VINEYARD PARK OF SURPRISE

<p>Based on documentation review and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outdoor area and controlled or alerted employees to a resident’s egress. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide Directed Care Services.</p><p><br></p><p> </p><p>2. The Compliance Officer observed multiple ambulatory residents.</p><p><br></p><p><br></p><p>3.A review of a communication log dated August 22, 2025 stated "During dinner time, the staff was brining all the residents to the dinning room for dinner and noticed that one of the resident's was not in the room...staff checked all the rooms...One of the staff saw him sitting at the courtyard...staff approached and noticed was weak and could not walk by self....resident was warm to touch...gave water to cool down...staff noticed not moving and head down...not responding...breathing was getting slower and blood pressure was low...911 called...was able to assess and able to get stable...was not sent to the hospital."</p><p><br></p><p> </p><p><br></p><p><br></p><p>4. In an interview, E1 reported that the exterior door that R2 exited from, which led into the courtyard area, was not broken. However, the dietary kitchen staff used the door to deliver dinner, and the door did not close. E1 acknowledged <span style="background-color: rgb(255, 255, 255);">that a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.</span></p><p> </p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2’s medical record revealed a service plan which indicated R2 received medication administration. The review revealed a medication order dated October 10, 2023, for “TORSEMIDE 10 MG TABLET TAKE 1 TABLET BY MOUTH ONCE DAILY.” The review further revealed a medication administration record (MAR) dated June 2025 which indicated R2 did not receive torsemide on June 2-3, 2025, as the “Medication [was] Not Available.”</p><p><br></p><p><br></p><p>2. A review of R3’s medical record revealed a series of service plans which indicated R3 received medication administration. The review revealed a medication order dated April 22, 2025, for the following medications:</p><p><br></p><p>- “Atorvastatin Calcium Oral Tablet 40 MG…Take one tablet by mouth daily;”</p><p><br></p><p>- “Jardiance Oral Tablet 10 MG…Take one tablet by mouth daily;”</p><p><br></p><p>- “Tamsulosin HCI Oral Capsule 0.4 MG…Take one tablet by mouth every evening;” and</p><p><br></p><p>- “Xarelto Oral Tablet 15 MG…take 1 tab daily.”</p><p><br></p><p>The review further revealed a MAR dated June 2025 which indicated the following:</p><p><br></p><p>- R3 did not receive atorvastatin on May 23-25 and 28-29, 2025, as the “Medication [was] Not Available;”</p><p><br></p><p>- R3 did not receive Jardiance on May 23-26 and 28-29, 2025, as the “Medication [was] Not Available;”</p><p><br></p><p>- R3 did not receive tamsulosin on May 2-3 and 6-15, 2025, as the “Medication [was] Not Available;” and</p><p><br></p><p>- R3 did not Xarelto on May 22-26 and 28-29, 2025, as the “Medication [was] Not Available.”</p><p><br></p><p><br></p><p>3. In an interview, E1 acknowledged medications administered to R2 and R3 were not administered in compliance with medication orders.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection completed on October 17, 2024.</p>

Based on record review, documentation review, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R1's medical record revealed a service plan July 17, 2024 that indicated R1 received the following services:
- Personal hygiene assist - Set up/Stand by/Cueing - Resident requires staff assistance with Set up/Stand by/Cueing for daily hygiene tasks.

2. A review of R1's activities of daily living (ADL) documentation for January 2025, revealed documentation of the following services:
- Personal Hygiene Assist - 8:00AM and 8:00PM - Documented as completed on the following dates:
- January 2, 2025 at 8:00AM;
- January 6, 2025 at 8:00AM; and
- January 7, 2025 at 8:00AM.
However, no other documentation of Personal Hygiene assistance being provided was available.

3. A review of R2's medical record revealed a June 2024 service plan that indicated R2 was to receive the following services:
- Behavior-Exit Seeking - Redirect;
- Dressing - Set up/Stand by/Cueing;
- Encourage resident to hydrate with fluids and eat snacks;
- Laundry Assist - Total;
- Housekeeping - Weekly Room Clean;
- Housekeeping - Daily Bed Making, Daily Trash Removal; and
- Supervision/Monitoring - "Resident requires staff monitoring 3-4x for safety."

4. A review of R1's activities of daily living (ADL) documentation for January 2025, revealed documentation of the following services being provided on the following dates:
- Dressing - Set up/Stand by/Cueing:
- January 2, 2025 - January 4,2025 and January 8, 2025;
- Housekeeping - Daily Bed Making:
- January 4, 2025;
- Housekeeping - Daily Trash Removal:
- January 4, 2025; and
- Monitoring/Supervision - "3-4x/shift":
- January 4, 2025 - January 5, 2025
- January 7, 2025 - January 9, 2025.
However, no other documentation of assisted living services in R2's service plan being provided was available and R2 was documented as being out of the facility from January 4, 2025 through the time of review.

4. In an interview, E4 reported R1's and R2's had received all assisted living services documented in R1's and R2's although they were not documented correctly. In an interview, E3 and E4 acknowledged a caregiver failed to document the services provided in R1's and R2's medical record.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing 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), for one of four caregivers reviewed. The deficient practice posed a health and safety risk to the residents if the employee was not trained.

Findings include:

1. Review of E3's personnel record revealed a certificate issued by "Sunshine Care Training Program ALTP0085 dated December 15, 2012".

2. A review of the NCIA verification of caregiver training portal revealed the training program number for the aforementioned certificate closed on May 31, 2012. A reviw of the NCIA database (https://az.tmuniverse.com/) revealed E3 had not completed a caregiver training program after August 3, 2013. There was no documentation showing that E3 had completed a caregiver training program approved by the Department or the NCIA Board.

3. Review of the personnel schedule dated May 14, 2024 through September 3, 2024 showed the following:
- E3 worked from 10PM-6AM Sunday through Thursday.

4. In an interview, E1 reported being unaware that the document was not a valid caregiver certificate. E1 acknowledged E3 did not provide documentation of completing a caregiver training program approved by the Department or the NCIA Board.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R1's medical record revealed a written service plan dated May 2, 2024. The service plan revealed R1 required minimum assistance with daily living activities and was not at risk for wandering or behaviors. However, progress notes dated May and June 2024 revealed R1 has had an increase in wandering, increased confusion, taking others' property, and hoarding paper items.

2. Review of R1's medical record revealed R1's service plan was not updated to show these changes.

3. In an interview, E1 reported R1 required the increased need for services and acknowledged R1's service plan was not updated.

This is a repeat deficiency from the complaint investigation conducted on March 13, 2024.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every six months, for one of three residents reviewed receiving personal care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. Review of R5's medical record revealed written service plans dated for September 7, 2023 and June 12, 2024 for personal care services. However, the service plans were not completed within the six month time-frame required by this regulation.

2. In an interview, E1 acknowledged R5 received personal care services and the service plan was not updated at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of six residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated June 2024. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed a signed medication order dated April 2024. This medication order stated "Memantine 10 mg take one tablet twice daily at 9AM and 8PM".

3. Review of R2's medical record revealed a Medication Administration Record (MAR) from April 2024. This MAR stated "Memantine 10 mg take one tablet twice a day". The MAR administered times were 8AM and 5PM. There was no further documentation available for review.

4. In an interview, E1 acknowledged R2's medication was administered as documented on the MAR, and not in compliance with the available medication order.

Based on interview and record reviewed, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk.

Findings include:

1. In an interview, E1 reported that R2 was transported to the hospital from the facility by emergency medical services on July 24, 2024.

2. Review of R2's medical record revealed no documentation for the incident.

3. In an interview, E1 acknowledged R2's medical record did not include documentation showing the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of five caregivers. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."

2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. Review of E2's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E2's hire date, this documentation was required.

4. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required.

5. In an interview, E1 acknowledged E2 and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on observation, record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who had a change of condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.

Findings include:

1. Review of R1's medical record revealed a signed doctor's order dated February 13, 2024 that stated "Wound care dressing per physician order".

2. Review of R1's medical record revealed a current written service plan for personal care services dated September 23, 2023. This service plan stated " ...Skin Evaluation - Clean/dry/Intact...".

3. Based on observation of R1's spine area, there was a wound observed. The hospice file contained notations of the wound being treated by an RN hospice nurse.

4. Review of R1's medical record revealed R1's service plan was not updated to show this significant change.

5. In an interview, E1 acknowledged R1's service plan was not updated after a significant change of condition.

Based on documention review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility to include the requirements in R9-10-807(D)(1-10), for two of four current residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. A review of Department documentation revealed the perpetual license for AL12384 was effective October 17, 2022.

2. A review of R1's and R2's medical records revealed residency agreements dated March 1, 2021. However, the residency agreements were with a closed facility and documented residency agreements for Vineyard Park Of Surprise, AL12384, were not available for review.

3. In an interview, E1 and O1 reported R1 and R2 have fiduciaries and would need to reach out to obtain updated residency agreements.