MOSAIC GARDEN MEMORY CARE AT SCOTTSDALE

<p>Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for two of two sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's and R2’s medical records revealed residency agreements. However, the residency agreements did not include R1's and R2’s dates of occupancy or expected dates of occupancy.</p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged R1’s and R2’s residency agreements did not include this information.</p>

Based on documentation review and interview, the manager of an assisted living center who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.

Findings include:

1. A review of facility documentation revealed an incident report which indicated R1 had an accident, emergency, or injury on December 21, 2024, that resulted in facility personnel contacting an emergency responder on R1's behalf. The review further revealed an incident report which indicated R3 had an accident, emergency, or injury on December 9, 2024, that resulted in facility personnel contacting an emergency responder on R3's behalf.

2. In an interview, the Compliance Officer requested documentation in compliance with this statute for the two aforementioned incidents. E1 stated, "just the face sheets" attached to the incident reports were the documents provided to the emergency responders.

3. A review of facility documentation revealed face sheets for R1 and R3. However, R1's face sheet provided to the emergency responder did not include the following:
- The reason or reasons the emergency responder was requested on behalf of R1;
- The name, address and telephone number of R1's current pharmacy;
- Basic information about R1's medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes;
- The point-of-contact information for the assisted living center, including the email address; and
- A copy of R1's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center to plan for R1's discharge.

4. R3's face sheet provided to the emergency responder did not include the following:
- The reason or reasons the emergency responder was requested on behalf of R3;
- The address number of R3's current pharmacy;
- Basic information about R3's medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes;
- The point-of-contact information for the assisted living center, including the email address; and
- A copy of R3's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center to plan for R3's discharge.

5. In an interview, E1 acknowledged the written documents provided to emergency responders on December 9 and 21, 2024, did not include all required information.

Technical assistance was provided on this statute during the complaint and compliance inspection conducted on September 11, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirement in R9-10-814(F)(2), for two of three sampled residents.

Findings include:

1. R9-10-814(F)(2) states, "In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes offering sufficient fluids to maintain hydration."

2. A review of R1's and R3's medical records revealed current service plans which revealed R1 and R3 were receiving directed care services. However, the service plans did not include offering sufficient fluids to maintain hydration.

3. In an interview, E1 acknowledged R1's and R3's service plans did not include offering sufficient fluids to maintain hydration.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care.

Findings include:

1. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay."

2. A review of facility documentation revealed an incident report which indicated R1 had an accident, emergency, or injury on December 21, 2024, that resulted in R1 needing medical services. However, the incident report revealed facility personnel did not notify R1's primary care provider until December 23, 2024. The review further revealed an incident report which indicated R3 had an accident, emergency, or injury at 11:00 AM on December 9, 2024, that resulted in R3 needing medical services. However, the incident report revealed facility personnel did not notify R3's primary care provider until 1:25 PM on December 9, 2024.

3. In an interview, E1 acknowledged a caregiver or an assistant caregiver did not immediately notify R1's and R3's primary care providers as required by rule.

Technical assistance was provided on this rule during the complaint inspection conducted on September 30, 2024.

Based on documentation review, interview, and observation, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454 and document the names of witnesses to the suspected abuse and the actions taken by the manager to prevent the suspected abuse from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A.R.S. \'a7 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online."

2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay."

3. A review of facility documentation revealed an incident report dated October 16, 2024. The incident report revealed the manager had a reasonable basis to believe abuse occurred on the premises. The report included a section titled "ABUSE REPORTING" which stated: "If abuse can not be ruled out at time of incident, then it must be reported immediately. Ruled out abuse and neglect? No." The report revealed facility personnel reported the suspected abuse on October 17, 2024, at 8:04 AM, more than 20 hours after the incident.

4. In an interview, E1 reported E1 first learned of the incident via text message on October 16, 2024, at 5:24 PM. E1 reported E1 asked facility personnel via text message on October 17, 2024, at 7:26 AM to report the suspected abuse to Adult Protective Services.

5. The Compliance Officer observed the text messages in question confirmed E1's report.

This is an uncorrected citation from the compliance and complaint inspection conducted on September 11, 2024.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk if measures were not in place for staff to always know the whereabouts of a resident.

Findings include:

1. In documentation review, the facility's policies and procedures revealed no documentation covering methods by which the facility was aware of the general or specific whereabouts of a resident, as required.

2. In an interview, E2 acknowledged not having a policy that covered methods by which the facility was aware of the general or specific whereabouts of a resident.

Technical assistance was provided on this rule during the complaint and compliance inspection conducted on September 11, 2024.

Based on documentation review, interview, and record review, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident. The deficient practice posed a risk as employees were unable to ensure the health and safety of a resident.

Findings include:

1. A review of facility documentation revealed an incident report dated January 22, 2024. The incident report stated: "[R1] was found on floor during room check by [personnel]. Resident was on floor, face down, head towards top of bed, feet pointing towards bathroom. [R1] has a laceration to [R1's] right side head." The report stated, an"Investigation of carestaff activities" was to be conducted to "lead to concludion [ sic ] of how fall occurred." The report stated revealed R1 was last seen by facility personnel at 8:00 PM the night before and stated, "Hourly checks were not completed by carestaff on duty. Carestaff responsible [E4] was terminated...[E4] claimed [R1's] apartment door was propped open and [E4] could see [R1] in bed. Watching the camera the door was not open enough to see [R1] in bed. [R1] was not checked on until 2:35am."

2. In an interview, E1 reported E4's employment was terminated for leaving R1 in R1's bedroom, not putting R1 to bed, and not checking on R1 every two hours as required.

3. A review of E4's personnel record revealed a "Corrective Action Form" dated January 24, 2024. The document indicated E4's employment had been terminated. The document stated: "On 1/22/24 you reported a fall for [R1]. In your written statement you stated that you put [R1] in [R1's] bed and checked on [R1] during your shift. After reviewing the video we were unable to substantiate your statement. [R1] was placed in [R1's] apartment at 7:52pm and you left [R1's] apartment at 7:55pm. [R1] was in the same clothing and [R1's] bed was made indicating that [R1] had not been put in bed...Based on the severity of these issues and potential harm to the residents we are terminating your employment immediately."

4. In an interview, E1 confirmed E4's employment was terminated due to E4 not meeting the needs and ensuring the health and safety of R1.

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

Findings include:

1. A review of R1's medical record revealed a service plan dated January 3, 2024. The service plan stated: "Resident needs carestaff assistance with dressing and undressing...Incontinence pads, Briefs, Bowel incontinent, Bladder incontinent, Night checks. Carestaff to assist resident with toileting every two hours, including changing brief and cleaning."

2. A review of facility documentation revealed an incident report dated January 22, 2024. The incident report stated: "[R1] was found on floor during room check by [personnel]. The report stated, an"Investigation of carestaff activities" was to be conducted to "lead to concludion [sic] of how fall occurred." The report stated revealed R1 was last seen by facility personnel at 8:00 PM the night before and stated, "Hourly checks were not completed by carestaff on duty. Carestaff responsible [E4] was terminated...[E4] claimed [R1's] apartment door was propped open and [E4] could see [R1] in bed. Watching the camera the door was not open enough to see [R1] in bed. [R1] was not checked on until 2:35am."

3. A review of E4's personnel record revealed a "Corrective Action Form" dated January 24, 2024. The document indicated E4's employment had been terminated. The document stated: "On 1/22/24 you reported a fall for [R1]. In your written statement you stated that you put [R1] in [R1's] bed and checked on [R1] during your shift. After reviewing the video we were unable to substantiate your statement. [R1] was placed in [R1's] apartment at 7:52pm and you left [R1's] apartment at 7:55pm. [R1] was in the same clothing and [R1's] bed was made indicating that [R1] had not been put in bed."

4. In an interview, E1 confirmed E4's employment was terminated for leaving R1 in R1's bedroom, not putting R1 to bed, and not checking on R1 every two hours as required.

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

Findings include:

1. A review of facility documentation revealed an incident report which revealed R1 was sent to the hospital at approximately 3:00 AM on January 22, 2024.

2. In an interview, E1 reported R1 returned to the facility from the hospital after noon on January 22, 2024.

3. A review of R1's medical record revealed documentation of assisted living services provided to R1 (ADLs) on January 22, 2024. The ADLs revealed documentation demonstrating E7 provided R1 assistance with dressing, grooming, and toileting the morning of January 22, 2024. However, R1 was in the hospital at this time. The review further revealed no other ADLs for R1 between admission and termination of residency other than several days in February and a few shower reports.

4. A review of facility documentation revealed E7 was not scheduled to work on January 22, 2024.

5. In an interview, E1 reported E7 was the Resident Care Coordinator at the time, was not working as a caregiver, and did not provide any services to R1 on January 22, 2024. When the Compliance Officer asked why E7 signed off on R1's ADLs, E1 stated, "Just to check it off [E7's] list." Regarding the missing ADLs, E1 reported the facility switched to a different ADL documenting system in March and the ADLs provided were all the ADLs the facility had for R1.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for four of five sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population and the Department provided false or misleading information.

Findings include:

1. A.R.S. \'a7 36-411(C)(1) states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to 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. A review of Department documentation revealed a Plan of Correction (POC) for the complaint inspection conducted on April 2, 2024. The POC revealed this rule violation was cited during that inspection and was documented as corrected on April 18, 2024. The POC stated: "A complete audit of all employee files was performed followed by an all staff meeting to have all employees sign a reference form; to then be verified by executive director and business office manager. Record of the reference check was added to each employee file. Monitoring Systems: The Executive Director or designee will call new hire references and have feedback before employee begins employment."

3. A review of the personnel records of E5 and E6 revealed E5 and E6 were hired as medication technicians and caregivers after April 18, 2024 (the correction date for this rule violation listed on the aforementioned POC). The review revealed "Employment Application[s]" which indicated E5 and E6 had prior employment. The review revealed untitled documents which included contact information for E5's and E6's previous employers. The review revealed no documentation in compliance with A.R.S. \'a7 36-411(C)(1) for E5 and E6. The review further revealed the "Executive Director or designee [did not] call new hire references and have feedback before [E5 and E6 began] employment."

4. A review of the personnel records of E7 and E8 revealed E7 and E8 were hired as caregivers before April 18, 2024 (the correction date for this rule violation listed on the aforementioned POC). The review revealed "Employment Application[s]" which indicated E7 and E8 had prior employment. The review revealed untitled documents which included contact information for E7's and E8's previous employers. The review revealed no documentation in compliance with A.R.S. \'a7 36-411(C)(1) for E7 and E8. The review further revealed a "complete audit of all employee files was [not] performed" nor did E7 and E8 "sign a reference form" and a "record of the reference check was [not] added to each employee file."

5. A review of facility documentation revealed a series of personnel schedules which indicated the following:
- E5 worked in August 2024;
- E6 worked in June 2024 and August 2024;
- E7 worked in November-December 2023, May-June 2024, and August 2024; and
- E8 worked in January-February 2024 and August 2024.

6. In an interview, E4 reported the personnel records provided to the Compliance Officers contained all documentation available for said personnel members. E1 acknowledged the personnel records of E5, E6, E7, and E8 did not include documentation in compliance with A.R.S. \'a7 36-411(C)(1).

This is a repeat citation from the on-site initial follow-up inspection conducted on July 11, 2023, and the complaint inspection conducted on April 2, 2024.

Based on documentation review, interview, and observation, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) \'a7 46-454 and document the names of witnesses to the suspected abuse and the actions taken by the manager to prevent the suspected abuse from occurring in the future. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A.R.S. \'a7 46-454(A) states: "A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online."

2. Arizona Administrative Code (A.A.C.) R9-10-101(111) states "[i]mmediate" means "without delay."

3. A review of facility documentation revealed a policy and procedure (P&P) titled "Abuse, Neglect, and Exploitation Policy," dated March 27, 2024. The P&P stated, "All staff are mandated to report abuse or suspected abuse immediately." The review further revealed an incident report dated July 30, 2024. The incident report revealed the manager had a reasonable basis to believe abuse occurred on the premises. The report included a section titled "ABUSE REPORTING" which stated: "If abuse can not be ruled out at time of incident, then it must be reported immediately. Ruled out abuse and neglect? No." However, the review did not reveal the names of witnesses to the suspected abuse and the actions taken by the manager to prevent the suspected abuse from occurring in the future.

4. In an interview, E1 reported having reported the suspected abuse to adult protective services (APS). However, E1 confirmed E1 did not report the suspected abuse immediately. In reference to the reports not including the names of witnesses to the suspected abuse and the actions taken by the manager to prevent the suspected abuse from occurring in the future, E2 stated, "It's not on here."

5. In a telephonic interview, a representative from APS confirmed the aforementioned suspected abuse was not reported immediately. The representative reported the suspected abuse was reported on August 1, 2024.

6. In an interview, E1 reported another incident involving potential suspected abuse was caught on camera on August 21, 2024.

7. The Compliance Officers observed a video recording in which R1 grabbed R5 by the arm.

8. A review of facility documentation revealed no incident report(s) or other report(s) regarding the suspected abuse of R5.

9. In an interview, E1 reported the incident was not reported to a peace officer or the APS central intake unit. E1 asked the Compliance Officers if the incident should have been reported. The Compliance Officers instructed E1 to report the suspected abuse immediately.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of four sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed no policy and procedure (P&P) covering how the manager would verify and document a caregiver or assistant caregiver's skills and knowledge. The review further revealed a personnel schedule dated August 2024 which indicated E5 worked on August 29-31, 2024.

2. In an interview, E2 reported the facility didn't have a P&P covering how the manager would verify and document a caregiver or assistant caregiver's skills and knowledge.

3. A review of E5's personnel record revealed E5 was hired as a caregiver. The review revealed a "Caregiver Skills Competency" checklist dated September 11, 2024, after E5 began providing physical health services.

4. In a series of interviews, E3 reported E5 administered medications on August 29, 2024. E1 and E2 confirmed E5's skills and knowledge were not verified and documented before E5 provided physical health services.

This is a repeat citation from the complaint inspection conducted on April 2, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of four sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency and the Department was provided false or misleading information.

Findings include:

1. A review of Department documentation revealed a Plan of Correction (POC) for the complaint inspection conducted on April 2, 2024. The POC revealed this rule violation was cited during that inspection and was documented as corrected on May 8, 2024. The POC stated: "Upon audit of employee files, executive director signed up all employees to a CPR/FA in person class at the facility. American Emergency Response Training Headquarters will perform an in-person CPR/FA course on May 8th to certify any employee not certified or properly certified. All information will be added into our quality assurance program to keep track of dated and renewals along with double checking any upcoming expiring credential through monthly audits."

2. A review of facility documentation revealed a policy and procedure (P&P) titled "CPR/FA," dated May 31, 2024. The P&P stated: "All employees will be required to provide a valid CPR/FA card through an approved program that demonstrated cognition and physical skills. Ongoing, employee will need to continue training upon renewal of card." The review revealed a series of personnel schedules which indicated E7 worked in November-December 2023 and May-June 2024. The review further revealed a printout of an email chain between E4 and E7. In the email chain, on May 28, 2024, E4 stated, "You need a current CPR/First Aid [card]" to which E7 responded on May 29, 2024, stating: "I have a CPR training next week. I will bring it as soon as I get it."

3. A review of E7's personnel record revealed the following:
- E7 was hired as a caregiver;
- A photocopy of E7's first aid training certification dated as expired on May 12, 2024;
- A printout of E7's current first aid training certification dated as issued on June 14, 2024;
- A photocopy of E7's CPR training certification from NationalCPRFoundation dated as issued on May 12, 2022, and expired on May 12, 2024;
- A photocopy of E7's current CPR training certification from American Heart Association dated as issued on June 4, 2024;
- E7 worked approximately one month without first aid training certification and seven months without CPR training certification which included a demonstration of E7's ability to perform CPR; and
- The "executive director [did not sign] up all employees to a CPR/FA in person class at the facility" as stated in the POC.

4. A review of the NationalCPRFoundation website revealed E7's CPR training was online-only and did not include a demonstration of E7's ability to perform CPR.

5. In a series of interviews, E4 reported E7's personnel record provided to the Compliance Officers contained all documentation available for E7. E1 acknowledged E7 did not provide current documentation of first aid training and CPR training certification specific to adults before providing assisted living services to a resident.

This is a repeat citation from the on-site initial follow-up inspection conducted on July 11, 2023, and the complaint inspection conducted on April 2, 2024.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

Findings include:

1. A review of the medical records of R3 and R4 revealed current services plans which indicated R3 and R4 received directed care services. However, the service plans did not include coordination of communications with the R3's and R4's respective representatives, family members, and, if applicable, other individuals identified in R3's and R4's service plans.

2. In an interview, E2 reported the coordination of communications should have been on the first pages of the service plans but acknowledged it was not.

Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on July 11, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of four sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency and the Department was provided false or misleading information.

Findings include:

1. A review of facility documentation revealed a policy and procedure (P&P) titled "Medication & Treatment Administration," dated May 28, 2024. The P&P stated: "Mosaic Gardens will maintain accurate documentation for each administration of medication (including over-the-counter medication), if staff assists with administration. The Community has established a MAR system to serve the need for documentation. Staff will follow the correct procedures."

2. A review of R4's medical record revealed a current service plan which revealed R4 was to receive medication administration. The review further revealed a medication administration record (MAR) dated September 2024. The MAR revealed R4 received valproic acid 250 mg at 1:00 PM on September 1, 2024, and 7:00 PM on September 3 and 5, 2024.

3. In an interview, when the Compliance Officers asked when R4's valproic acid was delivered to the facility, E3 reported it was never delivered. E3 stated R4 "hasn't even had it yet" and the caregivers "were marking it" in error.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for two of four sampled residents and three of five sampled employees. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."

2. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel."

3. A review facility documentation revealed a policy and procedure (P&P) titled "INFECTION CONTROL." The P&P stated: "Residents moving into the community will have proof of freedom of TB upon move in or within 7 days of residency...All employees and volunteers will have proof of freedom of TB before rendering services to residents. 1. A 2 step PPD performed before starting."

4. A review of the medical record of R1 and R4 revealed documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if R1 and R4 had signs or symptoms of TB. However, the documentation was dated approximately six months after R1 and R4 were admitted to the facility. The review revealed negative TST results for R1 and R4. However, the results were also dated approximately six months after R1 and R4 were admitted to the facility.

5. In an interview, E3 reported the facility did not have the risk assessment, signs and symptoms screening, and TST results for R1 and R4 before or within seven calendar days after R1's and R4's respective dates of occupancy.

6. A review of E6's personnel record revealed E6 was hired as a medication technician and caregiver. The review further revealed the following:
- A "State Survey List of Documents" which indicated E6 received E6's first TST but not the second;
- One negative TST result dated as read before E6 began providing services at or on behalf of the assisted living facility; and
- No second negative TST result dated before E6 began providing services at or on behalf of the assisted living facility.

7. A review of E7's personnel record revealed E7 was hired as a caregiver. The review further revealed the following:
- Documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if E7 had signs or symptoms of TB, dated after E7 began providing services at or on behalf of the assisted living facility.
- One negative TST result dated as read before E7 began providing services at or on behalf of the assisted living facility; and
- A second and third negative TST result dated as read after E7 began providing services at or on behalf of the assisted living facility.

8. A review of E8's personnel record revealed E8 was hired as a caregiver. The review further revealed the following:
- Documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if E8 had signs or symptoms of TB, dated after E8 began providing services at or on behalf of the assisted living facility.
- Two negative TST results dated as read after E8 began providing services at or on behalf of the assisted living facility.

9. In a series of interviews, E4 reported the personnel records provided to the Compliance Officers contained all documentation available for said personnel members. E2 reported knowing personnel members needed 2-step TB testing before providing care.

Technical assistance was provided on this rule during the on-site initial follow-up inspection conducted on July 11, 2023.

Based on record review documentation review, and interview, for five of seven employees reviewed, the manager failed to make good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility. The deficient practice posed a risk to residents, if the facility did not make efforts to obtain information or recommendations relevant to a caregiver's fitness to work with residents at the facility.

36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions. 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.

Findings include:

1. In record review, the personnel records for E3 (hired as a caregiver on February 15, 2024), E4 (hired as a caregiver on January 28, 2024), E5 (hired as a caregiver on January 30, 2024), E6 (hired as a caregiver on February 28, 2024), and E7 (hired as a caregiver on January 24, 2024), did not include documentation the facility made efforts to contact previous employers.

2. In documentation review, the staffing schedule for March 2024, included documentation the caregivers worked shifts at the facility.

3. During an interview, E1 acknowledged the personnel records for the caregivers did not include documentation the facility made efforts to obtain information or recommendations relevant to the caregivers' fitness to work in the facility.

This is a repeat deficiency from the abbreviated inspection and complaint investigation conducted on July 11, 2023.

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Findings include:

1. In documentation review, the Compliance Officer requested to review the facility's policy and procedures which covered how a caregiver will respond to a resident's sudden, intense, or out of control behavior. No policy was provided during the inspection.

2. E1 acknowledged the policy was not provided during the inspection, as required.

3. The policy was not provided within two hours of a request.

Based on record review, documentation review, and interview, for five caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents.

Findings include:

1. In record review, the personnel records for E3 (hired as a caregiver on February 15, 2024), E4 (hired as a caregiver on January 28, 2024), E5 (hired as a caregiver on January 30, 2024), E6 (hired as a caregiver on February 28, 2024), and E7 (hired as a caregiver on January 24, 2024), did not include documentation the caregivers' skills and knowledge were verified.

2. In documentation review, the staffing schedule for March 2024, included documentation the caregivers worked shifts at the facility.

3. During an interview, E1 acknowledged the personnel records for the caregivers did not include documentation of the verification of the caregivers' skills and knowledge, and acknowledged the documentation was required before a caregiver provided services for residents.

Based on record review, documentation review, and interview, for five of five caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff.

Findings include:

1. In record review, the personnel records for E3 (hired as a caregiver on February 15, 2024), E4 (hired as a caregiver on January 28, 2024), E5 (hired as a caregiver on January 30, 2024), E6 (hired as a caregiver on February 28, 2024), and E7 (hired as a caregiver on January 24, 2024), did not include documentation the caregiver provided evidence of freedom from TB, as required. The personnel records for E3, E4, and E5 contained no documentation of freedom from TB. E6's personnel record included documentation of a single negative TB test within the past 12 months; however, did not include documentation of a second negative TB test on hire, and a screening and risk assessment completed by a health provider. E7's record included documentation of a single negative TB test within the past 12 months; however, did not include documentation of a second negative TB test, and a screening and risk assessment completed by a health provider.

2. In documentation review, the staffing schedule for March 2024, included documentation the caregivers worked shifts at the facility.

3. During an interview, E1 acknowledged the personnel records for the caregivers did not include documentation the caregivers provided evidence of freedom from TB, as required by R9-10-113.

Based on record review, documentation review, and interview, for five caregivers reviewed, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver was not oriented, as required.

Findings include:

1. In record review, the personnel records for E3 (hired as a caregiver on February 15, 2024), E4 (hired as a caregiver on January 28, 2024), E5 (hired as a caregiver on January 30, 2024), E6 (hired as a caregiver on February 28, 2024), and E7 (hired as a caregiver on January 24, 2024), did not include documentation the caregivers received orientation.

2. In documentation review, the staffing schedule for March 2024, included documentation the caregivers worked shifts at the facility.

3. During an interview, E1 acknowledged the personnel records for the caregivers did not include documentation the caregivers received orientation.

Based on record review, and interview, for two of five caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid training (FA) and cardiopulmonary resuscitation training (CPR) certification specific to adults which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR.

Findings include:

1. In record review, E5's personnel record (hired as a caregiver on January 30, 2024) included documentation of CPR certification, dated October 9, 2022, from ProCPR, which was an online training program, and did not include a demonstration.

2. In record review, E7's personnel record (hired as a caregiver on February 28, 2024, did not include documentation E7 completed FA training.

3. During an interview, the findings were reviewed with E1, who acknowledged E5's CPR was provided by an online training program, and did not include a demonstration, and E7's record did not include documentation of FA training.

This is a repeat deficiency from the abbreviated inspection and complaint investigation conducted on July 11, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication services included procedures for assisting a resident in procuring medication. The deficient practice posed a health risk if the facility did not have procedures to ensure a resident had prescribed medications available for administration.

Findings include:

1. In documentation review, a review of the facility's medication policies and procedures revealed the facility did not have a policy and procedure for assisting a resident in procuring medication.

2. During an interview, E1 acknowledged the facility did not have a policy and procedures for assisting a resident in procuring medication, and acknowledged a policy was required.

Based on record review, documentation review, and interview, for three of six personnel members reviewed, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411. The deficient practice posed a safety risk to residents if a caregiver was a danger to a vulnerable population.

A.R.S. \'a7 36-411(C) states "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."

Findings include:

1. In record review, E3's (hired March 9, 2023) personnel record included a FP clearance card, issued May 23, 2019; however, there was no documentation of the verification of the current status of the FP card, and no documentation previous employers were contacted to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution.

2. In record review, E6's (hired March 29, 2023) personnel record included a FP clearance card, issued February 23, 2021; however, there was no documentation of the verification of the current status of the FP card, and no documentation previous employers were contacted to obtain information or recommendations that may be relevant to E6's fitness to work in a residential care institution.

3. In record review, E7's (hired March 30, 2023) personnel record included a FP clearance card, issued January 27, 2020; however, there was no documentation of the verification of the current status of the FP card, and no documentation previous employers were contacted to obtain information or recommendations that may be relevant to E7's fitness to work in a residential care institution.

4. In research, an online review at the Department of Public Safety website revealed the FP clearance cards for E3, E6, and E7 were valid.

5. During an interview, the findings were reviewed with E1 and E2, who acknowledged having no documentation of the verification of the FP clearance cards for E3, E6, and E7, and no documentation the previous employers were contacted to obtain information or recommendations that may be relevant to E3, E6, and E7's fitness to work in a residential care institution.

Based on documentation review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident covering staffing and recordkeeping.

Findings include:

1. In documentation review, a review of the facility's policies and procedures revealed the facility had a policy on "Staffing," however, did not have a policy and procedures which covered recordkeeping.

2. During an interview, E1 acknowledged not being able to locate a policy and procedures covering recordkeeping for personnel.

Based on record review and interview, for two of six personnel records reviewed, the manager failed to ensure a caregiver provided documentation of cardiopulmonary resuscitation training (CPR) certification specific to adults, which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR.

Findings include:

1. In record review, the personnel record for E4 (hired June 6, 2023, as a caregiver) included documentation of CPR certification provided by NationalCPRFoundation, which was an online training program, and did not include a demonstration of an individual's ability to perform CPR.

2. In record review, the personnel record for E6 (hired March 29, 2023, as a caregiver) included documentation of CPR certification by "NewLife," which was an online training program, and did not include a demonstration of an individual's ability to perform CPR.

3. During an interview, the findings were reviewed with E1 and E2, who reported being unaware the CPR training programs were online programs, and acknowledged the CPR training received by the employees did not include the required demonstration of the employees' ability to perform CPR.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided.

Findings include:

"Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident.

1. In record review, R1's medical record included documentation of diagnoses as "Alzheimer's Disease." R1's service plan did not include documentation of R1's medical and health problems.

2. In record review, R2's medical record included documentation of "Dementia, unspecified... and Xerosis Cutis" R2's service plan did not include documentation of R2's medical and health problems.

3. During an interview, the findings were reviewed with E1 and E2, who reported R1 and R2 received directed care services, and acknowledged the service plans did not include a description of the residents' medical and health problems, as required.

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure at the time of admission, a resident or resident's representative received a written copy of the requirements in subsection (B), and the resident rights in subsection (C). The deficient practice posed a health and safety risk as the resident or resident's representative could be unaware of these requirements.

Findings include:

1. In record review, R1's medical record did not include documentation the resident or resident's representative received a copy of the requirements in subsection (B) and the resident rights in subsection (C). Based on R1's acceptance date, this documentation was required.

2. During an interview, E1 and E2 acknowledged the resident received directed care services, and the resident's representative did not receive a copy of the requirements in subsection (B). and the resident rights in subsection (C).

Based on observation, record review, and interview, for one resident reviewed, who was unable to walk and receiving directed care services, the manager failed to ensure the resident's primary care provider (PCP) or other medical practitioner (MP) examined the resident at the onset of the condition and at least every six months throughout the duration of the resident's condition, reviewed the facility's scope of services, and signed and dated a determination stating the resident's needs were being met by the facility. The deficient practice posed a health risk to a resident if a resident's condition was not reviewed by a PCP or MP, to approve a resident's stay at the facility.

Findings include:

1. In observation, the surveyor observed R2 in a wheelchair during the inspection.

2. During an interview, E2 reported R2 was unable to walk, even with assistance, and was observed by E2 to be confined to a bed or chair, when E2 started employment in April 2023.

3. In record review, R2's medical record did not include a signed and dated determination stating the resident's needs could be met by the facility. Based on R2's acceptance date, this documentation was required to be completed.

4. During an interview, the findings were reviewed with E1 and E2, who acknowledged R2's record did not include a signed and dated determination stating the resident's needs could be met by the facility.