CHAPARRAL WINDS ASSISTED LIVING

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of four sampled personnel members. 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...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 E3's personnel record revealed documentation of a negative two-step TB skin test. However, documentation of a TB screening was not available for review at the time of inspection.

3. In an interview, E2 acknowledged E3's personnel records did not contain documentation of TB screening at the time of the inspection.

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 one of seven 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 R2's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection.

2. In an interview, E2 acknowledged R2's medical record did not contain documentation of R2's orientation to exits from the assisted living facility at the time of the inspection.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services.

2. During the facility tour with E1, the Compliance Officer observed a door leading out to the courtyard in the memory care unit. The outside area, in the courtyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the courtyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work.

3. During an interview, E1, E2, E3, E4, E5, and E6 acknowledged the residents did not have access to an outside area controlling or alerting employees of the egress of the resident.

4. This is a repeat deficiency from the compliance inspection conducted June 6, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of six residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated February 1, 2023. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed a signed medication order dated March 28, 2023. This medication order stated "Metoprolol Tart 25mg Tab Take 1/2 tablet by mouth twice daily, Hold for SBP [Systolic Blood Pressure] less or equal to 110 or HR [Heart Rate] less than or equal to 60".

3. Review of R2's medical record revealed a May 2023 medication administration record (MAR). This MAR stated "Metoprolol Tart 25mg Tab Take 1/2 tablet by mouth twice daily, Hold for SBP less or equal to 110 or HR less than or equal to 60" and indicated the following:
-R2's SBP was recorded as 110 at 8am on May 19th, however, indicated 1/2 tab was administered.
-R2's HR was recorded as 60 at 4pm on May 20th, however, indicated 1/2 tab was administered.
-R2's HR was recorded as 60 at 4pm on May 21st, however, indicated 1/2 tab was administered.

4. During an observation of R2's medications, Metoprolol Tartrate 25mg was observed.

5. During an interview, E1, E2, E3, E4, E5, and E6 acknowledged R2's medication was not administered in compliance with the available medication order.

6. This is a repeat deficiency from the compliance inspection conducted June 6, 2022.

Based on documentation review and interview, the manager failed to ensure a dog was licensed with Maricopa County. The deficient posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements.

Findings include:

1. Review of the Maricopa County Animal Care and Control website stated "all dogs three months of age and older are required to have a license..."

2. Review of the pet records revealed O2 was over three months of age. However, documentation of a license with Maricopa County was not available for O2.

3. During an interview, E1, E2, E3, E4, E5, and E6 acknowledged O2 did not have a current Maricopa County license.

Based on documentation review and interview, the manager failed to ensure a cat was vaccinated against rabies. The deficient posed a risk if a cat allowed into the facility did not meet the vaccination requirements.

Findings include:

1. Documentation of a rabies vaccination was not available for O1.

2. During an interview, E1, E2, E3, E4, E5, and E6 acknowledged O1 did not have a current rabies vaccination.