A Cottage at Pampa Assisted Living
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State Inspection History
State Inspections
Source: AZ State Licensing Agency
Aug 8, 2024Complaint
An on-site investigation of complaint AZ00214244 and AZ00214245 was conducted on August 8, 2024, and the following deficiencies were cited :
Based on documentation review and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers who worked each day, including the hours worked by each, was maintained. The deficient practice posed a risk if there was not sufficient staff to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed employee work schedules from August 2023 to August 2024. However, the documentation did not include the hours worked by each caregiver. 2. In an interview, E2 acknowledged the employee work schedule did not include the hours worked by each caregiver.
Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for three of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's service plan dated April 1, 2024 revealed the following services and frequency to be provided: -Complete Bath three times a week; -Shampoo once a week; -Oral Care two times daily; -Nail Care daily; and -Incontinence check every 3 to 4 hours. However, a review of R1's Activities of Daily Living (ADL) sheet for July 2024 and August 2024 revealed the following dates not documented as provided at any time to R1: -Complete Bath from August 1, 2024 to August 7, 2024; -Shampoo from August 1, 2024 to August 7, 2024; -Oral Care from July 1, 2024 to July 31, 2024 at PM, and August 1, 2024 to August 7, 2024 for both AM and PM; -Nail Care from July 1, 2024 to August 7, 2024; and -Incontinence checks every 3 to 4 hours from July 1, 2024 to August 7, 2024. 2. A review of R2's service plan dated June 27, 2023 (sic) revealed the following services and frequency to be provided: -Complete Bath two times a week; -Shampoo two times a week; -Oral Care two times daily; -Nail Care daily; and -Incontinence check every 3 to 4 hours. However, a review of R1's ADL sheet for July 2024 and August 2024 revealed the following dates not documented as provided at any time to R2: -Complete Bath from August 1, 2024 to August 7, 2024; -Shampoo from August 1, 2024 to August 7, 2024; -Oral Care from July 1, 2024 to July 31, 2024 at PM, and August 1, 2024 to August 7, 2024 for both AM and PM; -Nail Care from July 1, 2024 to August 7, 2024; and -Incontinence checks every 3 to 4 hours from July 1, 2024 to August 7, 2024. 3. A review of R3's service plan dated March 16, 2024 revealed the following services and frequency to be provided: -Complete Bath two times a week; -Shampoo two times a week; -Oral Care two times daily; -Nail Care daily; and -Incontinence check every 3 to 4 hours. However, a review of R3's ADL sheet for July 2024 and August 2024 revealed the following dates not documented as provided at any time to R3: -Complete Bath from July 12, 2024 to August 7, 2024; -Shampoo from July 12, 2024 to August 7, 2024; -Oral Care from July 1, 2024 to July 31, 2024 at PM, and August 1, 2024 to August 2, 2024 for both AM and PM; -Nail Care from July 12, 2024, July 14, 2024 through July 15, 2024, July 17, 2024 through July 18, 2024, July 20, 2024 through July 25, 2024, and July 27, 2024 through August 2, 2024; and -Incontinence checks every 3 to 4 hours from July 1, 2024 to August 2, 2024. 4. In an interview E2 reported R2's service plan date was a mistake and it was 2024, not 2023. R2 also reported resident had been receiving services and not sure why they were not marked. 5. In an interview, E2 acknowledged services provided to
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