A CARING MANOR I

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(A), for one of three personnel records sampled. The deficient practice posed a risk as required information was not included in E3's personnel record.

Findings include:

A.R.S. \'a7 36-411(A) states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work."

1. A review of E3's personnel record revealed a fingerprint clearance card from the Arizona Department of Public Safety. However, E3's fingerprint clearance card expired on February 2, 2023.

2. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website, using the fingerprint clearance card number provided in E3's personnel record, revealed E3 was issued a fingerprint clearance card on March 8, 2023.

3. A review of the facility's work schedule revealed a staff work schedule for February 2023. E3 was scheduled to work alone the following dates and times from February 3, 2023 to February 28, 2023, during which E3 did not have a valid fingerprint clearance card:
-February 3, 2023: 1:00 PM to 6:00 PM;
-February 4, 2023: 8:00 AM to 6:00 PM;
-February 5, 2023: 8:00 AM to 6:00 PM;
-February 6, 2023: 8:00 AM to 6:00 PM;
-February 7, 2023: 8:00 AM to 1:00 PM;
-February 10, 2023: 1:00 PM to 6:00 PM;
-February 11, 2023: 8:00 AM to 6:00 PM;
-February 12, 2023: 8:00 AM to 6:00 PM;
-February 13, 2023: 8:00 AM to 6:00 PM;
-February 14, 2023: 8:00 AM to 1:00 PM;
-February 17, 2023: 1:00 PM to 6:00 PM;
-February 18, 2023: 8:00 AM to 6:00 PM;
-February 19, 2023: 8:00 AM to 6:00 PM;
-February 20, 2023: 8:00 AM to 6:00 PM;
-February 21, 2023: 8:00 AM to 1:00 PM;
-February 24, 2023: 1:00 PM to 6:00 PM;
-February 25, 2023: 8:00 AM to 6:00 PM;
-February 26, 2023: 8:00 AM to 6:00 PM;
-February 27, 2023: 8:00 AM to 6:00 PM; and
-February 28, 2023: 8:00 AM to 1:00 PM.

4. In an interview, the Compliance Officer requested the work schedule for March 2023. However, E1 reported there was no documented schedule available for review for the month of March 2023.

5. In an interview, E1 acknowledged E3 did not have a valid fingerprint clearance card from February 3, 2023 to March 7, 2023.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if a resident was not assessed and determined to be within the scope of an assisted living facility prior to receiving services.

Findings include:

1. A review of R1's medical record (admitted December 2022) revealed documentation dated January 6, 2023, signed by a physician and documenting R1's level of care and needs. However, the document was not dated within 90 calendar days before R1's date of admission.

2. In an interview, E1 acknowledged R1's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for a resident receiving directed care services, for two of two residents sampled. The deficient practice posed a risk if services provided to a resident's current needs were not being met.

Findings include:

1. A review of R1's medical record revealed a service plan indicating R1 received directed care services. The service plan was dated December 14, 2022. However, subsequent reviewed or updated service plans were not available for review.

2. A review of R2's medical record revealed a service plan indicating R2 received directed care services. The service plan was dated November 25, 2022. However, subsequent reviewed or updated service plans were not available for review.

3. In an interview, E1 acknowledged R1's and R2's service plans were not reviewed and updated at least once every three months as required.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when updated, was signed and dated by the resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of two residents sampled. The deficient practice posed a risk if the needs and services were not agreed upon before providing these services.

Findings include:

1. A review of R2's medical record revealed a service plan dated November 25, 2022. The service plan identified R2 received medication administration and directed care services. The service plan was not signed and dated by the resident's representative, the manager, and a nurse or medical practitioner who reviewed the service plan.

2. In an interview, E1 acknowledged R2's service plan was not signed by the resident's representative, the manager, and the nurse of medical practitioner who reviewed the service plan.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of medication administered to the resident that included the time of administration for two of two residents sampled. The deficient practice posed a risk of a potential adverse reaction or outcome with an error in administering a residents medication.

Findings include:

1. A review of R1's and R2's April 2023 and May 2023 medication administration record (MAR) listed each medication administered to R1 and R2. However, the MAR reported medication was administered MORN (morning), EVE (evening), and BED (bedtime) rather than the actual time of medication administration.

2. In an interview, E1 acknowledged the April 2023 and May 2023 MARs for R1 and R2 did not indicate the time of medication administration.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk of a potential adverse reaction or outcome with an error in administering a residents medication.

Findings include:

1. A review of R1's medical record revealed a service plan dated December 14, 2022. The service plan revealed R1 received medication administration.

2. A review of R1's medication administration record (MAR) revealed R1 received Pravastatin 80 milligrams (mg) every morning.

3. A review of R1's medical record revealed a medication order signed by a medical practitioner, dated February 28, 2023 for Pravastatin 80 mg every evening.

4. A review of R1's medications revealed a medication bottle containing Pravastatin 80 mg with instructions to administer every evening. The compliance officer observed Pravastatin in the evening slot of R1's medication organizer.

5. In an interview, E1 acknowledged the Pravastatin was not correctly documented in R1's MAR. E1 reported R1 received the medication as ordered.

6. A review of R2's medical record revealed a service plan dated November 25, 2022. The service plan revealed R2 received medication administration.

7. A review of R2's medical record revealed a medication list signed by a medical practitioner, dated April 28, 2023. The medication list included Furosemide 20 mg, one tablet on Sunday, Monday, Wednesday, and Friday.

8. A review of R2's medications revealed a medication bottle containing Furosemide 20 mg with instructions to administer Sunday, Monday, Wednesday, and Friday. The compliance officer observed Furosemide in R2's medication organizer on the appropriate days.

9. A review of R2's MAR revealed R2 received Furosemide every day in April 2023 and every day from May 1, 2023 to May 11, 2023.

10. In an interview, E1 acknowledged the Furosemide was documented correctly as being administered on Sunday, Monday, Wednesday, and Friday. However, E1 reported R2 received the medication as ordered.

11. A review of R2's medical record revealed a medication list signed by a medical practitioner, dated April 28, 2023. The medication list included Hydroxyzine 25 mg, one tablet three times a day.

12. A review of R2's medications revealed a medication bottle containing Hydroxyzine 25 mg. The compliance officer observed Hydroxyzine in R2's medication organizer.

13. A review of R2's medical record revealed a MAR dated May 2023. However, Hydroxyzine 25 mg was not listed on the MAR.

14. In an interview, E1 acknowledged the Hydroxyzine administered to R2 was not documented in R2's medical record. E1 reported R2 received the Hydroxyzine as ordered. However, the administration of the aforementioned medication was not documented in the MAR as required. E1 reported R2 has gone off and on the medication several times, and it mistakenly did not get transferred to the MAR.

15. A review of R2's medical record revealed a medication list signed by a medical practitioner, dated April 28, 2023. The medication list included Celexa (Citalopram) 10 mg, one tablet at bedtime.

16. A review of R2's medical record revealed a MAR dated May 2023. Citalopram was listed on the MAR as being administered each day in the morning.

17. A review of R2's medications revealed a medication bottle containing Citalopram 10 mg. The bottle directed the Citalopram to be administered at bedtime.

18. A review of R2's medications revealed the Citalopram was in the bedtime slot.

19. In an interview, E1 acknowledged the Citalopram was not getting documented correctly as being administered at bedtime. However, E1 reported R2 received the medication as ordered.

20. A review of R2's medical record revealed a medication list signed by a medical practitioner, dated April 28, 2023. The medication list included Clonidine 0.2 mg, one tablet daily as needed (PRN) for Systolic Blood Pressure (SBP) > 170 mmHg, re-check BP after receiving PRN dose.

21. A review of R2's MAR revealed R2 received Clonidine 0.2 mg daily from April 1, 2023 to May 11, 2023.

22. Further review of R2's medical record revealed the following blood pressure readings on the following dates:
-April 10, 2023: 154/40;
-April 11, 2023: 161/50;
-April 12, 2023: 159/41;
-April 13, 2023: 158/39;
-April 13, 2023: 133/89;
-April 14, 2023: 156/46;
-April 15, 2023: 151/79;
-April 16, 2023: 162/58;
-April 17, 2023: 172/88;
-April 20, 2023: 148/62;
-April 22, 2023: 147/79;
-April 23, 2023: 137/79;
-April 24, 2023: 136/78;
-April 25, 2023: 162/56;
-April 28, 2023: 151/91;
-April 29, 2023: 179/99;
-April 30, 2023: 171/86;
-May 1, 2023: 137/88:
-May 2, 2023: 150/72;
-May 8, 2023: 149/89
-May 9, 2023: 190/127;
-May 9, 2023: 120/73;
-May 10, 2023: 139/73; and
-May 11, 2023: 129/81.

23. In an interview, E1 acknowledged (based on the blood pressure readings), R2 should have received Clonidine 10 mg only on the following four occasions:
-April 17, 2023;
-April 29, 2023;
-April 30, 2023; and
-May 9, 2023.

24. In an interview, E1 reported R2 did not receive Clonidine daily as recorded on R2's MAR. E1 reported the caregivers just "followed suit" when documenting medication administration and incorrectly documented R2's medication as received daily.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the health and safety of the residents.

Findings include:

1. Upon entry to the facility, the Compliance Officer observed keys hanging in a closet door. The Compliance Officer was able to open the closet door when walking by.

2. In an interview, the Compliance Officer confirmed the aforementioned medication closet contained the residents' medications. The Compliance Officer observed the medication closet had been locked at some point after the Compliance Officers arrival.

3. In an interview, E1 acknowledged E1 failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. The deficient practice posed a risk to the health and safety of the residents.

Findings include:

1. The Compliance Officer observed the hot water temperature to be 132.3 \'b0F in a shared resident bathroom.

2. In an interview, E1 acknowledged the hot water temperature was not maintained between 95 \'b0F and 120 \'b0F. E1 reported E1 would have the temperature adjusted as soon as possible.