SEDONA WINDS

Based on record review, observation and interview, the manager failed to ensure that a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan.

Findings include:
1. Review of R1's service plan dated December 9, 2024 indicated the resident was at the directed care level and was incontinent for both bowel and bladder, requiring "moderate" caregiver assistance.
2. Review of the September 2024 "Sedona Winds Memory Care-Q2 hour checks and BM tracking" log revealed that during the 12am to 6am shift, on the following dates R1 was not checked: September 17, 24, 28, 29, and 30.
3. During an interview, E2 acknowledged that the documentation failed to indicate the resident was being provided the services specified in their service plan.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services.

Findings include:
1. Observation of the bedrooms used by directed care residents on the "memory unit" revealed there was no bell, intercom or other mechanical means to alert employees to a resident's needs or emergencies in the residents' bedroom. A pull cord that activated a red light was observed in the resident bathrooms however, the alarm system was not connected to the facility alarm system.
2. During an interview, E1 stated, "The bathroom alarm call system no longer works on the memory unit. We use room monitors for the residents who need observation but, we don't have a system in place for all of the residents on this unit."

Based on record review and interview, the manager failed to ensure that when a resident had an injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver immediately notified the resident's emergency contact.

Findings include:
1. Review of the incident report belonging to R1, dated January 8, 2025 revealed that on January 7, 2025 at 3:00am the resident fell out of bed and sustained an injury that required medical services. Records indicate that the resident's emergency contact was notified of the incident at 8:24am and the resident's primary care provider was notified at 3:00am.
2. During an interview, E2 acknowledged the resident sustained an injury that required medical services and the caregiver did not immediately notify the resident's emergency contact.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the quality management plan.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "quarterly" basis.
2. The last report submitted to the governing authority was dated August 4, 2022.
3. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review, observation and interview, the manager failed to ensure that one 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 service plan dated July 19, 2023 that did not include how the resident's medication would be stored and controlled.
3. During an interview, E1, acknowledged the service plan did not indicate how the resident's medication would be stored and controlled in their room.

This is a repeat deficiency from the compliance inspection conducted on August 29, 2022.

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of a service plan that when updated, was signed and dated by the nurse or medical practitioner who reviewed the service plan.

Findings include:
1. The record for R1 (personal care, receiving medication administration services), contained a service plan dated June 1, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan.
2. The record for R2 (personal care, receiving medication administration services), contained a service plan dated May 26, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan.
3. During an interview, E1 acknowledged that the service plans did not reflect the dated signature of the nurse or medical professional.

Based on record review and interview, the manager failed to ensure that one of one 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 R4 contained no documentation indicating that the resident had been notified of the availability of either the influenza or pneumonia vaccination on a yearly basis. 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. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview for one of one sample personal care resident record, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs can be met by the facility as per their scope of services.

Findings include:
1. During an interview, E1 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility and there was no statement from the medical practitioner indicating that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that the required documentation was not in the resident's record.

Based on documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:
1. The facility medication administration policies and procedures failed to reveal evidence that the policies had been reviewed and approved as required.
2. During an interview, E1 acknowledged that some facility residents receive medication administration services.
3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that snacks provided by the assisted living facility were served according to posted menus.

Findings include:
1. The posted menus failed to reveal a record of snacks provided.
2. No additional snack menu documentation was available for review.
3. During an interview, E1 stated, "We serve lots of snacks, we used to have that documented."
4. During an interview, E1 acknowledged that the required documentation was not available for review.