A Place for Your Loved Ones

Based on observation and interview, the manager failed to ensure when medication was stored by an assisted living facility, medication was stored in a self-contained unit used only for medication storage. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked refrigerator. Inside the refrigerator was an black metal container with a combination lock. When the Compliance Officer removed the container and turned the latch to unlock the container without changing the numbers on the combination lock, the container opened, and medication was accessible. 2 . In an exit interview, the findings were discussed with E4 and no additional information was provided.

Based on record 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 the assisted living facility, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical records revealed documentation dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant to include whether R1 was expected to receive supervisory care services, personal care services, or directed care services, or required continuous medical services, continuous or intermittent nursing services, or restraints, was completed on December 8, 2022. However, the documentation was not completed 90 calendar days before R1 was accepted by the assisted living facility. 2. In an interview, E1 acknowledged documentation was not dated within 90 calendar days before the individual was accepted by the assisted living facility for R1.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 2. A review of R1's medical records revealed documentation of freedom from TB. However, documentation of TB screening was not available for review at the time of inspection. 3. In an interview, E2 acknowledged failure to ensure R1's medical record contained documentation of freedom from infectious tuberculosis.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of facility documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door in the master bedroom leading to the back porch allowed a resident to be at least 30 ft away from the facility. However, the door did not control or alert employees of the egress of a resident from the facility. 3. In an interview, E2 acknowledged E1 failed to ensure the means of exiting the facility controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed an orientation form signed on February 17, 2022 by the manager and February 24, 2022 by the resident representative. However, neither date was within 24 hours after acceptance. 2. A review of R2's medical record revealed an orientation form signed on February 15, 2024 by the manager and February 29, 2024 by the resident representative. However, neither date was within 24 hours after acceptance. 2. In an interview, E2 acknowledged documentation was not completed showing R1 and R2 was oriented to the facility's evacuation routes and plans 24 hours after acceptance.

Based on observation, documentation review, and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the poisonous or toxic materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the sink in the hallway bathroom. The door to the cabinet was hanging from one hinge, and falling off. Inside the cabinet was a bottle of "Oxi Clean" bathroom cleaner. 2. In an interview, E2 acknowledged the "Oxi Clean" bathroom clean was not stored in a locked area and inaccessible to residents.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the sink in the hallway bathroom. The door to the cabinet was hanging from one hinge, and falling off. 2. In an interview, E2 acknowledged the cabinet door under the sink in the hallway bathroom was not maintained in a working order.

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. Review of facility documents revealed a policy and procedure titled "Fall Prevention" reviewed and signed by E1 June 26, 2023. 2. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of July 7, 2023. The personnel record did not include documentation showing E4 completed fall prevention and fall recovery training. 3. In an interview, E1 and E2 acknowledged E4 had not completed a training program for fall prevention and fall recovery.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental tour of the facility with E1, the Compliance Officer observed Latanoprost unlocked in the kitchen refrigerator. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E1 and E2 acknowledged the medication was stored unlocked. 4. This is a repeat deficiency from the compliance inspection conducted July 12, 2022.

Based on documentation review, record review, observation, and interview, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of one resident reviewed. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Opioid Policy and Procedure" reviewed and signed by E1 June 26, 2023. This policy and procedure stated "...4. For residents receiving an opioid medication on a routine basis as per resident's medical practioner's order, caregiver will assess the resident's need for the opioid prior to administering...the medication by ensuring the resident is responsive and able to communicate...8. Staff will assess the resident by having the resident communicate the reason for the need, the pain level, from a scale of 0 to 10 with 0 being the lowest and 10 being the highest, before and after the...administration of an opioid and observe the resident 30 minutes after the...administration. 9. Staff will document the monitoring of the resident before and after the...administration..." 2. Review of R2's medical record revealed a signed medication order dated June 30, 2023. This medication order stated "Oxycodone HCL/Acetaminophen 5mg/325mg/1 tab PO TID". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated "Oxycodone HCL/Acetaminophen 5mg/325mg Give 1 tab by mouth three times a day" and indicated one tab was administered at 8am, 2pm, and 8pm July 1st - present. However, documentation was not available showing the identification of R2's need for the opioid and the effect of the opioid administered. 4. During an observation of R2's medications, Oxycodone HCL/Acetaminophen 5mg/325mg was observed. 5. Review of R2's medical record revealed no documentation stating R2 had an end of life condition or an active malignancy. 6. In an interview, E1 and E2 acknowledged the caregiver did not document in R2's medical record the identification of R2's need for the opioid and the effect of the opioid administered.