ROBSON RESERVE AT SUN LAKES

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for six of eight residents sampled. The deficient practice posed a 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. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required.

3. A review of R4's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R4 had signs or symptoms of TB. Based on R4's date of acceptance, this documentation was required.

4. A review of R5's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R5 had signs or symptoms of TB. Based on R5's date of acceptance, this documentation was required.

5. A review of R6's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R6 had signs or symptoms of TB. Based on R6's date of acceptance, this documentation was required.

6. A review of R8's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R8 had signs or symptoms of TB. Based on R8's date of acceptance, this documentation was required.

7. A review of R9's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R9 had signs or symptoms of TB. Based on R9's date of acceptance, this documentation was required.

8. In an interview, E1, E2, and E3 acknowledged R2, R4, R5, R6, R8 and R9's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.

This is a repeat deficiency from the compliance inspection conducted on July 25-26, 2023.

Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide which is a health and safety risk.

Findings include:

1. The compliance officer observed residents residing at the facility.

2. The compliance officer requested and was not provided with the facility's policy and procedure that cover the methods by which the facility was aware of the general whereabouts of a resident.

3. In an interview, E1 acknowledged there was no policy and procedure available that covered the whereabouts of all the assisted living residents.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of eight residents' medical records reviewed. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

1. Review of R6's medical record contained no documentation of freedom from TB as specified in R9-10-113. BaseD on the date of acceptance this documentation was required.

2. In an interview, E1 and E2 acknowledged R6's record had no documentation of freedom from TB as required.

Based on record review and interview, the manager failed to ensure one of one sampled resident's written service plan was updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, which posed a health and safety risk.

Findings include:

1. During an interview, E2 reported that R1 had a significant change in condition in March/April (2023). R1 went from able to walk with assistance to unable to walk even with assistance.

2. Review of R1's medical record and current service plan that was dated June 20, 2023 stated the resident required directed care and medication administration services. The previous service plan was dated February 6, 2023. Neither service plan identified R1 was unable to ambulate even with assistance. When R1 had a change in condition in March/April to unable to ambulate even with assistance there was no updated service plan within 14 days of the change in condition .

3. In an interview, E1 and E2 acknowledged the service plan had not been updated as required to reflect the significant change in R1's physical and functional condition.

This is a repeat deficiency from the compliance inspection conducted on August 24-25, 2022.

Based on record review and interview, the manager failed to ensure that one of four sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk.

Findings include:

1. Review of R7's medical record revealed that R7 required personal care services. The service plans for the past twelve months were dated: August 16, 2022 and May 1, 2023. R7's service plan was not updated at least every six months.

2. In an interview, E1 and E2 acknowledged R7's service plan had not been updated as required. E2 acknowledged R7 was receiving personal care services.

Based on record review and interview, the manager failed to ensure that three of four sampled residents who were receiving directed care services had a written service plan reviewed and updated at least once every three months, which posed a health and safety risk.

Findings include:

1. Review of R1's medical record revealed that R1 required directed care services. The written service plans and updates during the past twelve months were dated: June 29, 2022, February 6, 2023, and June 20, 2023.

2. Review of R2's medical record revealed that R2 required directed care services. The written service plans and updates during the past twelve months were dated: September 25, 2022 and June 23, 2023.

3. Review of R3's medical record revealed that R3 required directed care services. The written service plans and updates during the past twelve months were dated: June 19, 2022, April 4, 2023, and July 23, 2023.

4. In an interview, E1 and E2 acknowledged the sampled residents' service plans did not appear to have been updated every three months as required for these three residents receiving directed care services.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccination available to the resident on site on a yearly basis; for one of three sampled resident's medical records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk.

Findings include:

1. Based on the date of acceptance, R3's medical record provided no documentation to indicate R3 had been offered the pneumonia vaccine in the past twelve months. There was no other documentation available in R3's medical record to indicate the vaccine was offered, given, refused or contraindicated during the past twelve months. Based on the resident's date of acceptance, this documentation was required.

2. In an interview, E1 and E2 acknowledged there was no documentation available the pneumonia vaccine had been made available to R3 during the past 12 months.

Based on record review and interview, the manager failed to ensure that for three of three sampled residents who were unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner signed a determination stating that the resident's needs were being met. This determination was to be completed at onset and at least once every six months throughout the duration of the resident's condition to determine if the resident's needs could be met which was based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. In an interview, E1 and E2 reported R1 was unable to ambulate even with assistance since March/April of 2023 when there was a change in condition. R2 was unable to ambulate even with assistance since June 23, 2023 when the service plan was updated with the change in condition. R3 has been unable to ambulate since August of 2022.

2. Review of R1's medical record found no documented determination completed by R1's PCP or medical practitioner at the onset of R1's change in condition in March/April. The determination should have been based on an examination of the resident, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility.

3. Review of R2's medical record found no documented determination completed by R2's PCP or medical practitioner at the onset of R2's change in condition on June 23. 2023 when the service plan was updated. The determination should have been based on an examination of the resident, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility.

4. Review of R3's medical record revealed no documented determination completed by R3's medical practitioner every six months throughout the duration of the resident's condition. The most current determination available was dated August 2022. Each determination should have been based on a current resident's examination, the facility's scope of services, and should have included a statement that the resident's needs could be met by the facility.

5. In an interview, E1 and E2 acknowledged the three sampled residents who were unable to ambulate did not have a determination completed as required. All three residents were receiving directed care services.

This is a repeat deficiency from the compliance inspection conducted on August 24-25, 2022.

Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented which posed a safety risk.

Findings include:

1. During an interview, E1 provided documentation of the personnel schedule that revealed the facility had three shifts: First shift from 6:00 AM to 2:30 PM, the second shift from 2:00 PM to 10:30 PM, and the third shift was from 10:00 PM to 6:30 AM.

2. In the past twelve months, the second shift employee disaster drills were conducted on: October 14, 2022, November 23, 2022, February 23, 2023, and April 28, 2023.

3. In the past twelve months, the third shift employee disaster drills were conducted on: May 17, 2023 and June 23, 2023.

4. In an interview, E1 acknowledged the required employee disaster drills had not been conducted at least once every three months on the second and third shifts.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.

Findings include:

1. A review of the facility's documentation revealed one evacuation drill, dated May 17, 2023 was conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during this six month time period.

2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.