THE PEAKS, A SENIOR LIVING COMMUNITY

Based on record review and interview, the manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order.

Findings include:
1. The record for R1 contained a physician's order for Eliquis 5mg tab, take 1 tab by mouth, twice daily.
2. Record review further indicated that the medication was to be discontinued on December 7, 2024.
3. The medication administration record (MAR) for R1 indicated that the medication had continued to be administered until December 10, 2024 at 8am.
4. During an interview, E1 stated, "There was a miscommunication. We discontinued the medication as soon as we realized the error."

Based on record review and interview, the manager failed to ensure that a sample resident record contained a service plan that included the level of service the resident was expected to receive.

Findings include:
1. The record for R3 contained a service plan dated November 4, 2023 that did not include the level of service the resident received.
2. During an interview, E1 acknowledged the resident record did not contain the required information.

Based on record review and interview, the manager failed to ensure that a sample resident record contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services.

Findings include:
1. The record for R3 contained service plan reviews reflecting the following dates of completion: November 4, 2023 and August 28, 2024.
2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview the manager failed to ensure for a sample service plan, the service plan that when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan.

Findings include:
1. Review of the record for R3 (receiving medication administration), revealed that the service plan dated August 28, 2024 was not signed and dated by the resident or their representative, the manager or the nurse or medical practitioner who reviewed the service plan.
2. During an interview E1 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that two of two sample resident records, had service plans that were reviewed and updated at least once every three months for a resident receiving directed care services.

Findings include:
1. The record for R1 contained a service plan that was last updated on January 18, 2024.
2. The record for R2 contained a service plan that was last updated on February 19, 2024.
3. During an interview, E1 acknowledged that service plan documentation did not reflect that updates were conducted at least once every three months.

Based on record review, facility documentation review and interview, the Manager failed to ensure that a resident was treated with dignity, respect and consideration.

Findings include:
1. Review of the record for R1 revealed an incident report dated April 2, 2024 that indicated witnesses had observed E2 "yelling" at R1 and telling R1 that "You are being mean to staff and need to stop". Additionally, witnesses claimed that E2 was observed "using frequent profanity" when referring to residents.
2. Review of facility documentation revealed that the internal investigation conclusion was that E2 "should be terminated from employment at The Peaks as to not put residents at risk of emotional abuse." E2 was terminated on April 10, 2024.
3. During an interview, E1 acknowledged E2 failed to treat R1 with dignity, respect and consideration.

Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for each resident.

Findings include:
1. The record for R1 did not contain the completed emergency responder patient information documentation.
2. The record for R2 did not contain the completed emergency responder patient information documentation.
3. The record for R3 did not contain the completed emergency responder patient information documentation.
4. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection can be found, was conspicuously posted.

Findings include:
1. Observation of the locked memory unit failed to reveal a posting indicating the location at which a copy of the most recent Department inspection report can be found.
2. During an interview E5 acknowledged the required documentation was not conspicuously posted.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

Based on record review and interview, the manager failed to ensure that one of four sample personnel records contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113.

Findings include:
1. The personnel record for E2 (Manager Designee, hired July 10, 2023) contained documentation indicating that only one TB test was administered; however, this TB test was not done within the 12 month period prior to the date of hire.
2. During an interview, E1 acknowledged that the employee worked more than 8 hours per week and the documentation did not reflect that the employee's record contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview, the manager failed to ensure for one of four records that before providing personal care services or directed care services to a resident, a caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults.

Findings include:
1. The record for E3 (hired February 24, 2023), revealed documentation of CPR and First Aid certifications that expired on December 8, 2023.
2. During an interview, E1 acknowledged that the required documentation was not available for review.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy as specified in R9-10-113.

Findings include:
1. The record for R2 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E1 acknowledged that the record did not contain evidence of freedom from TB.

Based on record review, observation and interview, the manager failed to ensure that two of two sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled.

Findings include:
1. During an interview, E1 indicated that R2 self-administered their own medications and stored the medications in their room.
2. The record for R2 contained a service plan dated August 10, 2023 that did not include how the resident's medication would be stored and controlled.
3. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room.
4. The record for R3 contained a service plan dated December 21, 2023 that did not include how the resident's medication would be stored and controlled.
5. During an interview, E1, acknowledged the service plans did not indicate how the resident's medication would be stored and controlled in their rooms.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia.

Findings include:
1. The record belonging to R1 contained no documentation indicating that the resident had been notified of the availability of pneumonia vaccination, and the last documentation indicating that the resident was last notified of the availability of the influenza vaccination was dated October 8, 2022. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
2. The record belonging to R3 contained documentation indicating that the resident was last notified of the availability of the influenza vaccination on November 2, 2022. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members.

Findings include:
1. The toxicology guide available for use by personnel members was the Poisoning and Drug Handbook, 6th. edition.
2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution.
3. During an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: March 11, 2023, and May, 2023. No other disaster drill documentation was available for review.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

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

Findings include:
1. Twelve months of facility employee and resident evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that an evacuation drill was conducted for employees on November 9, 2023. No other evacuation drill documentation was available for review.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on observation and interview, the manager failed to ensure that oxygen cylinders were secured.

Findings include:
1. Two large oxygen cylinders were observed sitting upright and unsecured on R4's closet floor.
2. During an interview, E5 acknowledged the oxygen cylinders were not secured.

This is a repeat deficiency from the compliance inspection conducted on February 23, 2023.

Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis.

Findings include:
1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis.
2. During an interview, E1 acknowledged that the required documentation was not available for review.

Technical assistance was provided on this Rule during the compliance inspection conducted on February 23, 2023.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.

Findings include:
1. Review of the record for E2 (hired June 25,2015), failed to reveal documentation of fall prevention and fall recovery training.
2. Review of the record for E3 (hired February 24, 2021), failed to reveal documentation of fall prevention and fall recovery training.
3. During an interview, E1 indicated that training for fall prevention and fall recovery had not been developed and administered to staff.
4. This is a repeat deficiency from the complaint investigation conducted on August 16, 2022.

Based on record review and interview, the governing authority failed to ensure that two of three sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety.

Findings include:
1. The record for E1 (start date November 5, 2018) contained a Department of Public Safety (DPS) fingerprint clearance card that expired on September 30, 2022. No additional documentation was present in the record reflecting that DPS was contacted to renew the fingerprint clearance card.
2. The record for E2 (start date June 25, 2015) contained a Department of Public Safety (DPS) fingerprint clearance card that expired on August 20, 2022. No additional documentation was present in the record reflecting that DPS was contacted to renew the fingerprint clearance card.
3. During an interview, E1 acknowledged the required documentation was not in the records.
4. Review of the DPS web site revealed that the cards were expired.

Based on observation and interview, the manager failed to ensure that a current list of resident rights were conspicuously posted.

Findings include:
1. Observation of the postings in the locked memory unit failed to reveal that the resident rights were posted.
2. During an interview E1 stated, "They were posted, I don't know where they went."
3. During an interview, E1 acknowledged that the resident rights were not conspicuously posted.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection can be found, was conspicuously posted.

Findings include:
1. Inspection of the locked memory unit failed to reveal the posting indicating the location at which a copy of the most recent Department inspection report can be found.
2. During an interview, E1 stated, "We had that posted."
3. During an interview, E1 acknowledged the required documentation was not conspicuously posted in the locked unit.

Based on documentation review, record review and interview the manager failed to ensure for two of three sample personnel records, that before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training.

Findings include:
1. The record for E1 (hired November 5, 2018), contained no documentation of first aid training.
2. The record for E3 (hired February 24, 2021), contained documentation of first aid training that expired on August 20, 2022.
3. During an interview, E1 acknowledged that the employee records failed to contain the required documentation.

Based on record review, observation and interview, the manager failed to ensure that two of two sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled.

Findings include:
1. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room.
2. The record for R3 contained a current service plan that did not include how the resident's medication would be stored and controlled.
3. During an interview, E1 indicated that R4 self-administered their own medications and stored the medications in their room.
4. The record for R4 contained a service plan dated February 9, 2023 that did not include how the residents medication would be stored and controlled.
5. During an interview, E1, acknowledged the service plans did not indicate how the resident's medication would be stored and controlled in their rooms.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services.

Findings include:
1. The record for R1 contained service plan reviews reflecting the following dates of completion: July 8, 2021 and February 9, 2023.
2. The record for R4 contained service plan reviews reflecting the following dates of completion: September 17, 2021 and October 3, 2022.
3. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview for two of two sample personal care and directed care resident records, the manager failed to obtain a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services.

Findings include:
1. During an interview, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. During an interview, E1 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
3. The resident's records did not contain a statement from their medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's dates of acceptance this documentation was required.
4. During an interview, E1 acknowledged that the required documentation was not in the resident's records.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members.

Findings include:
1. No toxicology guide was available for review.
2. During an interview, E1 stated, "I can't find that."

Based on documentation review and interview, the manager failed to ensure that documentation of the disaster plan review included: The name of each employee or volunteer participating in the disaster plan review; A critique of the disaster plan review and recommendations for improvement.

Finding include:
1. Review of the facility "Disaster Plan Review" dated January 3, 2023 revealed that the content of the review consisted of the Manager's signature.
2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: November 9, 2022 and May 27, 2022. No other disaster drill documentation was available for review.
2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill included the following: The amount of time taken for employees and residents to evacuate the assisted living facility; An identification of residents needing assistance for evacuation, and an identification of residents who were not evacuated.

Findings include:
1. Review of 12 months of facility evacuation drill documentation revealed that the documentation failed to identify the following: The amount of time taken to evacuate the facility; identification of residents needing assistance for evacuation; identification of the residents who were not evacuated.
2. During an interview, E1 stated, "We do have non-ambulatory and directed care residents here who would need assistance and some who do not evacuate."
3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on observation and interview, the manager failed to ensure that oxygen cylinders were secured.

Findings include:
1. Six small oxygen cylinders were observed sitting upright and unsecured on the floor in resident bedroom #109.
2. Two small oxygen cylinders were observed sitting upright and unsecured on the kitchen counter in resident room #317.
3. One large oxygen cylinder was observed sitting upright and unsecured on the floor in resident bedroom #319.
4. During an interview, E1 acknowledged the oxygen cylinders were not secured.

Based on documentation review and interview, the manager failed to ensure that the on the day that a resident uses the swimming pool, an employee tests the swimming pool's water quality at least once for compliance with chemical disinfection standards.

Findings include:
1. During an interview E1 indicated that the facility pool was regularly used by residents at least two times per week.
2. No documentation indicating that on the day that a resident uses the swimming pool, an employee tested the swimming pool's water quality at least once for compliance with chemical disinfection standards.
3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that one of two sample employee records for staff who were providing caregiver services, contained documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

Findings include:
1. Review of incident report documentation dated September 30, 2022 revealed that E3 was the "AM Caregiver" who assisted R1 with "AM care".
2. Review of the E3's job description signed and dated by E3 on March 15, 2022, revealed that E3 was employed as a "Caregiver", and required to perform the following personal care duties: "bathing, grooming, dressing, toileting, etc."
3. The record for E3 (hired March 23, 2022) did not contain documentation reflecting that the employee had completed a caregiver training program.
4. During an interview, E1 indicated that E3 was not a trained caregiver.
5. During an interview, E1 acknowledged the required documentation was not available for review.