BROOKDALE CHANDLER RAY ROAD

INSP-0108145

Complete

Date: 3/28/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-18

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00106496 conducted on March 28, 2025:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on documentation review, record review, and interview, the governing authority failed to make a documented good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in the facility, for three out of five employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1) A.R.S. § 36-411(C) states: "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. 2) A review of the personnel records for E2 (hired September 2024), E3 (hired October 2020), and E4 (hired December 2024) did not include documentation a good faith effort was made to contact previous employers. 3) In an interview, E1 acknowledged the facility did not have documentation that a good faith effort was made to contact previous employers, as required.

Temporary Solution:

E2 E3 and E4 references have been reviewed to ensure proper references were identified. Reference checks where in employees file at time of survey.

Permanent Solution:

BOC or hiring manager to continue to ensure references complete before start date.

Person Responsible:

Brandon Gaffey ED/ALM, Megan Murphy Business Office

Deficiency #2

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for one caregiver reviewed. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide care and services for a resident. Findings include: 1) A review of the facility's policies and procedures revealed a policy titled "Caregivers Job Descriptions, Duties and Qualifications." This policy stated, "A caregiver's or assistant caregiver's skills and knowledge are verified and documented." 2) A review of E3's personnel record revealed a hire date of October 30, 2020. E3's record revealed no documentation verifying E3's skills and knowledge. 3) In an interview, E1 acknowledged verification of E3's skills and knowledge was not documented before services were provided.

Temporary Solution:

E3 skills and knowledge is up to date as of today. Skills and knowledge completed and in file as of July 2024.

Permanent Solution:

ED/HWD or hiring manager to continue to ensure that skilled and knowledge documents complete before employee to begin start date.

Person Responsible:

Brandon Gaffney ED/ALM, Edward Evangelista Health & Wellness Director

Deficiency #3

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of five residents sampled. The deficient practice posed a 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. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R1's medical record did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs of symptoms of TB.

Temporary Solution:

Review of R1 and R2 TB documentation it was found both were completed at move in.
R1 (Agreement Start 3/25/24 - TB 3/21/24 & 3/28/24).
R2 (Agreement Start 1/10/23 – TB 1/9/23

Permanent Solution:

HWD/BOC to continue to ensure TB is complete and cleared prior to work and within policy.

Person Responsible:

Brandon Gaffney ED/ALM, Edward Evangelista Health and Wellness Director

Deficiency #4

Rule/Regulation Violated:

R9-10-818.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility, 2. The resident's orientation is documented.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for four of five sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1, R2, R3, and R5's medical records revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at the time of inspection. 2. In an interview, E1 acknowledged R1, R2, R3, and R5's medical records did not contain documentation of the resident's orientation to exits from the assisted living facility at the time of the inspection.

Temporary Solution:

Auditing resident files to ensure it reflects orientation to exits is included in resident files. (Policy: A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility) resident records were completed for R1 (3/26/24), R2 (1/13/24), R3 ((11/7/23) and R5 (10/10/24).

Permanent Solution:

MM to continue process of resident move in checklist. This to ensure that residents have completed orientation to building and evac within 24 hours of move in. Ed to verify completed within 24 hours of move in with MM.

Person Responsible:

Brandon Gaffney ED, Richard Roallos Maintenance Manager

INSP-0064421

Complete

Date: 2/1/2023 - 2/2/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-02-08

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on February 1-2, 2023:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provides current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults for one of four sampled caregivers and manager which posed a health and safety risk.

Findings include:

1. Review of employee records revealed that E2 was hired April 25, 2022. E2's record contained documentation of completing the online-only CPR training from National CPR Foundation, which did not include a return demonstration of E2's ability to perform CPR, that was issued on June 8, 2022 with an expiration date in two years.

2. Review of E2's personnel record revealed that E2 was a licensed practical nurse (LPN) working at the facility.

3. During an interview, E1 acknowledged E2's record contained documentation of completing online CPR training which did not include a return demonstration of E2's ability to perform CPR.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2022.

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;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure one of five sampled residents' written service plans when initially developed and updated were signed and dated by the resident or resident's representative, the manager, and if applicable, by the nurse or medical practitioner who reviewed the service plan, as required.

Finding included:

1. Review of R4's medical record contained no updated service plan since March 3, 2022. This service plan stated R4 required personal care and medication administration services.

2. In an interview, E2 reported that R4 did have a more current service plan in the computer that was dated August 26, 2022. This service plan stated the resident required personal care and medication administration services. E2 provided a printed copy of this service plan on the day of the compliance inspection, however, it did not contain any dated signatures from the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan. E1 and E2 acknowledged that the service plan was not signed.

Deficiency #3

Rule/Regulation Violated:

B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2):
1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that for one of the three sampled residents who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner had examined the resident, at the time of acceptance or within 30 days before 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. This determination should have been based upon a current resident examination and the assisted living facility's scope of services, which posed a health and safety risk. The facility was licensed to provided directed care services.

Findings include:

1. Review of randomly selected residents' records and interview, E2 reported R2 was unable to ambulate even with assistance since accepted to the facility.

2. Review of R2's medical record contained no documented determination from R2's PCP or medical practitioner at the time of acceptance nor anytime since that stated R2's needs could be met by the facility. This documented determination should have been completed at the time of acceptance and at least every six months update throughout the duration of the resident's condition, stating R2's needs were being met by the facility based upon a current resident examination and the facility's scope of services.

3. During an interview, E2 reported "no" the required confined determination documentation for R2 was never done.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2022.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that food is obtained, prepared, served, and stored as follows:
5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that a refrigerator used by the assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator.

Findings include:

1. During a facility tour of the facility's activity room, E1 and the compliance officer observed there was one reach-in refrigerator/freezers and one small reach in refrigerator, that were in use for food storage, however, neither of them contained a thermometer.

2. During an interview, E1 acknowledged the two refrigerators did not contain a thermometer.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months which posed a safety risk.

Findings include:

1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months.

2. In an interview, E1 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
5. An evacuation drill for employees and residents:
a. Is conducted at least once every six months; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of the facility's documentation revealed one evacuation drill, dated May 18, 2022 was conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during this six month time period.

2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months. There was no documentation of an employee and resident evacuation drill after May 18, 2022.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure oxygen containers were secured, which posed a safety risk.

Findings include:

1. During a facility tour of randomly selected areas of the facility, E1 and the compliance officer observed R1's unit contained five unsecured oxygen containers.

2. In an interview, E1 acknowledged the unsecured oxygen containers.

Deficiency #8

Rule/Regulation Violated:

A. A manager shall ensure that:
13. Equipment used at the assisted living facility is:
a. Maintained in working order;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure equipment at the assisted living facility was maintained in working order which posed a safety risk.

Findings include:

1. During a facility tour of randomly selected areas of the facility, E1 and the compliance officer observed the exhaust fans in common residents' spa and bathroom did not work when tested. This bathroom exhaust fan was located in a bathroom that had no window or any other means of ventilation.

2. In an interview, E1 acknowledged the sampled residents' spa bathroom exhaust fan was not kept in working order.

Facility Information

Inspection History

INSP-0161668

Summary:

INSP-0108145

Summary:

Deficiencies Found: 4

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:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0064422

Summary:

INSP-0064421

Summary:

Deficiencies Found: 8

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:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings: