MARDON ASSISTED LIVING HOMES I

Based on documenttation review, observation, record review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager.

Findings include:

1. A review of Department documentation revealed O1 was the facility's manager as of March 8, 2023.

2. The Compliance Officer observed E4's assisted living manager's license posted on the premises.

3. A review of E4's personnel record revealed E4 was hired as the facility's manager on July 1, 2023.

4. A review of Department documentation revealed the governing authority failed to notify the Department of E4's name and qualifications when E4 became the facility's manager.

5. In an interview, E1 reported an email had been sent to the Nursing Care Institution Administrators and Assisted Living Managers and not to the Department.

6. In an interview, E1 acknowledged the facility did notify the Department when E4 became the facility's manager.

Based on documentation review, observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom. The deficient practice posed a risk if residents were unable to summon help from personnel members.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. The Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies in two resident bedrooms.

3. In an interview, E2 reported a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available in two directed care resident's bedroom due to the residents misplacing the bells or buttons.

4. In an interview, E1 acknowledged E1 failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom.

Based on observation, documentation review, and interview, the manager of an assisted living facility authorized to provide directed care services failed to implement policies and procedures to ensure the safety of a resident who may wander. The deficient practice posed a risk id the facility was not aware of the general or specific whereabouts of a resident.

Findings include:

2. The Compliance Officer observed a gate leading to the side of the house. However, the gate was not locked.

3. The Compliance Officer observed a gate leading to the neighboring house yard. However, the gate was not locked.

4. A review of policies and procedures (dated January 2022) revealed a policy titled "Safety of Wandering Residents." The policy stated "Caregivers will maintain securely of locks on the front door, yards and hazardous areas at all times."

5. In an interview, E1 acknowledged E1 failed to implement the facility's policy and procedure.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents.

Findings include:

1. The Compliance Officer observed an unlocked metal storage container in the backyard of the facility. The container was held closed by a brick placed in front of the doors. The inside of the container had a can of WD-40 and paint thinner.

2. In an interview, E1 acknowledged E1 failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents.