CATALINA SPRINGS MEMORY CARE

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one resident sampled.

Findings include:

1. A review of department documentation provided by the Adult Protective Services (APS) revealed a nurse from Mercy Care reported medication was not given to R1 in compliance with a medication order.

2. A review of R1's medical record revealed a medication order dated April 22, 2024. The Compliance observed the following medications "Glipizide 50 MG TAB, Take 1 TAB by mouth every day for diabetes", and "Levetiracetam 500 MG TAB Take 1 Tablet by mouth 2 times daily".

3. A review of R1's medication record revealed on March 20, 21, 22, 23, and 24, 2024, "Glipizide" was not given. The medication was unavailable for the following reason: "medication not in the facility, waiting on delivery".

4. A review of R1's medication record revealed on February 15, 2024, "Levetiracetam" was not given for the following reason: "waiting on delivery".

5. A review of policy and procedures titled "Medication Availability" revealed the following "Policy: It is expected that medications will be given and documented as ordered. This is required by law and is a community expectation".

6. In an interview, E1 acknowledged the medication was not administered in compliance with a medication order.

Based on record review, documentation review, and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of four residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. A review of R2's medical record revealed a current written service plan for directed care services dated May 10, 2024. However, a service plan after August 10, 2024 was not available for review.

2. In an interview, E1, and E2 acknowledged R2 was receiving directed care services and the service plan was not updated at least once every three months.

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 one of four directed care residents sampled.

Findings include:

1. A review of R1's medical record revealed documentation of service plan dated May 10, 2024, indicating R1 was receiving directed care services. However, the service plans did not contain the following:

- Offering sufficient fluids to maintain hydration, and
- Encouragement to eat meals and snacks.

2. In an interview, E1 and E2 acknowledged the service plan for R1 did not contain all of the requirements for directed care residents.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of five employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

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.

Findings include:

1. A review of E2's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E2's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey.

2. A review of E3's personnel record revealed a valid fingerprint clearance card and an application listing four prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E3's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey.

3. A review of E5's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E5's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey.

4. In an interview, E1, acknowledged the personnel records provided for review had not included documentation of compliance with all subsections of A.R.S. \'a7 36-411.

Based on record review, documentation 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 five of five directed care residents sampled.

Findings include:

1. A review of R1's medical record revealed documentation of a service plan dated October 3, 2023. The service plan indicated R1 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Cognitive stimulation and activities to maximize functioning;
- Strategies to ensure a resident's personal safety; and
- Encouragement to eat meals and snacks.

2. A review of R2's medical record revealed documentation of a service plan dated October 18, 2023. The service plan indicated R2 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Cognitive stimulation and activities to maximize functioning;
- Strategies to ensure a resident's personal safety; and
- Encouragement to eat meals and snacks.

3. A review of R3's medical record revealed documentation of a service plan dated November 8, 2023. The service plan indicated R3 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Cognitive stimulation and activities to maximize functioning;
- Strategies to ensure a resident's personal safety; and
- Encouragement to eat meals and snacks.

4. A review of R4's medical record revealed documentation of a service plan dated October 27, 2023. The service plan indicated R4 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Cognitive stimulation and activities to maximize functioning;
- Strategies to ensure a resident's personal safety; and
- Encouragement to eat meals and snacks.

5. A review of R5's medical record revealed documentation of a service plan dated November 15, 2023. The service plan indicated R5 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections;
- Cognitive stimulation and activities to maximize functioning;
- Strategies to ensure a resident's personal safety; and
- Encouragement to eat meals and snacks.

3. In an interview, E1 reported being unaware the service plans did not contain all of the requirements for directed care residents and acknowledged the documents were missing these requirements.

Based on documentation review, record review, and interview, the manager failed to ensure a written notification was provided to the Department within two working days after a resident inflicted self-injury which required immediate intervention by an emergency services provider.

Findings include:

A.A.C. R9-10-101(67) states danger to self "has the same meaning as A.R.S. \'a7 36-501."

A.R.S. \'a7 36-501(8) states danger to self "a. Means behavior that, as a result of a mental disorder: i. Constitutes a danger of inflicting serious physical harm on oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out. ii. Without hospitalization will result in serious physical harm or serious illness to person."

1. A review of Merriam-Webster.com revealed it indicated that "injury" was a synonym for "harm."

2. A review of the Department's documentation revealed on January 18, 2023, a self report by E1 was sent to the department. The document revealed R1 had inflicted self-injury which required immediate intervention by an emergency services provider.

3. On further review of this document the date of the incident was January 4, 2023, however, E1 did not notify the department within two working days.

4. In an interview, E2, and E3 acknowledged E1 did not report the R1's self-injury resulting in immediate intervention by an emergency services provider within two working days.

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

Findings include:

1. A review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of October 1, 2022.

2. A review of E4's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the survey.

3. A review of the October, November, and December 2022 personnel schedules revealed E4 was scheduled to work
October 6 - 7, 10 - 14, 17 - 19 - 23, 25 - 27, 29, 31, November 1 -3, 6, 8, 9, 14 - 17, 21 - 23, 26 - 30, and December 1 and 5, 2022.

4. A review of the facility's policy and procedure revealed a policy titled "Qualified and Trained Staff. Policy: It is the policy of Frontier Management, LLC to staff our communities with trained and qualified staff to meet and/or exceed the state regulation in all states of operation. ....a. First aide - Relias online learning system and course exam. .... 2. Qualifications are to be reviewed annually with performance reviews and staff removed from the schedule if expired".

5. In an interview, E1 acknowledged E4 did not have current documentation of first aid training in E4's personnel file.

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 5, 2022, the surveyor requested the following documents during the on-site inspection:

- Documentation of R1's ADL documentation.

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

This is a repeat deficiency from the compliance inspection conducted on October 13, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, and according to policies and procedures for one of four caregivers sampled.

Findings include:

1. A documentation review of the facility's policies and procedures revealed a policy titled, "General Orientation: Qualified and Trained Staff". The policy stated, "Each Direct Care Staff member is provided with a job description and skills checklist to be reviewed by the Health Services Director and or Executive Director for completion, and .... 4. Staff competency will be verified through observation, evaluation or written formats and documented on a skills checklist".

2. A review of E2's personnel record revealed no documention E2's skills and knowledge were verified before providing physical health services to residents. Based on E2's employment date this documented was required.

3. In an interview, E1 reported being unaware E2 did not have skills and knowledge documentation in E2's personnel record as required according to their policies and procedures .

Based on record review, documentation review, observation, and interview the manager failed to ensure a caregiver or assistant caregiver documents the services provided in the resident's medical record.

Findings include:

1. A review of R1's medical records revealed R1 was receiving directed care services.

2. A review of R1's medical record revealed no documentation of Activities of Daily Living (ADLs) for R1 was available for review while Compliance Officer was on-site.

3. A review of R2's medical records revealed R2 was receiving directed care services.

4. A review of R2's, medical records revealed the resident's Service Plan and Activity of Daily Living (ADLs) document. The Compliance Officer observed on R2's documents the following days not documented that a caregiver or assistant caregiver provided services to R2:

- November 2022, from 7:00 am to 2:00 pm shift on November 9 and 27;
- November 2022, from 2:00 pm to 10: 00 pm shift on November 2, 7, 8,13, 16, 22, 23, 28, 29, and 30;
- November 2022, from 10:00 pm to 6:00 am shift on November 1;
- December 2022, from 7:00 am to 2:00 pm shift on December 3; and
- December 2022, from 2:00 pm to 10:00 pm shift on December 3 and 4.

5. A review of R3's medical records revealed R3 was receiving directed care services.

6.. A review of R3's medical records revealed the resident's Service Plans and Activity of Daily Living (ADLs) document. The Compliance Officer observed on R3's documents the following days not documented that a caregiver or assistant caregiver provided services to R3:

- November 2022, from 7:00 am to 2:00 pm shift on November 9 and 27;
- November 2022, from 2:00 pm to 10: pm shift on November 2, 7, 8,13, 16, 22, 23, 28, 29, and 30;
- November 2022, from 10:00 pm to 6:00 am shift on November 1;
- December 2022, from 7:00 am to 2:00 pm shift on December 3; and
- December 2022, from 2:00 pm to 10:00 pm shift on December 3 and 4.

7. A review of R4's medical records revealed R4 was receiving personal care services.

8. A review of R4's, medical records revealed the resident's Service Plans and Activity of Daily Living (ADLs) document. The Compliance Officer observed on R4's documents the following days not documented that a caregiver or assistant caregiver provided services to R4:

- November 2022, from 7:00 am to 2:00 pm shift on November 1, 13, 18, 27, and 28;
- November 2022, from 2:00 pm to 10: pm shift on November 1, 2, 3, 4, 6, 8, 10, 11, 12, 13, 17, 18, 19, 20, 24, and 27;
- November 2022, from 10:00 pm to 6:00 am shift on November 1; and
- December 2022, from 7:00 am to 2:00 pm shift on December 2 and 4.

9. The Compliance Officer observed on the ADL documents for R1, R2, R3, and R4 the following statement "By initialing this task I agree that I have read and understand the current service service plan and an interim service plans for resident and that all assigned care, assistance with ADL's and monitoring for the AM shift without exception have been provided as per current service plan and ISPS unless otherwise noted as an exception". This statement was documented for first shift, second shift, and third shift.

10. In an interview, E1 reported being unaware R1 did not have documentation of ADLs, and acknowledged the ADL documents for R2, R3, and R4 showed days the caregiver or assisted caregiver did not document services provided in the resident's medical record.

This is a repeat citation from the compliance survey conducted on November 12, 2020.

Based on documentation review, and interview the manager failed to ensure policies and procedures were implemented for discarding medication.

Findings include:

1. A review of the facility's policy and procedure titled "Medication Disposal" revealed "Purpose: To properly dispose of unused, over the counter and prescription medications. Policy: It is the community's policy to comply with FDA and the Office of National Drug Control Policy, when it comes to destroying discontinued, expired or unused medications. Procedure: Follow contract pharmacy policy on disposal on medication policy or utilize a third party service to provide a DEA/EPA/FDA approved methodology for disposal of medication. ....If the medications are narcotics, they need to be disposed of by the nurse and one Med Aid/Delegated ULP, RCC or Executive Director as soon as they are expired or discounted. All narcotics must be accounted for and written on a narcotic disposal form, which is a two-carbon form provided by your contract pharmacy. Place the pink carbon of the narcotic binder, which is maintained on the property for 7 years".

2. A review of documentation provided by E1 revealed an investigation had been done by E1 and Salibas Pharmacy, their contracted pharmacy. This document stated the following: "It was reported to my HSD, [E7], that our RCC, [E6] was disposing of some discontinued and expired narcotics. After we reviewed the medication log and speaking to [E6], did verify that E6 did this. [E6] then explained that E6 disposed of them into the narcotic safe. E6 did let us know that there was not a witness because that is not the way E6 was trained by [E8]. [E6] stated that [E8] told E6 to dispose the meds in the safe. [E8] did not train [E6] that we need a witness and our ED or HSD, needed to sign off. We did drug test [E6], and E6 was negative. We also educated [E6] of the proper way to dispose of narcotics. We did have Salibas out to our community and open the safe. Reported by my HSD, E8 stated that it looked like all narcotics were punched out of the bubbles individually and they did appear to all be there. We will be re-educating all Med Tech's on the right procedure when disposing of narcotics".

3. During a tour of the facility the Compliance Officer observed in the medication room the following: a large blue metal box with a label stating "Sharps", Unused Medication Disposal". E1 acknowledged the safe is used for discarding medication, and the facility contracts with Sharps to discard the medications.

4. In an interview, E1 acknowledged the facility had not discarded the medications according to their policies and procedures.