Acacia Health Center

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

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 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 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 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 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 observation and staff interviews, the facility failed to ensure the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to the harm of residents and staff in an emergency. NFPA 101 - 2012 Edition, Section 18.3.4.5.1, Detection systems, where required, shall be in accordance with 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code,. unless it is an approved existing installation, which shall be permitted to be continued in use, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72-2010 Edition, Section 10.5.5.2. For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." Findings include: Observations made in the electrical room on December 10, 2024, revealed the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers. During the exit conference on December 10, 2024, the management team confirmed that the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers.

Based on observations the facility failed to repair the patient sleeping room corridor doors. Failing to protect patient sleeping rooms from heat or smoke will cause harm to patients and/or staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." Findings include: Observations made while on tour on December 10, 2024, revealed the following; 1) room 223 door had an excessive gap on the upper handle side of the door, light can be seen from inside the room when the door is closed 2) room 16233 door not latching 3) room 347 door had an excessive gap on the upper handle side, light can be seen from inside the room when the door is closed 4) room 349 door had an excessive gap on the upper handle side of the door, light can be seen from inside the room when the door is closed 5) third-floor 90-minute door outside dining room missing strike plate. During the facility tour and exit conference conducted on December 10, 2024, the above findings were again acknowledged by the management team.