A Place in the Sun

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record for one of two sampled residents. Findings include: 1. A review of R1’s medical record revealed a service plan dated February 4, 2025 reflected R1 required repositioning every two to three hours. A review of the documentation provided reflected that R1 was not repositioned every two to three hours as required. 2. In an interview, E1 reported R1 refused to be repositioned due to the pain of R1’s diagnosis.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. In documentation review, the facility did not have documentation of a fall prevention and fall recovery training program. 2. In record review, the personnel record for E3 did not include documention E3 received training on fall prevention and fall recovery. 3. During an interview, E1 acknowledged the facility had not developed and implemented a fall prevention and fall recovery training program for all staff and E3's personnel record did not include documentation E3 had received the training.

Based on observation, interview, and record review for one of four caregivers or assistant caregiver's reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. Upon arrival, the Compliance Officer (CO) observed E2 and E3, working at the facility with seven residents on site. 2. During an interview, E2 reported E3 worked day shifts (with E2) as a caregiver. E3 reported [E3] provided care and services for residents. Two alert and oriented residents reported E3 was their primary caregiver. E1 reported E3 was a volunteer. 3. In record review, E3's personnel record (hired on January 7, 2024) did not include documentation of E3's job title, and did not include documentation E3's skills and knowledge were verified and documented before E3 provided services. 4. During an interview, the CO reviewed the findings with E1, who acknowledged E3's personnel record did not include documentation of the verification of E3's skills and knowledge, and the documentation was required before a E3 provided services for residents.

Based on observation, interview, and record review, for one of four caregivers and assistant caregivers reviewed, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver was not oriented, as required. Findings include: 1. Upon arrival, the Compliance Officer (CO) observed E2 and E3, working at the facility with seven residents on site. 2. During an interview, E2 reported E3 worked day shifts (with E2) as a caregiver. E3 reported [E3] provided care and services for residents. Two alert and oriented residents reported E3 was their primary caregiver. E1 reported E3 was a volunteer. 3. In record review, E3's personnel record (hired on January 7, 2024) did not include documentation of E3's job title, and did not include documentation E3 received orientation. 4. During an interview, the CO reviewed the findings with E1, who acknowledged E3's personnel record did not include documentation of orientation.

Based on observation, record review, documentation review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid (FA) and cardiopulmonary resuscitation training (CPR) certification specific to adults. The deficient practice posed a health and safety risk to residents if a caregiver did not have FA and CPR training. Findings include: 1. In observation E3 was observed working on site during the inspection. 2. In record review, E3's personnel record (hired January 7, 2024) did not include documentation of FA and CPR training per the facility's policies and procedures. 3. In documentation review, a facility policy, titled "Staffing and Record Keeping," on page 63, documented, "... 5. All staff must have completed a CPR and First Aid Course and ..." 4. During an interview, E2 reported E3 worked day shifts at the facility, as a caregiver. E1 reported E3 was a volunteer. E3 reported E3 assisted residents with care. Two alert and oriented residents reported E3 was their primary caregiver. E1 acknowledged the facility's policy indicated all staff must have completed a CPR and FA course, and acknowledged E3 did not have the training.

Based on documentation review, observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident 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 the license issued by the Department revealed the facility was licensed at the directed care level. 2. The Compliance Officer observed a dining room patio door to the backyard did not control or alert employees of the egress of a resident. The door had a non working alarm. Another patio door located by resident bedrooms, and a door exiting a resident bedroom, did not control or alert employees of egress of a resident from the facility. 3. During an interview, E1 acknowledged the doors provided access to the outside, and did not control or alert employees of the egress of a resident from the facility.

Based on observation, record review, and interview, for one of four residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not document a medication was administered. Findings include: 1. In observation, R4's medications were observed on site. 2. In record review, R4's medical record (received personal care and medication administration services) included medication orders to receive the following medications daily; Allopurinol, Eliquis, Bumetanide, Escitalopram, Losartan, Lorazepam, Pravastatin and Quetiapine. R4's medication administration record dated October 2024, did not include documentation R4 was administered the medications on October 28 - 29, 2024. 3. During an interview, E1 and E2 reported the caregiver administered the medications to R4 on October 28 and 29; however, acknowledged the medication administration was not documented, as required.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication, including expired medication. The deficient practice posed a health and safety risk if medications were not disposed of, as required. Findings include: 1. In observation, the facility stored expired medications in a medication cabinet located in the dining room. Expired medications included, but were not limited to the following medications: - Acetaminophen expired "04/10/24" - Tums expired "04/18" - Acetaminophen expired "12/16" - Theraflu Cold and Flu expired "4/22" - Acetaminophen expired "12/2023" - Polyethylene Glycol Powder expired "07/24/21" - Tylenol 8 Arthritis expired "04/2023" - Tylenol Extra Strength expired "05/2020" - Milk of Magnesia expired "06/17" - Allergy Relief expired "07/23" - Broncolin Honey Syrup expired "June 2021" - Stool Softener expired "04/20" - Cepacol Lozenges expired "05/2022" 2. In documentation review, the facility's medication policy documented, "... 13. Any resident medication which is discontinued by Physician's order shall be offered back to the resident's representative, resident family member, returned to the pharmacy or disposed of by flushing down the toilet. Written proof of return or destruction of narcotics will be maintained." 3. During an interview, E1 acknowledged the facility stored expired medications, and medications for residents no longer at the facility, and the medications were not disposed of according to the facility's policies and procedures.

Based on observation, documentation review and interview, the manager failed to ensure a resident's dog was licensed consistent with local ordinances. Findings include: 1. During an environmental inspection, the Compliance Officer observed a resident's dog, D1, was on the premises, and locked in an outside laundry room. 2. In documentation review, the facility did not have documentation D1 was licensed consistent with the local ordinance (which is required annually by Maricopa County). 3. During an interview, E1 and E2 reported the dog was accidentally locked in the laundry room; however, belonged to R2. The facility did not have documentation the dog was licensed consistent with local ordinances.

Based on record review, documentation review, and interview, for one of four residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In record review, R4's medical record (received personal care and medication administration services) included documentation R4 received Lorazepam medication October 1 through October 16, 2024, and Oxycodone medication on September 30, 2024, and October 1, - 3, 2024. R4's record did not include documentation of an inventory for the Lorazepam and Oxycodone medications. 2. In documentation review, the Compliance Officer requested to review the facility's policies and procedures on controlled substances. A review of the facility's policies and procedures revealed the facility did not have documented policies and procedures for storing, inventorying, and dispensing controlled substances. 3. During an interview, E1 acknowledged the facility did not inventory R4's controlled substances, and had not established, documented and implemented policies and procedures for storing, inventorying, and dispensing controlled substances.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection, the Compliance Officer observed a food storage pantry had opened items with labels, which required "refrigerate after opening." The items included Worcestershire sauce, chocolate syrup, caramel syrup, Fruit Spread, and Teriyaki sauce. 2. During an interview, E1 and E2 acknowledged the foods were not refrigerated after opening, as required.

Based on observation, record review, and interview, for one resident who had an emergency resulting in the need for medical services, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or an assistant caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a risk if the facility did not take action to prevent an accident, emergency, or injury from occurring in the future to ensure the health and safety of residents. Findings include: 1. The Compliance Officer observed R2 at the facility. 2. In record review, R2's medical record included documentation from SOMC Osborn Medical Center, which documented, "... Encounter... EDArrival ... Multiple fractures of ribs, left side, initial encounter for closed fracture..." 3. During an interview, E1 reported the facility contacted emergency medical services to transport R2 to the hospital, following a recent fall. 4. A review of R2's medical record revealed no evidence a caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. 5. During an interview, E1 reported R2 had a fall, the facility called 911, R2 required medical services, and was transported to the hospital. R2 returned to the facility three days later. E1 acknowledged a caregiver did not document the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future.

Based on observation and interview, the manager failed to ensure the facility premises was free from a condition or situation that could cause a resident or other individual to suffer physical injury. The deficient practice pose a safety risk to residents. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed the back and side yards of the facility were not maintained in a manner to ensure the safety of the residents. The following was observed: - a backyard storage unit was unlocked and contained multiple items including but not limited to, tools and supplies. - a side yard contained five gallon containers of paint, wash and wax liquid, yard tools, broken bed frames wood boards, and other refuse. - another side yard, accessed from a resident bedroom door to the outside, had containers of Eco 711 adhesive, Plastic Roof Cement, stacked buckets, yard tools, wood boards, and other miscellaneous items. The path had overgrown foliage and led to an open storage area filled with crates, plywood, cabinets, and multiple miscellaneous items. A door was observed at the end (which led to the front of the house). The area had spider webs, was cluttered with items, which posed a tripping hazard, and did not allow for entry or exit from the resident's bedroom in the event of an emergency evacuation. 2. During an interview, E1 acknowledged the back and side yards of the facility had multiple items, garbage and refuse that could pose a safety hazard for residents, and the area outside of the resident bedroom did not allow for emergency exit from the facility, to safety.

Based on observation and interview, the manager failed to ensure that garbage and refuse were removed from the premises at least once a week. The deficient practice posed a safety risk to those entering the patio/yard area. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed the back patio/yard and side yard areas were cluttered with unused items, including but not limited to; plastic crates, metal bed frames, headboards, a stroller, empty buckets, and large wood pieces. 2. In an interview, E1 acknowledged there were several items of garbage and refuse stored in the outside areas of the facility, and acknowledged garbage and refuse were required to be removed form the premises at least once a week.

Based on observation and interview, the manager failed to ensure poisonous and 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 a resident if toxic materials were accessible. Findings include: 1. During an environmental inspection with E1, the Compliance Officer observed the side yards of the facility had multiple containers of poisonous or toxic materials stored on the premises and accessible to residents. A side yard contained five gallon paint containers. Another side yard accessible from a resident bedroom, had several items, including but not limited to containers of Wash and Wax cleaner, Eco 711 Adhesive, Loctite Spray x 2, Tacky Spray, Water Proofer, Rubberized Wet Patch Roof leak repair, and Gaps and Cracks. 2. During an interview, E1 acknowledged the facility had containers and cans of poisonous and toxic materials on the premises, which were not stored in a locked area and inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure a resident's dog was vaccinated against rabies. The deficient practice posed a health and safety risk to residents, if an animal was not vaccinated against rabies. Findings include: 1. During an environmental inspection, the Compliance Officer observed a resident's dog, D1, was on the premises. 2. In documentation review, the facility did not have documentation D1 was vaccinated against rabies. 3. During an interview, E1 reported the dog belonged to R2, and the facility did not not have documentation D1 was vaccinated against rabies.

Based on observation and interview, the manager failed to ensure exterior doors were equipped with ramps or other devices to allow use by a resident using a wheelchair or other assistive device. The deficient practice posed a safety risk to residents who might exit the door. Findings include: 1. During an environmental inspection, the Compliance Officer observed an exit door from an area by resident bedrooms was unlocked and had a vertical drop of approximately 8 inches from the threshold to the ground. The exterior door was not equipped with a ramp or other device to allow use by a resident using a wheelchair or other assistive device. 2. During an interview, E1 acknowledged the exterior door was not equipped with a ramp or other assistive device.

Based on record review, and interview, for one of four employees reviewed, the health care institution failed to implement tuberculosis (TB) infection control activities including providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. In record review, the personnel record for E3 (hired on January 7, 2024), did not include documentation of training and education related to recognizing the signs and symptoms of TB. 2. During an interview, E1 acknowledged the facility did not provide E3 training and education related to recognizing the signs and symptoms of TB.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented. The deficient practice posed a safety risk to residents if the opioid rules were not understood and implemented by staff administering medications. Findings include: 1. In documentation review, the Compliance Officer requested to review the facility's policy and procedure on opioid medication administration. A review of the facility's policies and procedures revealed no documentation of policies and procedures covering opioid medication administration. 2. In record review, R2's medical record included documentation R2 received Oxycodone medication in September and October 2024. 3. During an interview, E1 reported R2 received opioid medication for pain following a fall, and acknowledged the facility did not establish, document, and implement policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented.

Based on record review, documentation review, and interview, for one of four residents reviewed, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. In record review, R2's medical record (received directed care and medication administration services) included documentation R2 received Oxycodone 0.25ml on September 30, October 1 (x 4), 2 and 3, 2024. R2's medical record did not include documentation of a malignancy or end of life condition, and did not include documentation of an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. 2. In documentation review, the Compliance Officer requested to review the facility's policy and procedure on opioid medication administration. A review of the facility's policies and procedures revealed no documentation of policies and procedures covering opioid medication administration. 3. During an interview, E1 reported R2 received opioid medication for pain following a fall, and acknowledged the caregivers did not document the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered, as required by R9-10-120.F.