AGAVE MANOR

Based on observation, interview, and documentation review, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a health and safety risk to residents if the facility did not maintain staffing schedules, with documentation of facility staffing coverage for residents, and an identification of the caregivers who provided services.

Findings include:

1. Upon arrival, E1, E2 and E4 were observed at the facility with 10 residents present.

2. During an interview, E1 reported [E1] worked shifts on Monday through Friday from 8:30am - 4:30pm. E2 reported [E2] worked shifts on Thursday through Tuesday, from approximately 6am - 6pm. E1 and E2 reported E4, E5 and E6 worked shifts at the facility, and E7 worked at the facility until approximately two months ago. E4 worked day shifts, and E6 worked night shifts from 7am - 7am. R1 and R4 also reported E4, E5 and E6 worked at the facility, and provided services for R1 and R4.

3. In documentation review, the Compliance Officer (CO) requested to review documentation of the caregivers who worked each day, including the hours worked by each. The CO was provided with a "Work Schedule," for September and October 2024. The work schedules did not include documentation of the days and hours worked by E4, E5, and E6. The schedules indicated E1 worked from 7am - 7pm on Monday through Fridays, and E7 worked shifts at the facility in September and October, 2024, although E7 no longer worked at the facility.

4. In documentation review, a facility policy titled, "Staffing and Record Keeping," documented "... A work schedule of all staff members who provide assisted living services to residents and volunteers is developed and maintained at the facility for at least 12 months from the date of the work schedule. The work schedule must contain facility name, dates, and a key of abbreviation (for names of working staff/volunteers, hours scheduled, hours worked, etc...)"

5. During an interview, E1, E3 and O2 acknowledged the facility did not ensure documentation was maintained of the caregivers working each day, including the hours worked by each, and this documentation was required to be maintained for at least 12 months.

Based on observation, interview, documentation review, and record review, for one of four employees reviewed, the manager failed to have a personnel record for an employee, as required by this Article. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing an employee met the requirements to provide services for the residents.

Findings include:

1. In observation, upon arrival at the facility, the Compliance Officer observed E4 was at the facility.

2. During an interview, E1 reported E4 "was visiting, and helped out sometimes." E2 reported E4 worked at the facility for approximately a year as a caregiver. R1 and R4 reported E4 assisted them, and provided services at the facility, along with E1 and E2.

3. In record review, the facility did not have a personnel record for E4.

4. In documentation review, the staffing schedules for September and October 2024, did not include E4.

5. In documentation review, a facility policy titled, "Staffing and Recordkeeping," documented, "... The facility manager shall ensure that a personnel record for each employee and volunteer includes: ... name, date of birth, contact telephone number... qualifications... skills, ... knowledge... education... experience... orientation... compliance with .. DPS fingerprinting clearance requirements..."

6. During an interview, E1, E3 and O2 acknowledged a personnel record for E4 was not provided for review, and a personnel record was required for all employees and volunteers.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure there was a documented residency agreement with the assisted living facility. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. In record review, R3's medical record did not include a documented residency agreement. Based on R3's date of acceptance, a documented residency agreement was required.

2. During an interview, E1 acknowledged R3's medical record did not include a documented residency agreement, which was required based on R3's date of acceptance.

Based on observation, record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance. The deficient practice posed a risk if the facility did not have a service plan, to direct services to be provided to a resident within the required timeframe, and the Department was provided false and misleading information.

Findings include:

1. Upon arrival, the Compliance Officer (CO) observed O3 on-site during the inspection. O3 and E1 reported [O3] was completing/updating resident service plans.

2. The CO, requested to review resident records, and E1 reported the residents' service plans were just completed (on October 22, 2024, during the inspection) by O3, and therefore were not yet signed by the resident or their representative, and the manager or manager designee, which the CO acknowledged. E1 reported R3's service plan was included in the service plans completed by O3 on October 22, 2024.

3. In record review, R3's service plan was dated and signed as completed on October 11, 2024, instead of October 22, 2024, when O3 completed the service plan. The service plan also included a date (documented by O3), next to the signature line for the "manager/designee's," signature, which was dated October 11, 2024.

4. During an interview, the findings were reviewed with E1, E3 and O2 who acknowledged R3's service plan was dated as completed by O3 on October 11, 2024, and not on the date of completion; October 22, 2024. E1, E3, and O2 acknowledged a resident's service plan was required to be completed no later than 14 calendar days after the resident's date of acceptance.

Based on observation, record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

A.R.S. \'a7 36-401.A.50. defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications.

A.R.S. \'a7 36-401.A.41. defines "Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law.

A.R.S. \'a7 36-401.A.16. defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

1. In observation and interview, R2 was observed and interviewed twice during the inspection. During an interview, R2 appeared alert and maintained eye contact with the Compliance Officer (CO); however, R2 was unable to communicate, and respond verbally, or indicate an understanding of the CO's questions.

2. In record review, R2's medical record included a service plan dated October 22, 2024. The service plan documented Medical Diagnosis as, "S/P Stroke, Cerebral Vascular Disease, HTN, DM, Gout, Gerd, Hypothyroidism and BS". The service plan indicated R2 was alert, oriented and forgetful at times, and documented "Speech" as "Normal for age... slow" The service plan documented R2's level of care as Personal Care, and "Res A & O able to make needs known w some forgetulness @ times..."

3. During an interview, E1 reported R2's condition had changed approximately three weeks ago, and R2 stopped talking. E1 acknowledged R2 was unable to direct [R2's] care, or make basic care decisions, and R2's care was directed by the caregivers.

Based on observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which 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 license issued by the Department revealed the facility was licensed at the directed care level.

2. During an environmental inspection, the Compliance Officer observed the bedrooms for R2 and R4 had a door which allowed exit to the outside area, and did not control or alert employees of the egress of a resident. The common area of the facility had a sliding glass door that allowed access to the back yard, and did not control or alert employees of the egress of a resident.

3. During an interview, E1 reported the doors were alarmed, and did not know why the alarms were not working. E3 reported the doors were alarmed, and E3 would check to ensure the alarms were not silenced.

Based on observation and interview, the manager failed to ensure the facility was free from a condition or situation that could cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents if medications were not stored in a locked manner, and were accessible to residents.

Findings Include:

1. During an environmental inspection with E1, the Compliance Officer observed O1's bedroom door was unlocked and O1 had medications stored in the bedroom on top of and inside of a drawer; to include: Levothyroxine, Sevelamer Carbonate, Veltassa powder packets, Laxative, Tylenol x 2, Bisacodyl, Naloxone, Neuropathy Rubbing Oil. A dresser drawer also contained multiple over the counter bottles of supplements and vitamins.

2. During an interview, E1 reported O1 resided in the facility; however, was not a resident. O1 managed [O1's] medications, and E1 acknowledged the medications were not stored in a locked manner and were accessible to residents.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident if toxic materials were accessible.

Findings include:

1. During an environmental inspection with E1, the Compliance Officer observed an unlocked cabinet beneath the kitchen sink had a bottle of Lysol Kitchen Pro cleaner. The common area bathroom, located by resident bedrooms, had an unlocked cabinet beneath the sink which had cans of Febreze Air Mist, Disinfectant Spray and another can of air freshener.

2. During an interview, E1 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.