R & D MARATHON ASSISTED LIVING HOME LLC

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an invidiual, the individual submitted documentation indicating whether the individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled.

Findings include:

1. A review of R2's medical record revealed a document titled, "Determination for Admission" dated February 24, 2023. The document indicated whether R2 was requesting or expected to receive supervisory, personal, or directed care services. However, the document was not signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

2. In an interview, E2 acknowledged R2's "Determination for Admission" was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant.

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

Findings include:

1. A review of R2's medical record revealed a service plan dated October 15, 2022. The service plan indicated R2 received personal care services. The service plan specified R2 would be provided assistance with bathing, toileting, transfers, and skin care.

2. A review of R2's medical record revealed a document titled "R&D Marathon Assisted Living Home LLC Activities of Daily Living Flowsheet" (ADL sheet) dated April 2023. An ADL sheet for the month of May 2023 was not available for review at the time of the survey.

3. In an interview, E1 reported R2 received the listed services documented in R2's service plan, and acknowledged the services were not documented as provided for May 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of two residents sampled.

Findings include:

1. A.R.S. \'a7 36-406(1) states: "The department shall...(d) 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."

2. A review of R2's medical record revealed no documentation to indicate R2 was notified of the availability of influenza and pneumonia vaccinations in 2022-2023.

3. In an interview, E2 reported E2 believed R2 was notified of the availability of the vaccinations for influenza and pneumonia. However, E2 acknowledged documentation of this notification was not available in R2' s medical record.