Ability Assisted Living LLC

Based on record review and interview, the manager failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for two of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's medical records revealed a standardized emergency responder patient information form. However, the form was not prescribed and R1's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living facility was not included with the documentation to be provided to emergency responders. 2. A review of R2's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9). However, the following was not included with the documentation: - A copy of R2's HIPAA release authorizing a receiving hospital to communicate with the adult foster care home. 3. In an interview, E1 reported E1 was not aware of the need for the HIPAA form requirement. E1 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on documentation, record review, and interview, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A for one of two residents sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R1's medical records revealed a standardized emergency responder patient information form. However, the form was not prefilled with R1's information as required by statute. 3. In an interview, E1 reported they believed with hospice it was not required for R1. E1 acknowledged the facility did not maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A.

Based on record review, documentation review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to meet the needs of residents. Findings include: 1. A review of E2's and E3's personnel records revealed documentation of skills and knowledge verification was not available for review at time of the inspection. 2. A review of facility documentation revealed a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection. 3. In an interview, E4 acknowledged a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provides physical health services, for two of two caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. The Compliance Officer observed E2 working at the facility and providing services to the residents when the Compliance Officer arrived at the facility at approximately 9:30 AM. 2. A review of E3's personnel record revealed E3 was hired as a caregiver in November 2022. 3. A review of E2's and E3's personnel records revealed no documentation to indicate E2's and E3's skills and knowledge were verified before E2 and E3 provided physical health services. 3. In an interview, E4 acknowledged E2's and E3's skills and knowledge were not verified and documented before E2 and E3 provided physical health services.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for two of three personnel sampled. The deficient practice posed a risk as required information for multiple personnel members could not be verified. Findings include: 1. A review of E2's personnel record revealed documentation of skills and knowledge verification, verification of fingerprint clearance card status, and documentation of a infectious tuberculosis screening by the facility was not available for review at the time of inspection. 2. A review of E3's personnel record revealed documentation of skills and knowledge verification was not available for review at the time of inspection. 3. In an interview, E4 acknowledged E2's and E3's personnel record had not included all documentation required by rule.

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 two of two residents sampled. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's personnel record revealed a service plan. The service plan listed the following services: -Oral Care Daily; -Partial bath on days when complete bath is not given; and -Skin check daily; However, the following services were not marked as provided on the Activities of Daily Living (ADL) sheets on the following dates: -Oral Care from August 15, 2024 to August 17, 2024; -Partial Bath from August 15, 2024 to August 17, 2024; and -Skin condition from August 15, 2024 to August 17, 2024. 2. A review of R2's personnel record revealed an ADL sheet for the month of August 2024 was not available for review at the time of inspection. 3. In an interview, E4 reported the services were provided to R1 but was unsure why they were not marked. E4 reported R2 was also provided services and unsure where R2's August ADL sheet was located. 4. In an interview, E4 acknowledged services provided to R1 and R2 were not documented.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. In an interview, E4 reported all residents receive medication administration. 2. A review of R1's personnel record revealed a signed medication orders for the following medications: -Aspirin 81 MG 1 tablet once a day; -Baclofen 20 MG 1 tablet once a day in the morning; -Baclofen 20 MG 2 tablet once a day at night; -Lexapro 20 MG 1 tablet once a day; -Colace 100 MG 1 capsule twice a day; -Quetiapine 25 MG 1 tablet once a day; -Senna 8.6 MG 1-2 tablets once a day; -Methenamine Mandelate 1 Gram tablet twice a day; and -Lyrica 75 MG capsule three times a day. However, the following medications were not documented as administered on R1's Medication Administration Record (MAR): -Aspirin 81 MG from August 14, 2024 to August 17, 2024; -Baclofen 20 MG 1 tablet from August 14, 2024 to August 17, 2024; -Baclofen 20 MG 2 tablet from August 14, 2024 to August 17, 2024; -Lexapro 20 MG from August 14, 2024 to August 17, 2024; -Colace 100 MG from August 14, 2024 to August 17, 2024; -Quetiapine 25 MG on August 17, 2024; -Senna 8.6 MG on August 17, 2024; -Methenamine Mandelate 1 Gram on August 17, 2024; and -Lyrica 75 MG capsule on August 17, 2024 at 8:00 AM, from August 15, 2024 to August 17, 2024 at 12:00 PM, and from August 14, 2024 to August 17, 2024 at 8:00 PM. 3. In an interview, E4 reported R1 had received their medication and was unsure why it was not marked on the MAR sheet. 4. In an interview, E4 acknowledged R1's medication administration was not documented in R1's medical record.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed a fridge located by the back door of the facility. Inside the fridge the Compliance Officer observed a box and bag of "Lorazepam", a bag of "Humalog", and boxes of "Humalog" and "Lantus" located in the fridge door. The Compliance Officer also observed a lockbox in the fridge. When the Compliance Officer tried to unlock the box, it came unlocked without modifying the code. Inside the box were loose "Lantus" and Humalog" pens. 2. In an interview, E4 acknowledged medication stored by the facility was not stored in a locked area.

Based on observation and interview, the manager failed to ensure food was protected from potential contamination which posed a health and safety risk. Findings include: 1. The Compliance Officer observed in the fridge in the kitchen a container of eggs. The Compliance Officer observed multiple eggs cracked open or missing parts of their shell, exposing the inside of the egg. 2. In an interview, E4 acknowledged the eggs in the fridge were not protected from potential contamination.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan review in 2023 was not available for review at time of inspection. 2. In an interview, E4 acknowledged a disaster plan review conducted in 2023 was not available for review at time of inspection.

Based on observation 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 the environmental inspection of the facility, the Compliance Officer observed the following under the sink in an unlocked cabinet in the kitchen: -Two cans of Sprayway glass cleaner; -One can of Weiman Cabinet and Wood polish; -One can of Weiman Stainless Steel polish; -One can of Pledge; and -One can of heavy duty oven and grill cleaner. The Compliance Officer also observed a can of "Lysol" disinfectant spray in the master bathroom and a common bathroom. 2. In an interview, E4 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area and inaccessible to residents at the time of the inspection.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Review of facility disaster drills revealed drills revealed the last documented disaster drills were conducted on May 28, 2023, at 10 am and 6 pm. 2. In an interview, E1 acknowledged the disaster drills provided to the Department reflected the last documented disaster drills occurred in May 2023. E1 reported E1 did not conduct drills at the facility since the documented drills conducted in May. E1 acknowledged disaster drills were not conducted on each shift at least once every three months.