Abracadabra Assisted Living #2

Based on record review and interview, the manager failed to ensure that the assisted living facility made vaccinations for influenza or pneumonia available to residents on site on a yearly basis. Findings include: 1 . During a review of R1's medical record, the Compliance Officer found no evidence that the pneumonia vaccination was offered to the resident. The last documented refusal was dated October 4, 2024, with no further denial or acceptance of this vaccination for 2025. 2 . In an interview, E1 acknowledged that the vaccine for pneumonia was not offered. 3. In an exit interview with E1, the finding was reviewed, and no additional information was provided.

Based on record review and interview, the manager failed to provide written notification to the Department of a resident’s death, if the resident’s death was required to be reported according to A.R.S. § 11-593, within one working day after the resident’s death, for one of one applicable resident. Findings include: 1. A.R.S. § 11-593 classifies reportable deaths to include "unexpected or unexplained deaths." 2. A review of R3's medical record contained an incident report dated December 4, 2022, that indicated R3 was found unresponsive, and 911 was called. 3. The Department received information that R3 never returned to the facility, as R3 passed away at the hospital on December 18, 2022. 4. In an interview, E1 reported being unaware that it was required to notify the Department since R3 passed away at the hospital and not at the facility. E1 acknowledged that the manager failed to provide written notification to the Department of R3’s death within one working day after the death. 5. In an exit interview with E1, no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was signed and dated by the resident or the resident's representative. Findings include: 1 . During a review of R1's medical record, the record contained a current service plan dated February 2026. However, the service plan was not signed by the resident or the resident's representative. 2 . In an interview, E1 acknowledged that the service plan for R1 was not signed by the resident or the resident's representative. 3. In an exit interview with E1, the finding was reviewed, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that food was stored to ensure it was free from spoilage, filth, or other contamination and was safe for human consumption. Findings include: 1 . During a tour of the facility, the Compliance Officer observed a package of raw chicken legs sitting on a pantry shelf. E2 reported that E2 set it out to thaw. 2 . In an interview, E2 acknowledged that the food was not stored to prevent spoilage, filth, or contamination. 3. In an exit interview with E1, the finding was reviewed, and no additional information was provided. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on April 3, 2025.

Based on observation, documentation review, and interview, the manager failed to ensure that pets were licensed consistent with local ordinances. Findings include: 1. The surveyor observed O1 in the facility’s backyard. 2. A review of the facility's pet records revealed O1's pet license expired on March 28, 2023. 3. In an interview, E1 acknowledged O1's pet license was not kept current, consistent with local ordinances.

Based on observation and interview, the governing authority failed to ensure that a caregiver who was able to understand and communicate in English was on the assisted living facility's premises. The deficient practice posed a risk if the caregiver was unable to write and communicate with an English-speaking resident in order to meet their needs. Findings include: 1. A review of the facility’s documentation revealed a policy and procedures revealed a policy titled “Employment Requirement” which reflected “In order to receive the manager delegated authority to act as a manager when the manager is not present at the facility, as well as be 21 years of age or older and able to read, write and communicate in English.” 2. A review of the facility’s documentation revealed a document titled “Weekly Employer's Work Schedule” dated April 1, 2025, through April 7, 2025, which reflected that on April 6, 2025, E3 was the only caregiver scheduled to work between 7 am to 7 pm. E3 was the only caregiver scheduled between 5 pm to 7 pm from April 1, 2025, to April 7, 2025. 3. A review of E2’s and E3’s personnel records revealed that E2 was an assistant caregiver and E3 was a certified caregiver. 4. In an interview, E1 and E2 reported R1’s breathing was labored and abnormal, and emergency services were called. E1 reported that E2 and E3 were the only staff members present during the incident. 5. In an interview, E3 was asked to recall the emergency of R1. E3 could not recall the event in English, and E1 translated E3’s language into English for the compliance officer. 6. In an interview, E3 was asked to read a document titled “Manager’s delegation.” However, E3 was unable to read and communicate the document’s content in English. 7. In an interview, E1 acknowledged E3 could not read, understand, or communicate in English.

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for two of four caregivers and assistant caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E2's and E3's personnel records revealed no documented verification of E2's and E3's skills and knowledge. 2. A review of the facility’s documentation revealed a document titled “Weekly Employer's Work Schedule” dated April 1, 2025, through April 7, 2025, which reflected that E2 and E3 worked various days. 3. In an interview, E1 reviewed E2's and E3's personnel records and acknowledged that the personnel records did not include documented verification of skills and knowledge.

Based on the record review and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident's service plan for two of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan dated March 7, 2025, which reflected R1 required the following assistance: oral care daily. R1’s document titled “Activities of Daily Living Chart,” which reflected that R1 was not assisted with oral care daily. 2. A review of R2’s medical record revealed a service plan dated February 17, 2025, which reflected that R2 required assistance with oral care and nail care daily. R2’s document titled “Activities of Daily Living Chart,” which reflected that R12 was not assisted with oral care or nail care daily. 3. In an interview, E1 acknowledged that there was no documentation available for review to reflect that R1 and R2 were provided the above assistance according to the residents’ service plans.

Based on observation and interview, the manager failed to ensure food was stored free from spoilage, filth, or other contamination and was safe for human consumption. The deficient practice posed a risk of foodborne illness. Findings included: 1. During the environmental inspection of the facility, the Compliance Officer observed the following expired items inside the facility’s kitchen refrigerator: - Oat milk with an expiration date of March 28, 2025; - Ranch with an expiration date of January 29, 2025. 2. In an interview, E1 acknowledged that the above items were not stored free from spoilage.

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41°F or below. Findings include: 1. During a tour of the facility, the compliance officer observed “Sweet Baby Rays: Mild Buffalo Wings,” which states to refrigerate after opening, stored inside the facility’s pantry. 2. In an interview, E1 acknowledged that the above food item was not stored at 41°F or below.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance unless the facility obtained a written determination from a medical practitioner, every six months, stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services. Findings include 1. A review of R1's medical record revealed a service plan dated June 10, 2023, which reflected R1 was wheelchair bound and unable to ambulate even with assistance. 2. A review of R1's medical record revealed a document titled "Authorization for Continued Residency" dated December 21, 2022. There was no written determination dated within the last six months to authorize R1's continued residency. 3. In an interview, E1 acknowledged there was no written determination dated within the last six months authorizing R1's continued residency.