FAIRBROOK GROVE INC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.C , for one of four personnel records sampled. The deficient practice posed a risk if the personnel were a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 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 E2's personnel record revealed no documention showing that the owner had made a good faith effort to contact previous employers to obtain information or recommendations.

3. Review of the employee schedule dated September 9-22 revealed E2 worked 6am-6pm September 16th.

4. In an interview, E1 acknowledged E2's personnel record did not include documentation of compliance with A.R.S. \'a7 36-411.C.1.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

Findings include:

1. Review of the facility's policy and procedure manual revealed a document titled "Policy and Procedure Review" which stated "Our Facility's policies and procedures were reviewed and updated as applicable on this date: April 28, 2021". No other documentation indicating the policies and procedures were reviewed by the manager was available.

2. In an interview, E1 acknowledged there was no documentation indicating the facility's policies and procedures were reviewed by the manager of the facility every three years.

Based on documentation review, record review, and interview, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803.J. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.

Findings include:

1. A.R.S. \'a7 46-454. stated, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures."

2. Review of Department documentation revealed an alleged incident of abuse that occurred on September 5, 2024 concerning R1.

3. The Compliance Officer requested the documentation required under this rule. However, the documents provided were an investigation of the former employee suspected by E1 of making the complaint, and documentation of legal action being taken against the former employee for allegedly filing the complaint.

4. A review of R1's medical record revealed no documentation that the manager had initiated an investigation of the suspected abuse, neglect, or exploitation, or of the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future.

5. In an interview, E1 stated "I just think they are lies". E1 acknowledged documentation was not available that showed compliance with the rule.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of four employees reviewed. The deficient practice posed a potential 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. Review of E2's personnel record revealed a negative TB skin test that was less than 12 months old at E2's date of hire, however no additional documentation of freedom from infectious TB was available for review.

4. Review of the employee schedule dated September 9-22 revealed E2 worked 6am-6pm September 16th.

5. In an interview, E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

Technical assistance was provided on this Rule during the compliance inspection conducted May 26, 2023.

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a health and safety risk.

Findings include:

1. Review of R1's medical record revealed a current written service plan for personal care services dated July 28, 2024. This service plan stated the following service was needed:
"Incontinent Assist: Change brief or inct[sic] product and performs peri care PRN and q 2hrs/ clean and dry: Requires total care". However, documentation was not available indicating this service was provided.

2. Review of R2's medical record revealed a current written service plan for personal care services dated August 14, 2024. This service plan stated the following service was needed:
"Incontinent Assist: Change brief or inct[sic] product and performs peri care PRN and q 2hrs/ clean and dry: Requires Min-Mod assistance". However, documentation was not available indicating this service was provided.

3. During an interview, E2 acknowledged R1's and R2's medical records did not include documentation of assistance with incontinence care.

Based on observation, documentation review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated.

Findings include:

1. During the environmental tour, the Compliance Officer observed, using a Department issued measuring tool, that R1's bedroom measured 9.2 feet by 8 feet, which totaled 73.5 square feet of floor space. The Compliance Officer observed that the room did not contain a window. Therefore, the room did not meet the minimum requirements for a resident's bedroom.

2. Review of Department documentation revealed a floor plan which showed that the location of R1's bedroom was not part of the floor plan provided to the Department initially or as part of an approved modification.

3. In an interview, E1 reported not being aware that R1's room had less than 80 square feet of floor space.

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 Department documentation revealed the facility was authorized to provide directed care services.

2. During the facility tour, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was switched off.

3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

This is a repeat deficiency from the compliance inspection conducted May 26, 2023.

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 Compliance Officer observed the facility's toxicology guide available for use by personnel members was the "Elsevier Toxicology Handbook 2nd Edition".

2. A review of the publisher's website revealed the "Elsevier Toxicology Handbook 4th Edition" was the most recent edition.

3. In an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on Record review, documentation review, and interview, the manager failed to ensure a current therapeutic diet manual was available for use by employees. The deficient practiced posed a risk if the employees did not have access to dietary information required to meet a resident's need.

Findings include:

1. Review of R1's medical record revealed a document titled "Fairbrook Grove Daily Activity Record" which reported that R1 received a pureed diet.

2. Review of R2's medical record revealed a document titled "Fairbrook Grove Daily Activity Record" which reported that R1 received a soft, pureed diet.

3. Review of the facility's policies and procedures revealed a policy titled "Therapeutic and Modified Diets" which stated "Therapeutic Diet Manual- is available and current to assist staff with any modifications or diet order based on the diets offered at the facility."

4. A therapeutic diet manual was not available for review.

5. In an interview, E1 reported having no therapeutic diet manual available on site, for use by employees.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents, which posed a health and safety risk to the residents.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed the hot water temperature at 142\'b0 F in the hall bathroom near resident bedrooms.

2. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents.

Based on observation, interview, and documentation review, the licensee failed to submit a request for approval of a modification of a health care institution.

Findings include:

1. During the facility tour, the Compliance Officer observed a modification to the facility. Two new rooms were observed off of the kitchen; a pantry had been converted into a bathroom, and a bathroom had been converted into a resident's room. These rooms did not appear in the facility floor plan on file with the Department.

2. During an interview, E1 reported the modifications were made "years ago".

3. Review of Department records revealed no documentation of a request for approval for the modification.

4. During an interview, E1 reported a request for approval for the modification was not submitted to the Department.

Based on observation, interview, and documentation review, the manager failed to ensure a resident bedroom was not used as a passageway to a common area or another sleeping area. The deficient practice posed a potential privacy rights violation to the resident.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed that the only access to the back yard was through R4's bedroom.

2. In an interview, E1 reported that when other resident's want to go outside, they were brought through R4's bedroom in groups.

3. Review of Department documentation revealed a floor plan which showed that the building of R4's bedroom in front of the back door was not part of the floor plan provided to the Department initially or as part of an approved modification.

Based on observation, documentation review, and interview, the manager failed to ensure that a resident's bedroom had at least 80 square feet of floor space, not including a closet or bathroom.

Findings include:

1. During the environmental tour, the Compliance Officer observed, using a Department issued measuring tool, that R1's bedroom measured 9.2 feet by 8 feet, which totaled 73.5 square feet of floor space.

2. Review of Department documentation revealed a floor plan which showed that the location of R1's bedroom was not part of the floor plan provided to the Department initially or as part of an approved modification.

3. In an interview, E1 reported not being aware that R1's room had less than 80 square feet of floor space.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training, including a demonstration of the individual's ability to perform CPR, for two of six personnel sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence E4 and E6 had the ability to perform CPR in an emergency.

Findings include:

1. A review of the facility's polices and procedures revealed a policy titled, "Caregiver Employment Requirements." Under the heading, "Procedure," the policy stated, "...6. Has current CPR and First Aid Cards - specifically for adults, from a valid classroom provider, the facility has verified original cards, and obtained a copy for the employee's file (no online training courses are accepted)."

2. A review of E4's personnel record revealed documentation of E4's CPR training from the "American Health Care Academy" issued September 3, 2022 and valid for two years.

3. In a telephone interview completed June 13, 2023, the compliance officer confirmed with O1 that the CPR training taken by E4 did not include a hands-on demonstration of techniques.

4. A review of E6's personnel record revealed documentation of E6's CPR/First Aid training from the "National CPR Foundation" issued January 12, 2023 and valid for two years. However, the CPR training did not include a hands-on demonstration of techniques.

5. In an interview, E1 acknowledged the personnel record for E4 and E6 did not include CPR training with hands-on demonstration as required.

Based on documentation review, record review and interview, the manager failed to ensure a caregiver provided 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 (NCIA Board), for one of six individuals sampled who were hired as a caregiver. The deficient practice posed a risk if the individuals were not qualified to provide the required services.

Findings include:

1. A review of the facility's polices and procedures (reviewed and approved April 28, 2021) revealed a policy titled, "Caregiver Employment Requirements." Under the heading, "Procedure," the policy stated, "...2. Has documentation of completion of a caregiver training program approved by DHS or the NCIA Board."

2. A review of E7's personnel record revealed a caregiver training certificate from Sunshine Care Training Program, ALTP 0085, dated June 21, 2014.

3. A review of the NCIA Board website (https://nciaboard.az.gov/news/caregiver-certificate-verification) revealed the aforementioned training program did not operate after May 31, 2012.

4. A review of the NCIA Board verification of caregiver training portal (https://az.tmuniverse.com/) revealed E7 had not completed a caregiver training program after August 3, 2013.

5. In an interview, E1 acknowledged E7 did not have documentation of completion of a caregiver training program approved by the NCIA Board.

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a 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 and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and 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. A review of the Department's documentation revealed the facility was authorized to provide directed care services.

2. The compliance officer observed when entering the facility's front door, no alarm sounded to alert employees of the egress of a resident from the facility. The compliance officer observed an alert system was installed on the front door.

3. During a tour of the facility, the surveyor observed when exiting the facility from R1's bedroom, no alarm sounded to alert employees of the egress of a resident from the facility. The compliance officer observed an alert system was installed on R1's bedroom door.

4. In an interview, E1 acknowledged when opening the front door and R1's bedroom door, no alarm sounded to alert employees of the egress of a resident from the facility. E1 activated the alert in R1's bedroom while the compliance officer was on-site, and the alert resumed functioning. E1 attempted to activate the alert on the front door. However, the alert did not function and may have needed a new battery.

Based on observation, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. A review of R1's medical record revealed a service plan dated May 1, 2023. The service plan revealed R1 received medication administration.

2. A review of R1's medical record revealed a medication list signed by a medical practitioner, dated May 4, 2023. The medication list included, "Simvastatin 40 mg 1 tablet po at hs."

3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. The compliance officer observed the Simvastatin was listed on the MAR and was documented as being administered.

4. A review of R1's medications revealed Simvastatin 40 mg was not available for use. However, the compliance officer observed Rosuvastatin 10 mg in R1's medications and in R1's medication organizer.

5. In an interview, E1 reported R1 received Rosuvastatin 10 mg every night. However, the administration of Rosuvastatin was not properly documented in R1's medical record. E1 reported E1 would clarify the medication order with the prescriber.