ATRIA CAMPANA DEL RIO

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for two of four caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency.

Findings include:

1. A review of E4's personnel record revealed E4 was hired as a caregiver in August 2023.

2. A review of E4's personnel record revealed documentation of an "American Safety & Health Institute CPR, AED, and Basic First Aid" card,. However, the card had a completion date of August 18, 2021, and an expiration date of August 20, 2023. No other documentation was provided to show E4 had current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

3. In an interview, E1, and E10 acknowledged E4 did not have current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Based on record review, documentation review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d) for five of seven residents sampled. This deficient practice posed a potential illness risk to residents.

Findings include:

A.R.S. \'a7 36-406(1)(d) states, " 1. The department shall... (d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized."

1. A review of R1's medical record revealed R1 has been residing in the assisted living facility for over eleven months. However, there was no documentation of evidence to indicate the facility offered the influenza and pneumonia vaccination on a yearly basis or documentation of R1's refusal of the pneumonia vaccination on a yearly basis.

2. A review of R2's medical record revealed R2 has been residing in the assisted living facility for more over four months. The Compliance Officer observed documentation on the influenza vaccination. However, there was no documentation of evidence to indicate the facility offered the pneumonia vaccination on a yearly basis or documentation of R2's refusal of the pneumonia vaccination on a yearly basis.

3. A review of R3's medical record revealed R3 has been residing in the assisted living facility for over 10 months. The Compliance Officer observed documentation on the influenza vaccination, However, there was no documentation of evidence to indicate the facility offered the pneumonia vaccination on a yearly basis or documentation of R3's refusal of the pneumonia vaccination on a yearly basis.

4. A review of R5's medical record revealed R5 has been residing in the assisted living facility for over four months. However, there was no documentation of evidence to indicate the facility offered the influenza and pneumonia vaccination on a yearly basis or documentation of R5's refusal of the pneumonia vaccination on a yearly basis.

5. A review of R7's medical record revealed R7 has been residing in the assisted living facility for over six months. However, there was no documentation of evidence to indicate the facility offered influenza and the pneumonia vaccination on a yearly basis or documentation of R7's refusal of the pneumonia vaccination on a yearly basis.

6. In an interview, E1 and E10 acknowledged vaccinations for influenza and pneumonia were not available to all residents on site on a yearly basis.

Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; and incontinence care that ensures that a resident maintained the highest practicable level of independence when toileting, for three of three residents sampled receiving personal care services.

Findings include:

1. A review of R5's medical records revealed documentation of their current written service plan dated December 18, 2023, for personal care services. The service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

2. A review of R6's medical records revealed documentation of their current written service plan dated November 22, 2023, for personal care services. The service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

3. A review of R7's medical records revealed documentation of their current written service plan dated December 14, 2023, for personal care services. The service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting.

4. In an interview, E1 and E10 acknowledged the service plans for R5, R6, and R7 did not include all the requirements in R9-10-814.F.1-4.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for four of four sampled residents receiving directed care services.

Findings include:

1. A review of R1's medical record revealed documentation of a service plan dated December 20, 2023, indicating R1 was receiving directed care services. However, the service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; and
- Documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated.

2. A review of R2's medical record revealed documentation of a service plan dated December 20, 2023, indicating R2 was receiving directed care services. However, the service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; and
- Documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated.

3. A review of R3's medical record revealed documentation of a service plan dated December 19, 2023, indicating R3 was receiving directed care services. However, the service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; and
- Documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated.

4. A review of R4's medical record revealed documentation of a service plan dated November 3, 2023, indicating R4 was receiving directed care services. However, the service plan did not contain the following:

- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; and
- Documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated.

5. In an interview, E1, and E10 acknowledged the service plans for R1, R2, R3, and R4 did not contain all the requirements in R9-10-815(C)(1-5).

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. A review of facility documentation revealed no evidence the facility had developed and administered a fall prevention and recovery training program for all staff specific to A.R.S. 36-420-01.

2. A review of E1, E2, E3, E4, E5, E6, E7, E8, and E9's personnel records revealed no documentation of fall prevention and fall recovery training specific to A.R.S. 36-420-01.

3. In an interview, E1 and O1 acknowledged the facility had not developed and administered a fall prevention and recovery training program for all staff.

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. A review of the facility's policies and procedures manual revealed no documentation the policies and procedures had been reviewed at least once every three years and updated as needed.

No other documentation was provided to show the policies and procedures were reviewed at least once every three years and updated as needed.

2. In an interview, E1 and O1 acknowledged there was no documentation to show the policies and procedures been reviewed at least once every three years and updated as needed.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article.

Findings include:

1. On December 27, 2022, the Compliance Officer requested the following documents during the on-site inspection:

- policies and procedures document showing the last time the policies were reviewed; and
- a document showing medication administration policies were reviewed and approved by a medical practitioner, registered nurse (RN), or pharmacist.

2. In an interview, E1 and O1 acknowledged this information was not provided to the compliance officer within the two hours requested.

This is a repeat citation from the compliance survey conducted on December 30, 2021.

Based on record review, documentation 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 an assisted living facility and included if an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for four of seven residents sampled.

Findings include:

1. A review of R3's medical record revealed a document titled "Residency/Continued Residency Agreement". This document did not include the following:

- whether the individual required continuous medical services;
- continuous or intermittent nursing services; and
- restraints.

2. A review of R4's medical record revealed a document titled "Residency/Continued Residency Agreement". This document did not include the following:

- this document was dated after the individual was accepted into the assisted living facility.

3. A review of R5's medical record revealed a document titled "Residency/Continued Residency Agreement". This document did not include the following:

- this document was dated after the individual was accepted into the assisted living facility.

4. A review of R7's medical record revealed a document titled "Residency/Continued Residency Agreement". This document did not include the following:

- this document was dated after the individual was accepted into the assisted living facility.

8. In an interview, E1 and O1 acknowledged R3, R4, R5, and R7's medical records did not contain the documentation required in R9-10-807.B.1.a-b.

Technical assistance was provided during the compliance inspection conducted on December 28, 2022.

Based on documention review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse (RN), or pharmacist.

Findings include:

1. Review of the facility's medication policies and procedures showed no documented evidence that the facility's medication administration policies and procedure had been reviewed and approved by a medical practitioner, RN, or pharmacist.

2. In an interview, E1 and O1 acknowledged there was no documented evidence that the facility's medication administration policies and procedures were approved by a medical practitioner, RN, or pharmacist.