CLEARWATER AHWATUKEE

Based on documentation review, record review and interview, the health care institution failed to provide appropriate first aid to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently, for one of two residents reviewed. The deficient practice posed a risk as the facility left a resident on the floor instead of providing first aid to a non-injured resident by assisting them off the floor after a fall.

Findings include:

1. A review of facility documentation revealed a report from the Phoenix Fire Department for R1. The document reported R1 had a fall, was uninjured, and needed assistance off the floor.

2. A review of R1's medical record revealed an incident report dated September 28, 2024. The document reported R1 had a fall. Following the fall, E2 conducted range of motion tests and took R1's vital signs. However, the documentation does not mention if R1 was assisted off the floor by facility personnel.

3. In an interview, E1 reported the resident should have been helped off the floor, but had no documentation reporting facility personnel helped R1 off the floor. E1 reported E1 could not remember exactly what happened.

Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's death within one working day after the resident's death, which was unexpected, according to A.R.S. \'a7 11-593.

Findings include:

1. Review of R1's medical record revealed that R1 required personal care and medication administration services.

2. Based on written documentation received from the facility, R1 unexpectedly expired. The facility notified the Department in writing of this unexpected death; however, this notification was three working days after R1 had passed away.

3. During the interview, E1 acknowledged the facility had not notified the Department in writing within one working day after the unexpected death of R1.

Based on observation, record review, and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of three sampled residents who was storing medications in the resident's unit, which posed a health and safety risk.

Findings include:

1. Review of R11's current service plan dated October 31, 2023 showed the resident required personal care and medication administration services. This service plan did not state that medications would be stored and controlled by R11 in R11's unit.

2. During a tour of R11's unit E1 and the compliance officer found that R11 was storing and controlling Alprazolam 2mg along with a number of over-the-counter medications in R11's bathroom.

3. In an interview, E1 and E2 acknowledged R11's current service plan did not state that R11 may self-administer these medications and how the medications would be stored and controlled by R11.

Based on record review and interview, the manager failed to ensure that two of three sampled residents who were receiving directed care services had a written service plan reviewed and updated at least once every three months, which posed a health and safety risk.

Findings include:

1. Review of R6's medical record revealed that R6 required directed care services. The written service plans and updates during the past twelve months were dated: May 19, 2023, July 26, 2023, and November 1, 2023. All service plans stated the resident required directed care services.

2. Review of R7's medical record revealed that R7 required directed care services. The written service plans and updates during the past twelve months were dated: March 2, 2023, June 12, 2023, November 1, 2023, and January 26, 2024. All service plans stated the resident required directed care services.

3. In an interview, E1 and E2 acknowledged the sampled residents' service plans did not appear to have been updated every three months as required for these two residents receiving directed care services.

Based on record review and interview, the manager failed to ensure that for four of five sampled residents who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at the onset or at the time of acceptance or within 30 days prior to acceptance and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. In an interview, E1 and E2 reported that R7, R8, R9, and R11 were unable to ambulate even with assistance.

2. Based on the date of acceptance or onset, R7's, R8's, R9's, and R11's medical records found no documented determination completed at onset, or at the time of acceptance by the residents' PCP or medical practitioner. There was no documented determination completed by their medical practitioner at least every six months throughout the duration of the residents' condition. The determination should have been based on a current examination of the resident, the facility's scope of services, and should have included a statement that the residents' needs could be met by the facility.

2. In an interview, E1 and E2 acknowledged there was no documentation of the required determinations available for review for these sampled residents who were unable to ambulate even with assistance.

Based on observation, document review, and interview, the manager failed to ensure there were pre-planned snacks posted with the posted pre-planned meal menu.

Findings include:

1. During a facility tour, E1 and the compliance officer observed there were no pre-planned snacks posted on that day's menu nor the week at a glance menu that was dated February 4 to February 10, 2024.

2. In an interview, E1 reported snacks are offered. E1 acknowledged there were no pre-planned snacks stated on the posted pre-planned menu.