Acacia Health Center

Based on record review and interview, the assisted living center failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder was contacted. Findings include: 1 . A review of R1's, R2's, R3's, R4's, R5's, R6's and R7's medical record revealed documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an interview, E1 reported the facility had standardized forms, but filled them out after calling emergency medical services, along with printing face sheets and other documents. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure if an assisted living facility maintained residents’ medical records electronically, that safeguards exist to prevent unauthorized access. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a laptop on top of a medication cart on the second floor. The screen for the Medication Administration Record (MAR) was hidden from view. However, there was a second tab open that allowed the Compliance Officer to access resident medical records. Further inspection of the facility revealed an unlocked desktop computer located on the second floor of the facility. The Compliance Officer was able to launch internet explorer and access resident medical records. 2 . In an exit interview, the finding was discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation of a disaster plan review included the time of the review, a critique of the disaster plan review, and, if applicable, recommendations for improvement. Findings include: 1 . A review of facility documentation revealed an "Annual Policy Review." The documentation included the date of the review and name of each employee participating. However, the documentation did not include a time of the review, any critiques of the review, and any recommendations of improvement, if applicable. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a container of "Tide" laundry detergent located in an unlocked cabinet of an unlocked laundry room on the second floor of the facility. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on interview and documentation review, if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect or exploitation had occurred while a resident was receiving services from an assisted living facility, the manager failed to initiate an investigation of the suspected exploitation and document the information required in R9-10-803.J.5.a-d, within five working days, which posed a health and safety risk. Findings include: 1. In an interview, R5 reported to the Compliance Officers that APS had come out to interview R5 regarding a family matter that involved finances. R5 reported that APS told R5 a detective would be coming out to interview R5 sometime in the future. R5 reported R5 had shared this information with the assisted living facility and wished there was more the facility could do to help R5. 2. In an interview, when asked for additional information regarding the incident with R5, E1 reported that APS had come to the assisted living home on November 7, 2024, to speak with R5. Per E1, APS reported to E1 that R5 had requested a welfare check of R5's daughter because R5 could not get in contact with her. E1 answered some billing questions for APS. Per E1, APS came out for a follow-up visit to meet with R5 a short time later but E1 was not available to talk with APS. However, E1 reported that APS reported there was no need to speak with E1 regarding the follow-up visit. 3. The Compliance Officers asked E1 if E1 initiated an internal investigation of the suspected abuse, neglect, or exploitation and documented the information required in subsection (J)(5) within five working days of APS coming to the facility on November 7, 2024. E1 reported E1 did not know E1 was required to conduct an investigation based on the information reported back to E1 from APS, and therefore an investigation had not been conducted. However, when asked, E1 acknowledged that APS coming to the facility to interview R5 was a reasonable basis to believe abuse, neglect, or exploitation could have occurred. E1 acknowledged the manager failed to conduct an investigation and document the information required in subsection (J)(5) within five working days of having a reasonable basis to believe abuse, neglect, or exploitation could have occurred.

Based on observation and interview, the manager failed to ensure that a resident's medical record was protected from unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During an environmental inspection of the facility with E5, the Compliance Officers observed three common area work stations. Inside an unlocked cabinet at one of the stations were binders labeled "Desert Willow - Service Plans - First Floor" and "ADL Sheets - Activities of Daily Living - Desert Willow - 1st Floor." Inside an unlocked cabinet at another station were binders labeled "Desert Willow - Service Plans - Second Floor" and "ADL Sheets - Activities of Daily Living - Desert Willow - 2nd Floor." On a counter at the third work station was a binder labeled "ADL Sheets - Activities of Daily Living - Rosewood." Inside of each of the binders were corresponding service plans and ADL's for residents at the assisted living facility. 2. In an interview, E5 reported E5 was in the process of trying to find and order appropriate locks for the cabinets. E1 and E5 acknowledged the manager failed to ensure that a resident's medical record was protected from potential unauthorized use.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees is conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's documents revealed no documentation of disaster drills conducted on each shift at least once every three months. 2. In an interview, E5 reported E5 believed evacuation drills and fire drills counted as disaster drills as well. The Compliance Officers explained the difference between evacuation and disaster drills, as well as the reason for both. E1 and E5 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of E6 and E8's personnel records revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 reported E1 was unaware the identified personnel members required fall preventing and fall recovery training. 3. In an exit interview with E1 and O1, E1 acknowledged the identified personnel members did not have documentation of fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted on April 18, 2022.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. At 10 am on June 8, 2023, the Compliance Officers requested all facility documents required by this Article. E1 reviewed the requested document request and acknowledged all documents were required to be provided by 12 p.m. 2. At 1:38 pm on June 8, 2023, the facility had not provided the following documents: - Fall Prevention and Fall Recovery Training policy and procedure and training documentation for all requested personnel members. 3. During an interview, E1 acknowledged the aforementioned documents were not provided within two hours after a Department request.

Based on record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services. Findings include: 1. Review of E3's personnel record revealed documentation E3 completed an online CPR training program through the "NationalCPRfoundation", on December 8, 2021. The CPR certification was completed online-only with no demonstration. No additional documentation was available for review. 2. In an interview, E10 acknowledged the identified CPR documentation was the only documentation available for review for E3. 3. In an interview, E1 reported E1 reviewed the identified CPR certification with E3 who confirmed completing the online CPR training with no demonstration and the identified training was the only current CPR training E3 completed. E1 acknowledged the manager failed to ensure a caregiver provides current documentation of cardiopulmonary resuscitation (CPR) training certification

Based on record review and interview, the manager failed to ensure a written service plan included the amount and frequency of assisted living services provided for two of two residents reviewed. Findings include: 1. Review of R1's record revealed a current written service plan for personal care services dated February 15, 2023. This service plan identified R1's need for bathing assistance however did not include the amount and frequency of assisted living services provided. 2. Review of R3's record revealed a current written service plan for personal care services dated April 19, 2023. This service plan identified R3's need for bathing assistance however did not include the amount and frequency of assisted living services provided. 3. In an interview, E1 reviewed R1 and R3's service plans and acknowledged the plans did not include the amount and frequency of assisted living services provided.

Based on record review and interview, the manager failed to ensure medication was administered in compliance with a medication order. Finding Include: 1. A review of R2's medical record revealed a current written service plan dated February 6th, 2023. The service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed no medication orders for the following medications administered to R2: Escitalopram Oxalate 20mg, Fluticasone Propionate (Nasal) 50 mcg, Memantine HCL 10mg, and Donepezil HCL 5mg. A review of R2's medical record revealed May 2023 and June 2023 medication administration records (MARs). The MARs stated the following; "Escitalopram Oxalate 20mg 1 tablet by mouth one time a day for depression" and indicated one tablet was administered daily at 7am May 1, 2023, through the present. "Fluticasone Propionate (Nasal) 50 mcg/act 1 spray alternating nostrils one time a day for allergies alternating nostrils" and indicated one spray was administered daily May 1, 2023, through the present. "Memantine HCL Oral Tablet 10mg give 1 tablet by mouth two times a day for dementia" and indicated two tablets were administered twice a day May 1, 2023, through June 7, 2023. "Donepezil HCL 5mg Give 1 tablet by mouth at bedtime for dementia" and indicated one tablet was administered daily June 1, 2023 through June 7, 2023. 3. During an interview, E1 reviewed R2's record and confirmed the record did not contain current signed medication orders to administer medications identified above. E1 reported the facility was contacting the physician to provide the identified medication orders however the documention was not provided to the compliance officers during the survey. E1 acknowledged R2's medical record did not include documentation to ensure medication was administered in compliance with a medication order.

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. Findings include: 1. During the facility tour with E1 and E2, the compliance officers observed a room tabled "Soiled Utility" located in the center's memory care unit. The room contained a keypad, however the door was unlocked and contained the following toxic materials stored by the facility accessible to the residents: Oxivir TB Spray, Liquid Tide, Mr. Clean Floor Cleaner, Carpet Spotter, and Crew Clinging Toilet Bowl Cleaner. 2. The compliance officers observed E2 attempt to lock the identified room however the key pad was not broken and would not lock. 3. During an interview, E2 reported the key pad would not lock. 4. In an interview, E1 acknowledged the Soiled Utility room was unlocked in the center's memory care unit. E1 acknowledged the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents.