CADENCE CHANDLER

<p><span style="font-size: 12pt;">Based on records review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for one of ten sampled employees.</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">Findings include:</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">1. A documentation review of E10’s personnel record revealed that E10’s blood test for TB was positive on March 21, 2024.</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">2. E10 submitted a chest x-ray with a negative reading that was dated September 22, 2023. There was no physician’s statement nor signature attached to the x-ray that pre-dated the blood test.</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">3. In an interview, E1 acknowledged that E10 did not provide documentation of freedom from infectious TB.</span></p>

<p><span style="font-size: 12pt; color: black;">Based on records review, documentation review, and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of eleven residents sampled</span><span style="font-size: 16px; color: black; font-family: serif;">.</span><span style="font-size: 16px; font-family: serif;"> </span><span style="font-size: 16px;">The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of</span></p><p><span style="font-size: 16px;">medication.</span></p><p><span style="font-size: 12pt; color: black;"> </span></p><p><span style="font-size: 12pt; color: black;">Findings include:</span></p><p><span style="font-size: 12pt; color: black;"> </span></p><p><span style="font-size: 12pt; color: black;">1. A documentation review of an incident report dated February 26, 2025 revealed that R11 was given another resident's medication in error.</span></p><p><br></p><p><span style="color: black; font-size: 12pt;">2. A review of progress notes for R11 revealed that the resident was given the 8 PM medication for a neighboring resident. </span></p><p><br></p><p><span style="color: black; font-size: 12pt;">3. A review of the physician's order for the neighboring resident revealed that R11 was given the following medications: Famotidine 20 mg, Gabapentin 300 mg, Pramipexole 0.75 mg, Hydralazine 25 mg, Lithium Carbonate 150 mg, and Meclizine 12.5 mg. </span></p><p><br></p><p><span style="color: black; font-size: 12pt;">4. In an interview, E1 reported that a new med tech accidentally gave R11 medication that belonged to the resident next door. E1 acknowledged that </span><span style="color: rgb(0, 0, 0); font-size: 16px; background-color: rgb(255, 255, 255);">medication was administered to a resident without a medication order.</span></p>

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to residents, for five of fifteen sampled personnel records reviewed.

Findings include:

1. Review of the facility's documents revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all staff.

2. Review of fifteen sampled personnel records revealed there was no documentation that E11, E12, E13, E14, and E15 had completed the required training.

3. In an interview, E1 and E16 acknowledged the facility did not have documentation that all the sampled employees had completed fall prevention and fall recovery training as required.

Based on observation, records review, and interview, the manager failed to ensure five of ten sampled caregivers 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 Board) which posed a health and safety risk to the residents residing at the facility if the employee was not trained as required.

Findings include:

1. Review of randomly selected employee personnel records from the printed database provided by the facility revealed that E11 was as working as a caregiver on May 24, 2023 and was observed working in the memory care unit at the time of the compliance inspection. E11's personnel record contained no documented evidence that E11 was a trained caregiver. E11 reported E11 was a "CNA". In E11's personnel record there was documentation that E11 was a certified nursing assistant (CNA). E1 provided documentation that E11 worked during the past 60 days on May 24 and May 25, 2023.

2. Review of E12's personnel record revealed E12 was working as a caregiver on April 30, 2023. E12's personnel record contained no documented evidence that E12 was a trained caregiver. In E12's personnel record there was documentation that E12 was a licensed nursing assistant (LNA). E1 provided documentation that E12 worked during the past 60 days on April 30, May 11, May 13, and May 15, 2023.

3. Review of E13's personnel record revealed E13 was working as a caregiver on April 8, 2023. E13's personnel record contained no documented evidence that E13 was a trained caregiver. In E13's personnel record there was documentation that E13 was a CNA. E1 provided documentation that E13 worked during the past 60 days on April 8, April 10, April 13, April 16, April 17, April 19, April 21, April 22, April 24, April 26, April 27, April 30, May 9, May 11, May 12, Mat 14, May 22, May 23, and May 24, 2023.

4. Review of E14's personnel record revealed E14 was working as a caregiver on April 7, 2023. E14's personnel record contained no documented evidence that E14 was a trained caregiver. In E14's personnel record there was documentation that E14 was a CNA. E1 provided documentation that E14 worked during the past 60 days on April 7, April 19, and April 23, 2023.

5. Review of E15's personnel record revealed E15 was working as a caregiver on March 31, 2023. E15's personnel record contained no documented evidence that E15 was a trained caregiver. In E15's personnel record there was documentation that E15 was a LNA. E1 provided documentation that E15 worked during the past 60 days on March 31, April 4, April 11, April 21, May 20, and May 23, 2023.

6. The tmuniverse.com website search revealed no evidence these sampled individuals were listed as completing the required caregiver training.

7. In an interview, E1 and E16 acknowledged these sampled individuals were working as caregivers, however, had not completed the Arizona required caregiver training.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for five of ten sampled caregivers' personnel records reviewed, which posed a health and safety risk.

Findings include:

1. Review of randomly selected personnel records revealed these employees were hired to work as caregivers in the past 60 days: E11 started working on May 24, 2023, E12 started working on April 30, 2023, E13 started working on April 8, 2023, E14 started working on April 7, 2023, and E15 started working on March 31, 2023. These sampled personnel records contained no documentation that these caregivers had the skills and knowledge that were verified to provide the services they were expected to provide according to the facility's scope of services.

2. In an interview, E1, E2, and E16 acknowledged these sampled caregivers' personnel records contained no verified documentation of their skills and knowledge, as required, before providing physical health services. E1 also acknowledged there was no job descriptions available for review for these five sampled caregivers according to the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for two of twelve personnel records reviewed.

Findings include:

1. Review of E13's record contained a copy of a first aid training certificate that had expired March 29, 2023. E13 was hired as a caregiver.

2. Review of E14's record contained documentation of online CPR training from the NationalCPR Foundation, completed March 29, 2021 and valid for two years. E14 was hired as a caregiver.

3. During an interview, E1 and E16 acknowledged that E13's record contained an expired first aid certificate, and that E14's record contained expired CPR training. Both E13 and E14 were hired as caregivers.

Based on record review and interview, the manager failed to ensure that two of two sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services. This deficiency posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. During an interview, E2 reported that R1 and R3 had been unable to ambulate even with assistance since accepted to the facility.

2. Review of R1's and R3's medical records contained no documented determinations from a medical practitioner at the time of acceptance and updated at least every six months throughout the duration of the residents' condition. These determinations should have been based on a current resident's examination and the facility's scope of services that the resident's needs could be met. R1's service plan stated the resident required supervisory care services. R3's service plan stated the resident required directed care services.

3. In interviews, E1 and E2 acknowledged there were no documented determinations completed as required for these sampled residents who were unable to ambulate even with assistance.

Based on record review and interview, the manager failed to ensure that one of one resident's medical record, who was receiving directed care services, included documentation of the resident's weight on the service plan or documentation from a medical practitioner stating that weighing the resident was contraindicated.

Findings include:

1. Review of R3's current service plan, dated April 5, 2023, stated the resident required directed care services. The service plan contained no documentation of R3's weight. There was no documentation in R3's medical record from R3's medical practitioner stating that weighing the resident was contraindicated.

2. During an interview, E1 and E2 acknowledged R3's weight was not documented as required. E2 reported there was no documentation from R3's medical practitioner stating that weighing the resident was contraindicated. No other medical documentation reflecting the resident's current weight was available for review.

Based on documentation reviewed 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. During an interview, E1 and E2 reported the facility had three shifts: First shift from 6:00 AM to 2:00 PM, the second shift from 2:00 PM to 10:00 PM, and the third shift from 10:00 PM to 6:00 AM.

2. Based on the documentation provided, the facility had an employee disaster drill during the past 12 months that was conducted on the third shift on July 28, 2022, February 23, 2023, and May 23, 2023.

3. In an interview, E1 acknowledged the required employee disaster drills were not conducted on the third shift every three months, as required. E1 confirmed the facility had three shifts.

Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented; for one of two sampled residents' records reviewed, which posed a safety risk.

Findings include:

1. Review of R5's record, based on their date of acceptance, revealed there was no documentation indicating the sampled resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility.

2. During an interview, E1 acknowledged there was no documentation to indicate the sampled resident had received evacuation orientation to the exits from the facility within 24 hours after the residents' acceptance, nor anytime since.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection.

Findings include:

1. During a tour of randomly selected resident bedrooms and units, E1 and the compliance officer observed in R3's and R4's bedrooms there were numerous different shades of dark spill like marks throughout the common areas of the bedrooms. The carpets did not appear clean.

2. During the tour of R8's unit, E1 and the compliance officer observed the dark marks in front of the recliners in the living room and dark marks in the resident's bedroom near the bed. The carpets did not appear clean.

3. In an interview, E1 acknowledged the sampled residents' carpets did not appear clean.