CANYON ASSISTED LIVING LLC

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents.

Findings include:

1. When the Compliance Officer arrived, E4 was the only person working at the facility.

2. Review of the posted personnel schedule dated July 2024 revealed E1 and E3 were scheduled to work the 6 am-6 am shift July 10th. E1 and E3 were not present when the Compliance Officer arrived, and E4 was not listed on the schedule.

3. In an interview, E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.

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

Based on record review and interview, the manager failed to ensure an employee provided documentation 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, as specified in R9-10-113, for one of three employees 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 the Centers for Disease Control and Prevention 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. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required.

4. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

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

Based on observation, record review, documentation review, and interview, the manager failed to ensure a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs.

Findings include:

1. When the Compliance Officer arrived, the manager was not present. E4 was the only employee at the facility with three residents.

2. There was no personnel record for E4, and no documentation that E4 had completed a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers provided. Therefor, E4 was no qualified to be left alone with the residents based on the lack of caregiver training.

3. A review of the azcg.tmutest.com website revealed no documentation of a caregiver training certificate for E4.

4. In an interview, E1 reported that E4 was not a caregiver, and that E1 left the residents alone with E4 so that E1 could pick up E1's child. E1 acknowledged neither a manager or caregiver was present at the facility when the Compliance Officer arrived.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for one of three employee records reviewed.

Findings include:

1. A review of E1's personnel record revealed the record did not include the starting date of employment.

2. In an interview, E1 acknowledged E1's personnel record did not include the starting date of employment.

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

Based on observation, record review, and interview, the manager failed to ensure a personnel record was available for one of two employees reviewed. The deficient practice posed a risk as required information could not be verified for E4.

Findings include:

1. When the Compliance Officer arrived, E4 was the only employee present at the facility.

2. Review of the personnel records revealed no record for E4.

3. During an interview, E1 acknowledged a personnel record was not available for E4.

This is a repeat deficiency from the on-site compliance and complaint inspection conducted on December 19, 2022.

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. Review of R1's medical record revealed a current written service plan for directed care services dated April 6, 2024. This service plan stated the following service was needed:
"Clean fingernails, Trimmed, clip, filed."

2. Review R1's medical record revealed documents titled "Vitals and Activities of Daily Living" for May, June, and July 2024. However, the service titled "Finger Nail Care" contained no signature or initial from a caregiver indicating the service had been provided on all three documents.

3. The Compliance Officer observed that R1's fingernails appeared as if the nail care was provided.

4. During an interview, E1 acknowledged R1's medical record did not include documentation of nail care.

This is a repeat deficiency from the on-site compliance and complaint inspection conducted on December 19, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R2's medical record revealed no documentation showing the flu vaccination was offered or received. Based on R2's date of admission, this documentation was required.

3. In an interview, E1 acknowledged R2's medical record did not include documentation showing the flu vaccination was offered or received.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one resident reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents.

Findings include:

1. Review of R1's medical record revealed a current written service plan for directed care services dated April 6, 2024. This service plan revealed no documentation of R1's weight. In addition, R1's medical record revealed no documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated.

2. In an interview, E1 acknowledged R1's service plan did not include documentation of R1's weight and documentation was not available in R1's medical record from a medical practitioner stating weighing R1 was contraindicated.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officer observed the following medications in an unlocked box in the kitchen refrigerator:
-Morphine Sulfate Oral Solution
-Lorazepam

2. During an environmental inspection of the facility, the Compliance Officer observed the following medications in an unlocked drawer in the kitchen:
-"Novothyral"
-"Dafalgan"
-"dapagliflozinum/metforminum"
-"Bisoprolol"
In an interview, E1 reported that these medication belonged to E4.

3. In an interview, E1 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

This is a repeat deficiency from the on-site compliance and complaint inspection conducted on December 19, 2022.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officer observed an open container of grape jelly and ketchup in a kitchen cabinet. Both of these containers stated "Refrigerate after opening."

2. During an interview, E1 acknowledged the foods were stored at room temperature and required refrigeration.

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. A review of the facility's policies and procedures revealed a document titled "Disaster Plan". However, there was no documentation showing that the disaster plan had been reviewed.

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

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

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents, which posed a health and safety risk to the residents.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed the hot water temperature at 127.2\'b0 F in the hall bathroom near resident bedrooms.

2. In an interview, E1 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents.

This is a repeat deficiency from the on-site compliance and complaint inspection conducted on December 19, 2022.

Based on observation and interview, the manager failed to ensure poisonous or toxic material stored by the assisted living facility was maintained in a locked area 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, the Compliance Officer observed, in an unlocked kitchen cabinet, a bottle of "Lemon Scent Cleaning Bleach" which stated "Keep out of reach of Children DANGER".

2. In an interview, E1 acknowledged poisonous or toxic material stored by the assisted living facility was not maintained in a locked area inaccessible to residents.

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

Based on observation, interview, and record review, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents.

Findings include:

1. The Compliance Officer observed R2 laying in bed during the inspection.

2. In an interview, R2 reported R2 could not walk.

3. In an interview, E3 confirmed R2 was unable to ambulate even with assistance.

4. A review of R2's medical record revealed a "Physician Visit Report" from R2's primary care provider (PCP) dated October 13, 2022. The report indicated there were no Activities of Daily Living (ADLs) recorded since October 9, 2022.

5. A review of R2's medical record revealed "Vitals And Activities Of Daily Living" documentation indicating R2 required assistance with bathing, dressing, oral care, and toileting. A review of the ADL documentation from October 2022 revealed documentation indicating care was provided during the entire month. However, R2's medical record did not contain any documentation indicating care was provided between September 17, 2022 and September 30, 2022.

6. A review of R2's medical record revealed a medication administration record (MAR) from September 2022. There was documentation of medication administration occurring between September 17, 2022 and September 30, 2022, indicating R2 was present in the facility during that time.

7. An exit interview was conducted in-person with E3 while E2 participated telephonically. E2 confirmed R2 was present in the facility between September 17, 2022 and September 30, 2022. E2 acknowledged the care provided to R2 was not documented in R2's medical record between September 17, 2022 and September 30, 2022.

Based on record review and interview, the manager failed to ensure documentation of medication administered to a resident included the name of the individual administering the medication, for one of two sampled residents.

Findings include:

1. A review of R2's medical record revealed a "Physician Visit Report" from R2's primary care provider (PCP) dated August 25, 2022. The report indicated there was no record of medication administration on R2's medication administration record (MAR) since August 18, 2022.

2. A review of R2's medical record revealed a "Physician Visit Report" from R2's PCP dated September 7, 2022. The report indicated there was no record of medication administration for R2 since September 4, 2022.

3. A review of R2's medical record revealed a "Physician Visit Report" from R2's PCP dated October 13, 2022. The report indicated there was no record of medication administration for R2 since October 9, 2022.

4. A review of R2's medical record revealed a "Physician/Provider Order" from R2's PCP dated November 17, 2022. The document indicated there was no record of medication administration for R2 since November 14, 2022.

5. A review of R2's medical record revealed a "Physician/Provider Order" from R2's PCP dated November 29, 2022. The document indicated there was no record of medication administration for R2 since November 28, 2022.

6. A review of R2's medical record revealed R2's MARs were filled out, including the name of the individual administering the medication, to indicate medications were administered to R2.

7. An exit interview was conducted in-person with E3 while E2 participated telephonically. The Compliance Officer brought up the documentation from R2's PCP. E2 reported the medications were administered. However, E2 explained facility staff were "running late" signing the MARs.

Based on record review, observation, 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 R1's medical record revealed a medication order dated July 14, 2022, for two tablets of "Tylenol Extra Strength 500 mg" (milligrams) every eight hours.

2. A review of R2's medical record revealed a progress note from R2's primary care provider (PCP) dated August 25, 2022. The progress note stated "Pill box medications do not match MAR [medication administration record] or physician orders. Other residents medication in [R2's] box".

3. A review of R2's medical record revealed a medication order dated September 29, 2022, for one tablet of "Amitriptyline 25 mg" every night at bedtime once R2 stopped taking "Oxycodone". R2 was to stop taking "Oxycodone" two days after the order was written.

4. A review of R2's medical record revealed a MAR dated December 2022. R2's December 2022 MAR indicated the following:
-Two tablets of "Acetaminophen [Tylenol] 500 mg" were administered at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM every day; and
-One tablet of "Amitriptyline 25 mg" was administered every night at bedtime.

5. The Compliance Officer observed the following while reviewing R2's medication organizer for the week:
-One tablet of "Tylenol 500 mg" was in R2's medication organizer with R2's morning medications, noon medications, and bedtime medications. R2's morning medications were already administered prior to the observation on the day of the inspection. However, R2's medication organizer was prepared for the five days following the inspection and there was no evidence to suggest R2 was receiving two tablets of "Tylenol 500 mg" every eight hours; and
-R2's "Amitriptyline 25 mg" bottle was empty. However, a tablet matching the exact description on the bottle, including shape, color, and markings, was found with R2's morning medications. There was no evidence to suggest R2 was receiving one tablet of "Amitriptyline 25 mg" every night at bedtime.

6. In an interview, E3 acknowledged the medications were not administered to R2 in compliance with the medication orders. E3 then corrected R2's medication organizer according to the medication orders.

7. An exit interview was conducted in-person with E3 while E2 participated telephonically. The Compliance Officer explained the discrepancies with R2's medication to E2. E2 denied being aware of any previous medication errors when asked by the Compliance Officer.

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of facility documentation revealed an undated policy and procedure, titled "Fall Prevention and Fall Recovery". The policy stated "The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery".

2. A review of the personnel record for E1 revealed no documented evidence to indicate E1 completed fall prevention and fall recovery training.

3. A review of the personnel records at the facility revealed there was no personnel record for E3.

4. A review of facility documentation revealed no documented evidence E3 completed fall prevention and fall recovery training.

5. An exit interview was conducted in-person with E3 while E2 participated telephonically. E2 acknowledged there was no documentation to indicate E1 and E3 completed a training program regarding fall prevention and fall recovery.

Based on interview, observation, record review, and documentation review, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of two individuals hired as a caregiver. The deficient practice of providing false or misleading information posed a risk as required information could not be verified to ensure E3 was qualified to work as a caregiver.

Findings include:

1. Upon arrival to the facility, the Compliance Officer was greeted by E3 who introduced E3's self using E4's first name. E3 confirmed E3 was the only individual working. The Compliance Officer observed E3 to be the only individual working throughout the inspection.

2. In an interview, E3 reported E3 had worked at the facility for approximately four months.

3. A review of the personnel records at the facility revealed a personnel record for E4.

4. A review of E4's personnel record revealed two identification cards including a picture of E4. E3 did not appear to be the individual in the pictures. Also, E3 did not appear to be the height indicated on one of the identification cards and E4's fingerprint clearance card.

5. In an interview, the Compliance Officer asked E3 to provide E3's last name. E3 reported E3 could not pronounce E3's last name. When the Compliance Officer asked E3 to spell E3's last name, E3 reported E3 could not spell E3's last name. When the Compliance Officer asked whether E3 could write down E3's name, E3 proceeded to write down a different first and last name. E3 explained the name E3 wrote down was the name E3 went by. When the Compliance Officer asked what E3's date of birth was, E3 provided a date of birth that did not match the date of birth indicated in E4's personnel record. E3 was asked multiple times whether E3 could recall the last name E3 went by when E3 took E3's caregiving course. E3 could not provide the last name indicated in E4's personnel record. E3 stated "I mostly go by [E3]. I don't like my given name".

6. A review of the personnel records at the facility revealed there was no personnel record for E3.

7. In an interview, E3 reported E3 was working on getting someone to send E3's caregiver certificate.

8. A review of facility documentation revealed a staffing schedule dated December 2022. The staffing schedule indicated E4 worked every Monday to Friday from 6:00 AM to 6:00 PM.

9. An exit interview was conducted in-person with E3 while E2 participated telephonically. The discrepancies were explained to E2. E2 reported E4's "nickname" was E3. The Compliance Officer then opened E4's personnel record and showed E3 the documents. E3 reported E4's personnel record was E3's and stated "oh that's how you spell my last name". E2 did not respond when the Compliance Officer asked E2 to confirm whether E3 and E4 were the same individual. E2 and E3 were unable to provide a caregiver certificate for E3.

10. A review of the NCIA website revealed no individual by the name of E3 completed an approved caregiver training program.

Based on interview, observation, record review, and documentation review, the manager failed to ensure one of three sampled employees had a personnel record. The deficient practice of providing false or misleading information posed a risk as required information could not be verified to ensure E3 was qualified to provide assisted living services and to ensure E3 was not a danger to a vulnerable population.

Findings include:

1. Upon arrival to the facility, the Compliance Officer was greeted by E3 who introduced E3's self using E4's first name. E3 confirmed E3 was the only individual working. The Compliance Officer observed E3 to be the only individual working throughout the inspection.

2. In an interview, E3 reported E3 had worked at the facility for approximately four months.

3. A review of the personnel records at the facility revealed a personnel record for E4.

4. A review of E4's personnel record revealed two identification cards including a picture of E4. E3 did not appear to be the individual in the pictures. Also, E3 did not appear to be the height indicated on one of the identification cards and E4's fingerprint clearance card.

5. In an interview, the Compliance Officer asked E3 to provide E3's last name. E3 reported E3 could not pronounce E3's last name. When the Compliance Officer asked E3 to spell E3's last name, E3 reported E3 could not spell E3's last name. When the Compliance Officer asked whether E3 could write down E3's name, E3 proceeded to write down a different first and last name. E3 explained the name E3 wrote down was the name E3 went by. When the Compliance Officer asked what E3's date of birth was, E3 provided a date of birth that did not match the date of birth indicated in E4's personnel record. E3 was asked multiple times whether E3 could recall the last name E3 went by when E3 took E3's caregiving course. E3 could not provide the last name indicated in E4's personnel record. E3 stated "I mostly go by [E3]. I don't like my given name".

6. A review of the personnel records at the facility revealed there was no personnel record for E3.

7. A review of facility documentation revealed a staffing schedule dated December 2022. The staffing schedule indicated E4 worked every Monday to Friday from 6:00 AM to 6:00 PM.

8. An exit interview was conducted in-person with E3 while E2 participated telephonically. The discrepancies were explained to E2. E2 reported E4's "nickname" was E3. The Compliance Officer then opened E4's personnel record and showed E3 the documents. E3 reported E4's personnel record was E3's and stated "oh that's how you spell my last name". E2 did not respond when the Compliance Officer asked E2 to confirm whether E3 and E4 were the same individual. E2 and E3 were unable to provide any of the required documents for E3.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. After requesting to review R2's medications, the Compliance Officer observed E3 take R2's medication organizer out of a drawer located next to the pantry. E3 did not use a key or other device to open the drawer. The Compliance Officer observed the drawer contained a child lock. However, the drawer was able to be opened when the Compliance Officer pushed down on the child lock, without a key. Inside the drawer, the Compliance Officer observed multiple medication organizers.

2. In an interview, E3 acknowledged the medications were not stored in a locked location.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. The Compliance Officer observed the hot water temperature to be 133.5 \'b0F in a hallway bathroom on the west side of the facility.

2. In an interview, E3 acknowledged the hot water temperature was not maintained between 95 \'b0F and 120 \'b0F.