The Legacy Rehab & Care Center

Findings include:

Review of the clinical record revealed a Pre-Admission Screening and Resident Review Level 1 dated September 17, 2021 which indicated a need for a Level II determination for Mental Illness. Additionally there was an email from the resident's case manager dated September 10mg 2021 which stated that the resident should have a Level II assessment completed.

During the initial screening conducted February 7, 2023 at 9:21 AM, review of the clinical record dated September 17, 2021 the resident was assessed with a Pre-Admission Screening and Resident Review Level I and was recommended for a PASSAR Level II. There was no documentation in the clinical record for the Level II PASSAR.

Review of the MDS Quarterly Assessment dated February 2, 2023 the resident is moderately cognitively impaired with a Brief Interview for Mental Status of 11 and requires extensive to total dependence for his activities of daily living. The resident is incontinent of both bowel and bladder. The resident does exhibit the rejection of evaluations or care, one to three days during the assessment period.

Care plans were located for: Advanced Directives; Type 2 diabetes mellitus with hypoglycemia without coma; Risk for Ineffective Therapeutic Regimen Management; Major depressive disorder, recurrent, unspecified Depression; Anxiety disorder, unspecified, Impaired Coping, Risk for Harm; Risk for Self-Care Deficit: Bathing, Dressing, Feeding; Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors

During an interview conducted on February 8, 2023 at 11:29 AM with a Certified Nursing Assistant, the Admissions Coordinator (staff #89), she stated that they do the initial PASARR Level 1 on admission and that after the admission further Pre-Admission Screening and Resident Reviews are completed by the Social Worker.

During an interview conducted on February 8, 2023 with the Medical Records Coordinator (staff #12), she stated that she does not thin the Pre-Admission Screening and Resident Reviews from the clinical record and that she did not have any in the resident's thinned chart.

During an interview conducted on February 8, 2023 at 11:43 with a Certified Nursing Assistant (staff #44), she stated that she was covering for the Social Worker who was out on leave. She added that she was not employed at the facility when the resident was admitted and was unaware of the missing Pre-Admission Screening and Resident Review Level II. She then reviewed resident's #3 file along with this writer and was unable to locate any documentation of a Level II assessment other than identifying the need for a Level II assessment from the social worker (staff #13).

During an interview conducted on February 8, 2023 with the Director of Nursing (staff #45), she stated that she does not work with the resident's Pre-Admission Screening and Resident Reviews, that they were handled by the admissions office and the Social Worker.

Review of the facility's policy Pre-Admission Screening and Resident Review, it states that "3. All individuals with mental disorders and intellectual disability will be referred to the State for all Level two determination prior to admission."

Based on clinical record review, staff interviews and review of facility policy, the facility failed to ensure that a required Pre-Admission Screening and Resident Review Level II was completed for one resident (#3).

Findings include:

Review of the clinical record revealed a Pre-Admission Screening and Resident Review Level 1 dated September 17, 2021 which indicated a need for a Level II determination for Mental Illness. Additionally there was an email from the resident's case manager dated September 10mg 2021 which stated that the resident should have a Level II assessment completed.

During the initial screening conducted February 7, 2023 at 9:21 AM, review of the clinical record dated September 17, 2021 the resident was assessed with a Pre-Admission Screening and Resident Review Level I and was recommended for a PASSAR Level II. There was no documentation in the clinical record for the Level II PASSAR.

Review of the MDS Quarterly Assessment dated February 2, 2023 the resident is moderately cognitively impaired with a Brief Interview for Mental Status of 11 and requires extensive to total dependence for his activities of daily living. The resident is incontinent of both bowel and bladder. The resident does exhibit the rejection of evaluations or care, one to three days during the assessment period.

Care plans were located for: Advanced Directives; Type 2 diabetes mellitus with hypoglycemia without coma; Risk for Ineffective Therapeutic Regimen Management; Major depressive disorder, recurrent, unspecified Depression; Anxiety disorder, unspecified, Impaired Coping, Risk for Harm; Risk for Self-Care Deficit: Bathing, Dressing, Feeding; Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors

During an interview conducted on February 8, 2023 at 11:29 AM with a Certified Nursing Assistant, the Admissions Coordinator (staff #89), she stated that they do the initial PASARR Level 1 on admission and that after the admission further Pre-Admission Screening and Resident Reviews are completed by the Social Worker.

During an interview conducted on February 8, 2023 with the Medical Records Coordinator (staff #12), she stated that she does not thin the Pre-Admission Screening and Resident Reviews from the clinical record and that she did not have any in the resident's thinned chart.

During an interview conducted on February 8, 2023 at 11:43 with a Certified Nursing Assistant (staff #44), she stated that she was covering for the Social Worker who was out on leave. She added that she was not employed at the facility when the resident was admitted and was unaware of the missing Pre-Admission Screening and Resident Review Level II. She then reviewed resident's #3 file along with this writer and was unable to locate any documentation of a Level II assessment other than identifying the need for a Level II assessment from the social worker (staff #13).

During an interview conducted on February 8, 2023 with the Director of Nursing (staff #45), she stated that she does not work with the resident's Pre-Admission Screening and Resident Reviews, that they were handled by the admissions office and the Social Worker.

Review of the facility's policy Pre-Admission Screening and Resident Review, it states that "3. All individuals with mental disorders and intellectual disability will be referred to the State for all Level two determination prior to admission."

Based on observations, staff interviews and review of facility policy the facility failed to ensure that hot was temperatures remained in the safe range in the resident rooms.

Findings include:

During the initial screening of the residents conducted on February 6, 2023 at 2:03 PM, the water temperatures at the restroom sink in room #312 was checked and it was 130.6 degrees F. The resident was unable to use the sink.

During the initial screening of the residents conducted on February 6, 2023 at 2:15 PM, the water temperature at the restroom sink in room #313 was checked and it was 131.4 degrees F. The resident was unable to use the sink.

Additional water temperatures were obtained on February 6, 2023 at 2:20 PM in the following rooms:

Room # 203 the water temperature was 126.0 degrees F.
Room # 204 the water temperature was 127.5 degrees F.
Room # 304 the water temperature was 131.9 degrees F.
Room # 307 the water temperature was 131.6 degrees F.
Room # 308 the water temperature was 130.6 degrees F.
Room # 314 the water temperature was 130.2 degrees F.
Room # 404 the water temperature was 131.1 degrees F.
Room # 405 the water temperature was 128.8 degrees F.
Room # 407 the water temperature was 130.0 degrees F.
Room # 415 the water temperature was 128.0 degrees F.

The administrator (staff #101) was notified on February 6, 2023 at 2:50 PM of the water temperatures being outside of the required temperatures, and the maintenance director accompanied by the surveyor to check temperatures which remained high.

During an interview conducted on February 6, 2023 at 3:00 PM with the the Maintenance Manager (staff #32), he stated that he was unaware of the water temperature being that high and that he would immediately correct the temperatures.

During observations conducted on February 7, 2023 revealed water temperatures in the follow rooms to be: Room #313 - 114.1 and Room #312 - 112.4.

Room # 313 the water temperature was 114.1 degrees F.
Room # 314 the water temperature was 112.4 degrees F.

During observations conducted on February 8, 2023 at 2:14 PM revealed water temperatures in the following rooms to be:

Room # 201 the water temperature was 111.5 degrees F.
Room # 202 the water temperature was 109.0 degrees F.
Room # 204 the water temperature was 111.0 degrees F.
Room # 213 the water temperature was 110.0 degrees F.
Room # 304 the water temperature was 105.0 degrees F.
Room # 317 the water temperature was 109.0 degrees F.
Room # 402 the water temperature was 105.5 degrees F.
Room # 214 the water temperature was 106.0 degrees F.

For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Arizona Administrative Code \'a7 9-10-819, Section R9-10-819 - Environmental Standards; A. A manager shall ensure that:; 6. Hot water temperatures are maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents.

Review of the facility policy Monitoring of Proper Water Temperatures states, "It is the policy of this facility to maintain proper water temperatures through out the facility to ensure water temperatures are safe to prevent any accidents and to ensure proper infection prevention throughout the facility." Additionally it states "3. All resident rooms will be maintained between 105 and 120 degrees F."

Findings include:

During the initial screening of the residents conducted on February 6, 2023 at 2:03 PM, the water temperatures at the restroom sink in room #312 was checked and it was 130.6 degrees F. The resident was unable to use the sink.

During the initial screening of the residents conducted on February 6, 2023 at 2:15 PM, the water temperature at the restroom sink in room #313 was checked and it was 131.4 degrees F. The resident was unable to use the sink.

Additional water temperatures were obtained on February 6, 2023 at 2:20 PM in the following rooms:

Room # 203 the water temperature was 126.0 degrees F.
Room # 204 the water temperature was 127.5 degrees F.
Room # 304 the water temperature was 131.9 degrees F.
Room # 307 the water temperature was 131.6 degrees F.
Room # 308 the water temperature was 130.6 degrees F.
Room # 314 the water temperature was 130.2 degrees F.
Room # 404 the water temperature was 131.1 degrees F.
Room # 405 the water temperature was 128.8 degrees F.
Room # 407 the water temperature was 130.0 degrees F.
Room # 415 the water temperature was 128.0 degrees F.

The administrator (staff #101) was notified on February 6, 2023 at 2:50 PM of the water temperatures being outside of the required temperatures, and the maintenance director accompanied by the surveyor to check temperatures which remained high.

During an interview conducted on February 6, 2023 at 3:00 PM with the the Maintenance Manager (staff #32), he stated that he was unaware of the water temperature being that high and that he would immediately correct the temperatures.

During observations conducted on February 7, 2023 revealed water temperatures in the follow rooms to be: Room #313 - 114.1 and Room #312 - 112.4.

Room # 313 the water temperature was 114.1 degrees F.
Room # 314 the water temperature was 112.4 degrees F.

During observations conducted on February 8, 2023 at 2:14 PM revealed water temperatures in the following rooms to be:

Room # 201 the water temperature was 111.5 degrees F.
Room # 202 the water temperature was 109.0 degrees F.
Room # 204 the water temperature was 111.0 degrees F.
Room # 213 the water temperature was 110.0 degrees F.
Room # 304 the water temperature was 105.0 degrees F.
Room # 317 the water temperature was 109.0 degrees F.
Room # 402 the water temperature was 105.5 degrees F.
Room # 214 the water temperature was 106.0 degrees F.

For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Arizona Administrative Code \'a7 9-10-819, Section R9-10-819 - Environmental Standards; A. A manager shall ensure that:; 6. Hot water temperatures are maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents.

Review of the facility policy Monitoring of Proper Water Temperatures states, "It is the policy of this facility to maintain proper water temperatures through out the facility to ensure water temperatures are safe to prevent any accidents and to ensure proper infection prevention throughout the facility." Additionally it states "3. All resident rooms will be maintained between 105 and 120 degrees F."

Based on Observation, the facility failed to test the alarm system monthly in the facility. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators".

Findings include:

During review of the facility's documentation on February 9, 2023, accompanied by the Administrator and the Director of Maintenance, the fire alarm system records were reviewed. There was no documentation of a monthly test of the fire alarm system on the months on the night shift and no documentation in months with no drills.

During the exit conference conducted on February 9, 2023, the above finding was acknowledged by the Administrator and the Director of Maintenance.

Based on Record Review and Interview with the Director of Maintenance conducted on February 9, 2023, it was determined the facility failed to fully complete all aspects of a fire drill to include the emergency phone call to the fire department (simulated). Review of the facility documentation for fire drills revealed no documentation of the required phone call.

NFPA 101 Life Safety Code Chapter 19, Section 19.7.2.2 "A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire.

During the exit conference on February 9, 2023, the above findings were acknowledged by the Administrator and the Director of Maintenance.

Failure to perform and conduct and document the life safety code fire procedures,could result in harm to the patients in time of a fire or emergency.