LEGACY MANOR

INSP-0130317

Complete

Date: 5/1/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-05-30

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of case ID 00128136 conducted on May 1, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-816.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in compliance with a medication order for one of two sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings Include: 1. A review of R1’s medical record revealed a medication order dated April 11, 2025, for Citalopram (Celexa) 10 mg one tablet once daily. R1’s service plan reflected that R1 received medication administration services. 2. The compliance officer observed a medication bottle for Citalopram (Celexa), which reflected it was dispensed on April 28, 2025. 3. A review of R1’s medical record revealed a medication administration record (MAR) dated April 2025 reflecting R1 was administered Citalopram (Celexa) from April 23, 2025, to April 27, 2025, at 8 am, despite the medication being dispensed on April 28, 2025. There was no evidence there was a previous Citalopram order. 4. In an interview, E1 reviewed R1’s Citalopram medication bottle, 2025 April MAR, and medication order, and acknowledged R1's Citalopram medication was not administered before R1's Citalopram was dispensed from the pharmacy. E1 acknowledged there was not a previous order of Citalopram.

Temporary Solution:

To address this issue, a training session was conducted on May 1, 2025, for the lead caregiver. The training emphasized adherence to the facility’s policy and procedure for medication administration, focusing on the "Route" method to ensure accuracy and prevent medication errors.

Permanent Solution:

To prevent future occurrences, Legacy Manor implemented the following corrective measures:
Regular training sessions have been scheduled to reinforce medication administration policies and procedures. In addition, monthly Synkwise e-MAR in-service will be offered to all staff by the facility manager on the following topics:
1) Facility Management;
2) Staff Management;
3) Progress Charting;
4) Medication Management (refills, tracking & LTC Pharmacy Integration);
5) Task Management (Reminders, Appointments, Charting) and Incident Reporting.

Person Responsible:

Annaliese Komota, Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-819.A.1.b. Environmental Standards 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 and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an uncovered hole roughly 4 inches wide inside the facility's shower. The uncovered hole presented a tripping hazard and could cause a resident to slip, fall, or cut themselves while in the shower. 2. In an interview, E1 acknowledged the uncovered hole inside the facility's shower.

Temporary Solution:

To address the identified safety hazard, a request was submitted to the facility’s maintenance personnel on May 3, 2025, to order a proper cover for the shower drain.

Permanent Solution:

The repair was completed on May 10, 2025, ensuring that the uncovered hole was securely covered to eliminate the risk of trips, falls, or injuries for residents using the shower.

Person Responsible:

Annaliese Komota, Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-819.A.14.a-c. Environmental Standards A. A manager shall ensure that: 14. If pets or animals are allowed in the assisted living facility, pets or animals are: a. Controlled to prevent endangering the residents and to maintain sanitation; b. Licensed consistent with local ordinances; and c. For a dog or cat, vaccinated against rabies;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies. Findings include: 1. The surveyor observed O1 to be the only pet in the facility. 2. A review of facility documentation revealed a rabies vaccination for O1, which expired on March 26, 2025. 3. In an interview, E1 acknowledged there was no documentation to reflect that O1 was currently vaccinated against rabies.

Temporary Solution:

Upon identifying the expired rabies vaccination during the May 1st, 2025, inspection, the facility was immediately notified of the issue. The pet owner was required to schedule an appointment with a licensed veterinarian to update the rabies vaccination on May 2, 2025.

Permanent Solution:

Documentation verifying the updated vaccination was obtained on May 9, 2025, by the pet owner and placed in the facility’s records to ensure compliance with health and safety regulations.

Person Responsible:

Annaliese Komota, Manager

INSP-0076746

Complete

Date: 8/28/2023

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-10-02

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00189593, AZ00192881, AZ00195501, and AZ00197241 conducted on August 28, 2023:

Deficiencies Found: 6

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on observation, record review and interview, the manager failed to ensure a written service plan included how medication would be stored and controlled, for one of one resident sampled who stored medication in their bedroom.

Findings include:

1. The Compliance Officer observed the following in R2's bedroom:
-A small lockbox that R2 reported contained Tylenol and other pain medications (R2 reported R2 knew the code and accessed the box to take medications as needed.)

2. A review of R2's medical record revealed a service plan, dated in March of 2023. The service plan stated "Staff controls, secures and administers medication." The box to indicate "Resident self-administers medication, keeps medications stored in locked containers in apartment and maintains own medication records" was not checked.

3. In an interview, E1 reported R2 was capable of administering some of R2's own medications. E1 acknowledged R2's service plan did not indicate as such, however.

Deficiency #2

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident's representative, for three of three terminated residents sampled.

Findings include:

1. A review of R5's medical record revealed an updated service plan, dated in May of 2023, for directed care services. However, the service plan was not signed and dated by the resident's representative.

2. In an interview, E1 acknowledged the service plan was not signed and dated by R5's representative.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that:
1. A caregiver or an assistant caregiver:
a. Provides a resident with the assisted living services in the resident's service plan;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for three of three current residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan dated in July 2023. The plan revealed R1 was to receive the following services:
-Shower 2x per week
-Laundry 1x per week and as needed

2. A review of R1's medical record revealed a document dated August 1-31, 2023 and titled "Vital Statistics." The document revealed R1 received a shower on the following days:
-August 4, 2023
-August 8, 2023
-August 11, 2023
-August 22, 2023

3. A review of R1's medical record revealed a document dated August 1-31, 2023 and titled "Vital Statistics." The document revealed R1 received a linen change on the following day:
-August 5, 2023

4. A review of R2's medical record revealed a service plan dated in March 2023. The plan revealed R2 was to receive the following service:
-Laundry 1x per week and as needed

5. A review of R2's medical record revealed a document dated August 1-31, 2023 and titled "Vital Statistics." The document revealed R2 received a linen change on the following day:
-August 5, 2023

6. A review of R3's medical record revealed a service plan dated in May 2023. The plan revealed R3 was to receive the following services:
-Shower 2x per week
-Laundry 1x per week and as needed

7. A review of R3's medical record revealed a document dated August 1-31, 2023 and titled "Vital Statistics." The document revealed R1 received a shower on the following days:
-August 1, 2023
-August 4, 2023
-August 8, 2023
-August 15, 2023
-August 25, 2023

8. A review of R3's medical record revealed a document dated August 1-31, 2023 and titled "Vital Statistics." The document revealed R3 received a linen change on the following day:
-August 5, 2023

9. In an interview, E1 acknowledged the "Vital Statistics" documents did not reflect the services according to R1's, R2's and R3's service plans. E1 reported to be uncertain whether or not services were provided based on the service plans and provided documentation or if the documention just didn't reflect the services provided.

Deficiency #4

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, record review 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 were not prescribed the accessible medication.

Findings include:

1. The Compliance Officer observed the following medication in an unlocked drawer in the kitchen:
-Triamcinolone Acetonide (belonged to a discharged resident)

2. The Compliance Officer observed the following medication in an unlocked cabinet in the kitchen:
-Salonpas medicated patches

3. The Compliance Officer observed the following medication in R1's private bathroom:
-Two tubes of Cortizone 10
-A box of Cepacol medicated cough drops
-Desoximetasone USP, .025%

4. The Compliance Officer observed the following medication in R3's private bathroom:
-Antifungal medicated cream

5. The Compliance Officer observed the following medications in an unlocked caregiver's room:
-2 bottles of Aspirin
-Vicks Vaporub
-Tylenol

6. The Compliance Officer observed the following medication in a resident bathroom:
-Voltaren medicated arthritis cream

7. The Compliance Officer observed the medication closet was unlocked. The closet contained medications for 10 residents.

8. The Compliance Officer observed several ambulatory residents on the premises.

9. In an interview, E1 acknowledged the unlocked medications throughout the facility were accessible to residents. E1 reported all residents received medication administration and residents were not to store and control their medications. E1 reported the medication closet's numbered keypad had malfunctioned earlier in the day and the door was unable to be locked. E1 reported a maintenance technician was on their way to the facility to address the lock on the medication closet door.

Deficiency #5

Rule/Regulation Violated:

D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver:
1. Immediately notifies the resident's emergency contact and primary care provider; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of three terminated residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services.

Findings include:

R9-10-101.110. "Immediate" means without delay.

1. A review of R5's medical record revealed an incident report (dated in May 2023) where R5 complained of pain in R5's legs. The incident report revealed E5 was sent to the hospital to be evaluated. The incident report stated "Resident's Medical Practitioner Notified? Yes." However, the name of the contacted person listed was "Julius," who was the facility's nurse, and not R5's primary care provider.

2. A review of R5's medical record revealed an incident report (dated in May 2023) in which R5 experienced a fall and 911 was called. The incident report stated "Resident's Medical Practitioner Notified? Yes." However, the name of the contacted person listed was "Julius," who is the facility's nurse, and not R5's primary care provider.

3. In an interview, E1 acknowledged the incident reports did not indicate that E5's primary care provider was contacted for either incident. E1 was unable to provide information on whether or not the primary care provider was indeed contacted and just not documented on the incident reports.

Deficiency #6

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 and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety to residents.

Findings include:

1. The Compliance Officer observed a cabinet beneath R2's bathroom sink. The cabinet was not locked. The cabinet contained the following poisonous or toxic material:
-Oxiclean
The bottle contained a warning label.

2. The Compliance Officer observed a cabinet beneath a hallway bathroom sink. The cabinet was not locked. The cabinet contained the following poisonous or toxic materials:
-Oxiclean
-Comet
The bottles contained warning labels.

3. The Compliance Officer observed in the backyard, a 5 gallon bucket of paint.
The bucket contained a warning label.

4. The Compliance Officer observed several ambulatory residents on the premises.

5. In an interview, E1 acknowledged the poisonous or toxic materials were left unlocked and accessible to residents.

Facility Information

Inspection History

INSP-0130317

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0076746

Summary:

Deficiencies Found: 6

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:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings: