022.

HERITAGE OAKS ASSISTED LIVING LLC

Facility Information

Inspection History

INSP-0130945

Summary:

INSP-0124567

Summary:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0070563

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

INSP-0070561

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings: