AZ OHANA CARE HOME

Based on record review and documentation review, the manager failed to ensure the assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk as employees were unable to ensure the health and safety of a resident.

Findings include:

1. A review of R2's medical record revealed a treatment order signed by a nurse practioner on April 28, 2023. The treatment order stated "... 8) Sacrococcygeal/buttocks wounds: wound care by HH nurse 2 times/week. CG to do PRN"

2. A review of facility policies and procedures (dated March 1, 2022) revealed a policy topic titled "1. Scope of Practice of the Assisted Living Facility". The scope of practice included supervisory care services, personal care services, respite care services and a list of individualized services provided at the facility. A review of the list of identified services revealed "wound care" was not included in the facility's scope of practice.

3. A review of E2's and E3's personnel record revealed E2 and E3 do not have the the qualifications, experience, skills, and knowledge necessary to provide wound care to residents.

Based on documentation review, observation, and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers who worked each day, including the hours worked by each, was maintained.

Findings include:

1. A review of the posted facility work schedule dated July 2023 identified "E2/E3" to work every day from July 1, 2023 to July 31, 2023. However the documentation did not include the hours worked by each.

2. The Compliance Officer observed E1, E2, and E3 working with residents on July 5, 2023.

3. In an interview E1 reported E2 and E3 work a 24 hour shift. E1 reported E1 periodically comes to conduct clerical work and help with residents if needed. E1 acknowledged the facility's posted July work schedule did not include the hours worked by each.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider (PCP), for one of one residents sampled.

Findings include:

1. A review of R2's medical record revealed a document titled "Progress Notes" dated from March 8, 2023, to June 25, 2023, and authored by the caregivers. The following entries include R2's incidents that resulted in the resident needing medical services:

On March 10, 2023 at 1:05 PM a caregiver wrote, "EMS (911) came & took resident to [hospital]...". However, no further documentation was provided that indicated R2's PCP was immediately notified.

On March 23, 2023 at 9:45 AM a caregiver wrote, "911 (EMS) arrived & took resident out to [hospital]. However, no further documentation was provided that indicated R2's PCP was immediately notified.

On June 11, 2023 at 8:00 AM a caregiver wrote, "Resident is less responsive ... Notified admin/manager, Accordingly house was ordered to call 911... 8:45 AM EMS came and attended resident... 9AM - Resident was taken to [hospital]...". However, no further documentation was provided that indicated R2's PCP was immediately notified.

2. In an interview E1 reported the incident identified in March 10, 2023, progress note was not documented accurately. E1 reported the caregiver (E2) documented the date of the event incorrectly. E1 reported the March 10, 2023 entry should have been documented as February 10, 2023. E1 acknowledged R2 did not have documentation that included R2's PCP was immediately notified following three aforementioned incidents.

Based on documentation review, interview, and record review, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, for one resident sampled who had three incidents resulting in the resident needing medical services.


1. A review of R2's medical record revealed a document titled "Progress Notes" dated from March 8, 2023 to June 25, 2023, and authored by the caregivers. The following entries include R2's incidents that resulted in the resident needing medical services:

On March 10, 2023 at 1:05 PM a caregiver wrote, "[R2] is in severe pain. [R2] doesn't want to be touched ... EMS (911) came & took resident to [hospital]...". However, no further documentation was provided that indicated the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.

On March 23, 2023 at 9:45 AM a caregiver wrote, "911 (EMS) arrived & took resident out to [hospital]. However, no further documentation was provided that indicated the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.

On June 11, 2023 at 8:00 AM a caregiver wrote, "Resident is less responsive ... Notified admin/manager, Accordingly house was ordered to call 911... 8:45 AM EMS came and attended resident... 9AM - Resident was taken to [hospital]...". However, no further documentation was provided that indicated the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.

2. In an interview E1 reported the caregiver (E2) documented the date of the event incorrectly. E1 reported the March 10, 2023 entry should have been documented as February 10, 2023. E1 indicated the transfer of care to the hospital on February 10th was requested by family after a visit. E1 reported not knowing the required documentation was needed. E1 reported the March 23rd admission was ordered by an RN from an outside agency. E1 reported not knowing the required documentation was needed. E1 acknowledged the provided progress notes for R2 did not detail the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.