Deficiency #1
Rule/Regulation Violated:
R9-10-816.F.1. Medication Services<br> F. When medication is stored by an assisted living facility, a manager shall ensure that: <br> 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
Evidence/Findings:
<p>Based on observation, record review, and interview, the manager failed to ensure that medication stored by the facility 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 unable to self-administer medication.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed the facility's medication cabinet to be equipped with a lock. However, the lock was not engaged at the time of inspection.</p><p><br></p><p>2. <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">During an environmental tour of the facility, t</span>he Compliance Officers observed a container of Visine Red Eye Drops stored on the nightstand in R2's bedroom.</p><p><br></p><p>3. A review of R2's medical record revealed R2 required directed care services and medication administration.</p><p><br></p><p>4. In an interview, E1 acknowledged medication stored by the facility was not maintained in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.</p>
Temporary Solution:
Plan of Correction.
R9-10-816.F.1
1. During an environmental tour of the facility, the Compliance Officers observed the facility's medication cabinet to be equipped with a lock. However, the lock was not engaged at the time of inspection.
The lock was open because the caregivers were actively getting out meds for the patients as the surveyors arrived and were tehre during the lunch / dinner hours. It is obvious that the lock would be disengaged while someone was going in and out of the cabinet. I (the manager) was there during the same time as the surveyor and it was not left open after the meds were obtained for the patients nor at any time after they left was the lock not used. We no longer use the same kind of lock system, but they were actively in use. The meds now have been moved inside a doored location with keycode access and only those who need access to that area know the keycode combination so the meds are locked down at all times.
2. During an environmental tour of the facility, the Compliance Officers observed a container of Visine Red Eye Drops stored on the nightstand in R2's bedroom.
All items marked keep out of reach of children, visine, etc., all have been removed from any / all patients rooms and caregivers were reinstructed to make sure there are no items ever in the rooms due to the level of care that the patients we mostly have are at in Queen Creek Carehomes LLC. We now do regular checks to make sure no items are left in those rooms and I regularly (the manager) spot check when there to make sure of compliance.
3. A review of R2's medical record revealed R2 required directed care services and medication administration.
We only do medication administration. Not sure of the reason for this comment. We do medication administration for all patients as we only have personal and directed (mostly directed care).
4. In an interview, E1 acknowledged medication stored by the facility was not maintained in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.
This is not a true statement, nor do I agree. All medication is locked and stored away. I do not agree with this input at all. Regardless of my input, we have moved any / all medications for all patients into a doored / keycode locked location and I review that location every visit.
Permanent Solution:
Plan of Correction.
R9-10-816.F.1
1. During an environmental tour of the facility, the Compliance Officers observed the facility's medication cabinet to be equipped with a lock. However, the lock was not engaged at the time of inspection.
The lock was open because the caregivers were actively getting out meds for the patients as the surveyors arrived and were there during the lunch / dinner hours. It is obvious that the lock would be disengaged while someone was going in and out of the cabinet. I (the manager) was there during the same time as the surveyor and it was not left open after the meds were obtained for the patients nor at any time after they left was the lock not used. The meds now are locked even after just being removed or accessed even if right beside the cabinets / storage area so no further confusion as to whether or not they are "secured". The medication is stored completely seperate of any other items also.
2. During an environmental tour of the facility, the Compliance Officers observed a container of Visine Red Eye Drops stored on the nightstand in R2's bedroom.
All items marked keep out of reach of children, visine, etc., all have been removed from any / all patients rooms and caregivers were reinstructed to make sure there are no items ever in the rooms due to the level of care that the patients we mostly have are at in Queen Creek Carehomes LLC. We now do regular checks to make sure no items are left in those rooms and I regularly (the manager) spot check when there to make sure of compliance.
3. A review of R2's medical record revealed R2 required directed care services and medication administration.
We only do medication administration. Not sure of the reason for this comment. We do medication administration for all patients as we only have personal and directed (mostly directed care).
4. In an interview, E1 acknowledged medication stored by the facility was not maintained in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.
This is not a true statement, nor do I agree. All medication is locked and stored away. I do not agree with this input at all. Regardless of my input, we have moved any / all medications for all patients into a doored / keycode locked location and I review that location every visit.
Deficiency #2
Rule/Regulation Violated:
R9-10-817.C.4.a. Food Services<br> C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: <br> 4. Potentially hazardous food is maintained as follows: <br> a. Foods requiring refrigeration are maintained at 41° F or below; and
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41° F or below. The deficient practice posed a risk for potential food-borne illnesses.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed the following foods open and stored in an unrefrigerated kitchen cabinet:</p><ul><li>Great Value Grape Jelly; and</li><li>Great Value Soy Sauce.</li></ul><p> </p><p>2. In an interview, E1 acknowledged that the foods requiring refrigeration were not maintained at 41° F or below.</p>
Temporary Solution:
Some caregivers had stored their own food in a cabinet in a manner not accepted by the manager or the facility. We checked all items that stated refrigerate after use and any found that were open were disposed of and everyone was updated on what to and what not to put in a cabinet for useage regardless of whom was to consume it.
Permanent Solution:
All items are monitired now when bought to check for refrigerate after use, etc and made sure to be refrigerated when opened.
Person Responsible:
Food Storage
Deficiency #3
Rule/Regulation Violated:
R9-10-819.A.1.b. Environmental Standards<br> A. A manager shall ensure that: <br> 1. The premises and equipment used at the assisted living facility are: <br> b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;
Evidence/Findings:
<p>Based on observation, record review, and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed the following materials stored on the counter in R2's bathroom: </p><ul><li>Dawn Dish soap:</li><li>Remedy Essentials Antifungal Cream: and</li><li>Remedy Clinical Antifungal Powder.</li></ul><p><br></p><p>2. A review of R2's service plan revealed R2 received directed care services. </p><p><br></p><p>3. In an interview, E1 acknowledged that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. </p><p><br></p><p><br></p>
Temporary Solution:
Plan of Correction.
R9-10-819.A.1.b. Environmental Standards
Based on observation, record review, and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents. Findings include:
1. During an environmental tour of the facility, the Compliance Officers observed the following materials stored on the counter in R2's bathroom: Dawn Dish soap: Remedy Essentials Antifungal Cream: and Remedy Clinical Antifungal Powder.
All items that can or could be accessed or etc by a person at the directed care level have been removed and put under locked location(s) so they cannot be used without the knowledge of the caregiver making sure the items are used as intended. We also spot check any / all areas to make sure someone visiting is not leaving behind items for their loved ones in their room or bathroom even we do instruct that is not supposed to be done. We again spot check any / all areass for compliance.
2. A review of R2's service plan revealed R2 received directed care services.
Correct, we have directed care patients and see above for POC on how we deal with those issues.
3. In an interview, E1 acknowledged that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.
That is correct, we provide a safe and amazing home for our residents and will continue to do so as long as we are open for business. We have implemented the items above to make sure we are in total compliance with the state for directed care. The caregivers are not instructed and retrained often. On the spot checks for items that have to be stored away since we do have directed level patients.
Permanent Solution:
Plan of Correction.
R9-10-819.A.1.b. Environmental Standards
Based on observation, record review, and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents. Findings include:
1. During an environmental tour of the facility, the Compliance Officers observed the following materials stored on the counter in R2's bathroom: Dawn Dish soap: Remedy Essentials Antifungal Cream: and Remedy Clinical Antifungal Powder.
All items that can or could be accessed or etc by a person at the directed care level have been removed and put under locked location(s) so they cannot be used without the knowledge of the caregiver making sure the items are used as intended. We also spot check any / all areas to make sure someone visiting is not leaving behind items for their loved ones in their room or bathroom even we do instruct that is not supposed to be done. We again spot check any / all areass for compliance.
2. A review of R2's service plan revealed R2 received directed care services.
Correct, we have directed care patients and see above for POC on how we deal with those issues.
3. In an interview, E1 acknowledged that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.
That is correct, we provide a safe and amazing home for our residents and will continue to do so as long as we are open for business. We have implemented the items above to make sure we are in total compliance with the state for directed care. The caregivers are not instructed and retrained often. On the spot checks for items that have to be stored away since we do have directed level patients.
Person Responsible:
Items in Patients Room
Deficiency #4
Rule/Regulation Violated:
R9-10-819.A.11. Environmental Standards<br> A. A manager shall ensure that: <br> 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:
<p>Based on observation and interview, the manager failed to ensure, poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. During an environmental tour of the facility, the Compliance Officers observed the following materials stored in an unlocked bottom cabinet under the kitchen sink:</p><ul><li>Lysol kitchen Pro cleaner; and</li><li>Great Value Disinfectant Spray.</li></ul><p>The cabinet was equipped with a lock; however, the lock was not in use at the time of inspection.</p><p><br></p><p>2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not maintained in a locked area and inaccessible to residents.</p>
Temporary Solution:
The caregivers were instructed if a lock is on a cabinet it is for a reason and is to be locked when not being accessed.
Permanent Solution:
Locks are checked often to make sure we stay in compliance with keeping items out of reach of residents.
Person Responsible:
Locks in place
Summary:
On June 9, 2025, an on-site review of the plan of correction was conducted. The plan of correction was accepted for all citations.