PALM HOUSE OF ARIZONA

INSP-0124467

POC

Date: 4/11/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-04-21

Summary:

The following deficiency was found during the on-site compliance inspection and investigation of complaint 00126190 and 00126191 conducted on April 11, 2025:

Deficiencies Found: 1

Deficiency #1

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.A, for one of three sampled employees. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S.§ 36-411.C states: "C. Owners 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." 2. A review of E2’s personnel record, revealed that the employee’s fingerprint card was not valid and was verified on February 20, 2025 as not being valid. 3. An online check by the Compliance Officer of the Arizona Department of Public Safety (DPS) web portal athttps://psp.azdps.gov/services/cardStatusRequest revealed that E2’s fingerprint card was not valid with a decision date of October 19, 2022. 4. A documentation review of the facility's employee schedule for January, February, and March 2025, revealed that E2 was documented as working the following days and shifts:: January - 1/4, 1/11, 1/20, 1/26 (24 hrs. shifts); 1/1, 1/2, 1/3, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/12, 1/17, 1/18, 1/19, 1/31 (6PM-6AM shifts); 1/13 and 1/25 (6AM-6PM shifts). February - 2/15 and 2/22 (24 hrs. shifts); 2/1, 2/2, 2/3, 2/7, 2/8, 2/9, 2/10, 2/14, 2/16, 2/17, 2/18, 2/19, 2/20, 2/21, 2/23, 2/27 (6PM-AM shifts) March - 3/1, 3/8, 3/15, 3/22, and 3/29 (24 hrs. shifts); 3/2, 3/6, 3/9, 3/13, 3/16, 3/20, 3/23, 3/27, 3/30 (6PM- 6AM shifts); 3/3 (6AM-6PM shift). 5. In an interview, E2 revealed that the employee received a letter a few weeks ago regarding the status of the fingerprint card. E2 stated that the decision date of October 19, 2022 was incorrect. 6. In an interview, E4 acknowledged the manager failed to ensure that E2 was in compliance with the fingerprint requirements.

Temporary Solution:

Since the caregiver fingerprint card was found to be invalid, the employee was immediately removed from the care home schedule so that there would be no more care home violations based on AZDHS employee guidelines. The care home management team also gave the caregiver guidance for how to seek a good cause exception to have his fingerprint clearance card reinstated soonest. Pursuing this path, the employee was able to attain an expedited review by the Arizona Board of Fingerprinting and was granted a good cause exception and enabled to receive his fingerprint clearance card again a little over two months after his invalid card was discovered.

Permanent Solution:

Torrey W Frank, Manager, spoke with his assistant manager about the incident and shared the expectations for the process which needs to be followed in order that another situation like this never happens. Moving forward, the care home management team will implement quarterly checks on employee records. Increasing the frequency of checking employee records will reduce the risk of files becoming invalid or otherwise unacceptable without the care home being aware of these changes or any issues impacting employees’ work status.

Person Responsible:

Torrey W Frank, Manager

INSP-0081654

Complete

Date: 8/21/2024

Type: Complaint

Worksheet: Assisted Living Home

SOD Sent: 2024-08-26

Summary:

An on-site investigation of complaints AZ00214909 and AZ00214939, was conducted on August 21, 2024, and the following deficiencies were cited :

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.

Evidence/Findings:

Based on observation, documentation review, record review, and interview, the administrator failed to document an alleged incident of sexual abuse, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.

Findings include:

1. In observation, the Compliance officer (CO) observed R1 in a bedroom at the facility. R1 did not acknowledge the CO or respond to the CO's verbal address; however, was alert and partially sitting up, and moving around on the bed.

2. In documentation review, the Department received a report, which documented on August 10, 2024, "... [R1] entered R2's room and dropped ... pants... then tried to get R2 to [perform sexual act] which [R2] wouldn't do. [R1] laid down on top of [R2]... was kissing R2. O1 called the facility and told E2, who answered to go .... [R2's] room and get... [R1] off of [R2] which E2 did... Although E2 got [R1] away... R1 didn't want to leave.... room, brought ... fists up and was ready to fight with E2, but ... persuaded.. to leave... room."

3. During an interview, E2 reported [E2] entered R2's bedroom, and observed R1 with pants down and kissing R2. E2 pulled R1's pants up and removed R1 from R2's room. E2 immediately notified E1 of the incident and logged it into the computer.

4. In record review, R1's medical record included a report titled, "Report of Unusual Occurrence," which documented the date and time, and a description of the incident; " [R1] were leaning towards [R2] and kissing... pants were down. Caregiver took R1 in [R1's] room and notified the manager about the incident. The report did not include documentation of the report of suspected abuse according to A.R.S. \'a7 46-454, and did not include documentation of a description of any injury to the resident related to the suspected abuse... and any change in the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse... the actions taken by the manager to prevent the suspected abuse... from occurring in the future.

5. In documentation review, a facility policy, titled "Quality Management Program Including Incident Reports," dated January 15, 2022, documented, "... All employees ... will immediately report to the facility manager any suspected abuse, neglect, or exploitation of the resident... If a manager has a reasonable basis to believe abuse, neglect.... has occurred on ... the manager, caregiver, .... shall: 1. If applicable take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Immediately report in person or by telephone the suspected abuse, neglect, or exploitation of the resident to a peace officer or to a protective services worker; 3. Mail or deliver to the peace officer or to the projective services worker a written report within forty-eight hours or on the next working day if the forty-eight hours expire on a weekend or holiday; 4. Intimate an investigation, investigate the suspected abuse, neglect, or exploitation and document by filling out "Report of suspected abuse, neglect or exploitation" form available at the facility, within five working days after the report is received. 5. Document the action taken in the facility specific form to report abuse, neglect or exploitation; 6. Maintain the documentation ... for at least 12 months... "

6. During an interview, E1 acknowledged the incident occurred, and reported the incident was handled internally, with the resident's family, and therefore not reported, as required, according to (A.R.S.) \'a7 46-454. E1 acknowledged the facility did not document a description of any injury to the resident related to the suspected abuse... and any change in the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse... the actions taken by the manager to prevent the suspected abuse... from occurring in the future.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall not accept or retain an individual if:
3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual;

Evidence/Findings:

Based on observation, documentation review, record review, and interview, for one resident reviewed, the manager accepted an individual when the services needed by the individual were not within the assisted living facility's scope of services. The deficient practice posed a risk to residents, if the facility was unable to meet a resident's needs, and the resident created an unsafe environment for others.

Findings include:

1. In observation, the Compliance officer (CO) observed R1 in a bedroom at the facility. R1 did not acknowledge the CO or respond to the CO's verbal address; however, was alert and half sitting up, and moving around on the bed.

2. In documentation review, a facility policy titled "Scope of Services...," documented, "... In order to ensure that our facility is able to provide the appropriate services to our residents as well as the safety of our community, we need to assess the physical, cognitive, functional, emotional and psychological condition of each of our residents before or at the time of admission as well as during their stay in our facility... 5. The facility shall not accept or retain a resident that needs restraints or who is experiencing behaviors that could be considered a threat for the resident himself or others..."

3. In documentation review, the Department received a report, which documented on August 10, 2024, "... [R1] entered R2's room and dropped ... pants... then tried to get R2 to [perform sexual act] which [R2] wouldn't do. [R1] laid down on top of [R2]... was kissing R2. O1 called the facility and told E2, who answered to to go .... [R2's] room and get... [R1] off of [R2] which E2 did... Although E2 got [R1] away... R1 didn't want to leave.... room, brought ... fists up and was ready to fight with E2, but ... persuaded.. to leave... room."

4. During an interview, E2 reported [E2] entered R2's bedroom and observed R1 with pants down and kissing R2. E2 pulled R1's pants up and removed R1 from R2's room. E2 immediately notified E1 of the incident and logged it into the computer.

5. In record review, R1's medical record included a copy "Discharge Instructions," signed by the medical practitioner, dated May 1, 2024, from "Phoenix VAMC," The report documented, "... You were admitted for the following CONDITION (Primary Diagnosis): Vascular dementia with inappropriate aggressive/sexual behaviors."

6. During an interview, E1 reported the medical practioner from VAMC (Veteran's Affairs Medical Center) said R1 was an appropriate placement for the facility. E1 reported R1 had a history of exhibiting sexual behaviors which required redirection; the behaviors were either self directed, or directed towards female caregivers or residents. E1 discussed the behaviors with the VAMC, to obtain assistance with medication management to address R1's behaviors (since R1's acceptance at the facility); however, the VAMC was slow to respond, and had not yet responded to E1's request. E1 reported the facility was able to manage R1's behaviors; however, acknowledged R1 entered R2's room and made inappropriate sexual advances toward R2.

INSP-0081652

Complete

Date: 6/11/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2024-06-14

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00186283 conducted on June 11, 2024:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

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;

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was 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 and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and 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 Department documentation revealed the facility was authorized to provide directed care services.

2. The Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officer observed an alert system was installed on the patio door. However, the alert system was not functioning.

3. In an interview, E2 acknowledged the aforementioned door did not alert employees of the egress of a resident from the facility. E1 reported E1 does not know why the alarm was not alerting the employees. However, the alarm located on the front door would alert the employees when the door was opened.

Deficiency #2

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication.

Findings include:

1. The Compliance Officer observed ambulatory residents in the facility.

2. The Compliance Officer observed the following unlocked medication in the kitchen refrigerator:
- Two 3ML insulin pens
- Acetaminophen 650 MG
- A box of Glucagon injection pens .5 mg per .1 ML
- Two boxes of Fiasp 100 unit/ ML
- Two pack of Gvoke Hypopen 1 MG/ .2 ML
- A box of Insulin aspart injections 100 units/ ML
- Two boxes of Lorazepam 2 MG/ ML
- Lantus Solostar 100 units/ ML
- Two Glucagon 1 MG emergency kits
- Lispro Ins 100 unit/ ML pen

3. The Compliance Officer observed the following unlocked medication in the kitchen cabinet:
- Megestrol Acet 40 MG/ ML
- A bottle of Megestrol Acet 40 MG/ ML
- Nidoflor 15G
- Bengay Menthol Pain Relieving Gel
- Polymoxin B Sulfate and Trimethoprim Opthalmic Solution 10 ML
- 6 FL oz bottle of Chloraseptic sore throat

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

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
1. The premises and equipment used at the assisted living facility are:
b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure the premises used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents.

Findings include:

1. The Compliance Officer observed ambulatory residents on the premises.

2. The Compliance Officer observed a stairway leading to the second story of the facility, upon entering the facility. A barrier was not observed on this stairway to prevent the residents from accessing this stairway.

3. A review of facility documentation revealed that the facility was licensed to provide directed care services.

4. In an interview, E1 reported a resident broke the gate that blocked the stairway. E1 acknowledged a barrier was not placed on the stairway to prevent the residents from accessing the stairway.

Deficiency #4

Rule/Regulation Violated:

A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were 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. The Compliance Officer observed ambulatory residents in the facility.

2. The Compliance Officer observed toxic materials stored in an unlocked shed. The list provided was a sampled list of the toxic materials that were stored.
- A 5 L bottle of Windex
- A two pack of Lysol Power Cleaning Gel
- Two spray bottles of Lysol all purpose cleaner
- A spray bottle of a Tile Grout Cleaner
- A bottle of Pine Sol

3. The Compliance Officer observed toxic materials stored in an unlocked kitchen cabinet.
- A bag of Cascade Platinum dish cleaner pods
- A spray canister of Weiman Stainless Steel Cleaner and Polisher

4. The Compliance Officer observed a spray bottle filled with a blue liquid stored in an unlocked caregiver closet on the first floor. One of the personnel confirmed that it was Windex glass cleaner inside the spray bottle.

5. A review of the facility's policy and procedures revealed a policy titled, "Environmental and Physical Plant Safety" revealed in subsection 15, "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas, and medications and are inaccessible to residents."

6. In an interview, E1 acknowledged the toxic materials were not stored in a locked area inaccessible to residents.

Facility Information

Inspection History

INSP-0124467

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0081654

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0081652

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings: