Agape Care Home of Scottsdale

Based on record review and interview, for one resident reviewed, and receiving services from a home health and hospice service agency, the manager failed to ensure a resident's medical record contained any information provided and follow up instructions provided by a Hospice service agency. The deficient practice posed a health and safety risk to a resident if the Department was unable to verify services were provided for a resident, as instructed. Findings include: 1. During an interview, E1 and E2 reported R1 had wounds, and received Hospice services. The nurse came to the facility three times a week initially, and then twice weekly, for wound care. The Hospice nurse instructed the caregivers on implementing measures to promote the healing of the wounds, and to provide dressing changes on the days Hospice did not provide services for R1. 2. In record review, R1's medical record (received directed care and medication administration services) did not include documentation Hospice came to the facility to provide services for R1, and did not include documentation of the instructions provided to the caregivers. 3. During an interview, E2 reported R1 received services from a Hospice agency, and also from the Veteran's Administration, to address R1's wounds. E2 reported the caregivers were provided with verbal instructions from the Hospice nurse, for R1; however, acknowledged the information provided was not documented in R1's medical record.

Based on observation, record review, and interview, for one of three residents reviewed, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident. The deficient practice posed a risk to the health and safety of a resident if a caregiver was unaware of the specific services to be provided to a resident. Findings include: 1. During an interview, E2 reported the caregivers provided R1 with wound care dressing changes, and Foley catheter care services. The caregivers changed the bandages on R1's wounds on the days the Home Health nurse did not provide wound care services for R1. 2. In record review, R1's service plan, dated May 7, 2024, (received directed care and medication administration services) included documentation R1 had "Left hand contractures, wound Left hip, left shoulder, some redness to buttocks... (illegible)... required foot care, had thin frail skin.." Received catheter care with frequency documented as "protocol" Received wound care "wound care performed under directions of Hospice until resolved." "CG to assist with prevention of bruises, injuries, pressure sores and infections." The service plan did not include the amount, type and frequency of services provided. 3. During an interview, O1 reported [O1] was an LPN with a Home Health agency, and provided wound care services for R1 from May 6, through May 24, 2024. O2 (Hospice agency nurse) reported [O2] did not provide wound care services, although R1 received Hospice services. 4. During an interview, E1 acknowledged R1's service plan did not include the amount, type and frequency of services provided for the R1.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a caregiver documented the services provided to a resident, in the resident's medical record. The deficient practice posed a risk as services could not be verified as provided according to a service plan, a resident experienced a negative health outcome, and the documentation included false and misleading information. Findings include: 1. In record review, R1's service plan, dated May 7, 2024, (received directed care and medication administration services) documented R1 had "Left hand contractures, wound Left hip, left shoulder, some redness to buttocks... (illegible)... required foot care, had thin frail skin.." Received catheter care with frequency documented as "protocol" Received wound care "wound care performed under directions of Hospice until resolved." "CG to assist with prevention of bruises, Injuries, pressure sores and infections." 2. In record review, R1's record included an "Activities of Daily Living (ADL) Chart," dated April, 2024, and May, 2024. The ADL chart did not include documentation of wound care services, catheter care services, or services provided by the caregivers to prevent pressure sores. 3. During an interview, O1 reported [O1] was an LPN with a Home Health agency, and provided wound care services for R1 from May 6, through May 24, 2024. O2 (Hospice agency nurse) reported [O2] did not provide wound care services, although R1 received Hospice services. 4. R1's record included documentation of "Narrative Notes." The narrative notes for April and May 2024, included documentation every two hours "Resident was rotated and adjusted," and was initialed by a caregiver. A review of the documentation revealed E1 entered the daily documentation; however, signed E2's initials. 5. During an interview, E2 reviewed the narrative notes with the Compliance Officer, and reported some of the daily notes were entered with E2's signature; however, the notes were not E2's handwriting or signature and were entered by someone other than E2. E1 reported the narrative notes were entered in response to the recent APS investigation related to R1's pressure sores, to show that R1 was repositioned, and said that R1 was repositioned every two hours. E1 acknowledged the documentation was entered by E1, who signed E2's initials.

Based on observation, record review, documentation review, and interview, for one resident reviewed, and receiving 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 if a resident's pain was not identified, monitored and documented, as required. Findings include: 1. In observation, R2 had Tramadol mg medication (a schedule IV controlled substance), 60 tablets dispensed on May 18, 2024, with 24 tablets remaining. 2. In record review, R2's medical record (received directed care and medication administration services) included documentation R1 received the opioid medication, as ordered; however, the record did not include documentation of an identification of the resident's need for the opioid, and the monitoring of the effect of the opioid administered. 3. In documentation review, a facility policy, titled "... Medications Including Opioids and Narcotics, on page 6, documented, "...Facility personnel will provide opioid medication based on doctor's orders for regular administration ( on a regular basis) and will identify and document the level of pain and/or the resident's need for the opioid medication. If opioid medication is administered on a PRN basis, at the request of the resident, or upon determination of the pain level and/or need, the caregiver will administer... the opioid based on the ... PRN written order... All residents who are subject to receiving opioid medication will have their responds to the opioid monitored by checking on the resident within the first half an hour after administration... or as often as is common sense and as the particular case requires. Effectiveness of the opioid administered will be documented in the NAR ..." 4. During an interview, E1 reported the resident received an opioid medication, and acknowledged the caregivers did not identify and document the residents' need for the opioid before the opioid was administered, and monitor and document the effect of the opioid administered, according to the facility's policies and procedures.

Based on observation, record review, and interview, for three of three residents reviewed who were unable to walk even with assistance, the manager failed to meet the requirements in R9-10-814.B.2. The deficient practice posed a health risk to a residents. Findings include: 1. In record review, R2's medical record included a signed and dated determination, December 28, 2020, which indicated R2 was unable to walk and was confined to a bed or chair. R2's record did not include a signed and dated determination stating the resident's needs could be met by the facility, since December 28, 2020. 2. During an interview, E1 and E2 reported R2 continued to be unable to walk, even with assistance, and acknowledged the facility did not ensure the resident's PCP or MP examined the resident at least every six months throughout the duration of the resident's condition, and signed and dated a determination stating the resident's needs were being met by the facility. 3. The Compliance Officer (CO) observed R3 laying in bed during the inspection. R3 was unresponsive to the CO. 4. In record review the medical records for R1 and R3 (received directed care services) included documentation the residents were unable to walk and were confined to a bed or chair. Both residents had a documented Power of Attorney. Neither record included documentation the residents' representative requested that the resident be accepted by or remain in the assisted living facility. 5. During an interview, E1 acknowledged R1 and R3 were unable to walk and were confined to a bed or chair, and the facility did not have the required documentation from the residents' representatives requesting the residents be accepted at the assisted living facility.

Based on observation. record review, and interview, the manager failed to ensure the a medication was administered to a resident only as prescribed. The deficient practice posed a health and safety risk to a resident who was given the wrong medications. Finding include: 1. In record review, R2's medical record (received Directed care and medication administration services) included a "Report of Unusual Occurrence," which documented R2 "was accidentally given another residents medication... Resident's vitals were monitored every 10 minutes and poison control was called. Morning meds were withheld as directed by poison control..." 3. During an interview, E2 reported E3 mistakenly gave R7's crushed medications to R2. E1 acknowledged R2 was administered medications without an order.

Based on observation, and documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a health and safety risk if medications, including narcotics, were not disposed of as required. Findings include: 1. During an environmental inspection, a refrigerated medication container included the following medications, for residents no longer residing at the facility: -R4 residency terminated: Novolog Insulin Vials, Levemir Flex Touch pens -R5 residency terminated: Lorazepam Intensol Concentrate -R6 residency terminated: Lorazepam 2 mg/ml oral concentrate, expired 04/2024 2. In documentation review, a facility policy, titled, "Medications Including Opioids and Narcotics," on page 9, documented "On a monthly basis the facility manager or manager designee will check all medication in the facility to identify and locate any discontinued medication (by the physician's or medical practitioner's order), expired medication, including medication of deceased residents." Such medication will be disposed of by the facility manager or manager designee on the last day of the month as follows..." 3. During an interview, E1 reported the residents no longer resided at the facility, and the medications were not discarded per the facility's policy and procedures.

Based on observation, documentation review, record review, and interview, for one resident 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 observation, R2 had Tramadol medication 50 mg tablets (a schedule IV controlled substance), 60 tablets dispensed on May 18, 2024, with 24 tablets remaining. 2. In record review, R2's medical record (received directed care and medication administration services) included documentation R1 received the medication, as ordered; however, the record did not include documentation of an inventory of the medication, as required. 3. In documentation review, a facility policy, titled "... Medications Including Opioids and Narcotics, on page 2-3, documented, "... All resident medications brought to the facility will be received by the caregiver ... who will ... check the contents of the medication... as soon as possible, medication will be inventoried... The opioid and narcotic medications will be inventoried and placed in the medication storage area... Daily narcotics or controlled substances administration will be recorded on each resident Narcotic Administration Record..." 4. During an interview, E1 reported the residents received controlled medications, and acknowledged medication was not inventoried per the facility's policy and procedures.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below, which posed a health risk to the residents. Findings include: 1. During an environmental inspection, the Compliance Officer observed a food storage pantry had items with labels which required "refrigerate after opening." The items include large containers of Molasses, Barbecue Sauce, Soy Sauce, Worcestershire Sauce and a bottle of green olives. All of the containers had been opened. 2. During an interview, E1 acknowledged the foods were not refrigerated after opening.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition. Findings include: 1. A review of R3's medical record revealed a service plan for personal care services created on November 2, 2021, and updated on May 2, 2022, November 2, 2022, and May 2, 2023. The service plan contained a section titled, "Mobility" which listed R3 as "Independent" with the use of a walker. The service plan also contained a section titled "Activity" which stated R3 was "Independent with device, Type: Walker." R2's service plan also contained a section titled "Summary of Level of Assistance Needed" which included boxes checked which indicated R2 needed "Min" level of assistance for "Ambulation," "Transfers," and "Toileting." The word "Self" was written in pen on the "Recommendations" column next to the boxes checked "Min" for each of the above services. 2. Further review of R3's medical record revealed documentation of activities of daily living (ADL) provided in May 2023. On the back of R3's May ADL sheet there were "Narrative Notes" which stated, "5/21/23...Resident was taken to the hospital. 5/28/23...Resident returned from the hospital. " 3. In an interview, R3 reported R3 had a fall "last month" in which R3's hip was broken. R3 reported R3 was bed bound since the fall and was unable to ambulate. R3 reported R3 required assistance with ambulation, transfers, and toileting. 4. In an interview, E1 reported the personal care service plan updated May 2, 2023 was the most recently updated service plan for R3. E1 reported R3 was bed bound since returning from the hospital on May 28, 2023. E1 reported R3 was scheduled to get an updated service plan within the week. E1 acknowledged R3's written service plan was not reviewed and updated no later than 14 calendar days after a significant change in the resident's physical condition.

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented any action taken to prevent the accident, emergency, or injury from occurring in the future, for five of six current residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: 1. A review of facility documentation revealed a document titled "Report of Unusual Occurrence," dated May 6, 2023, which detailed an emergency involving R2. The report stated, "Resident complaining about not being able to see, and was nodding off...Emergency personnels were contacted, they came, assessed the resident and took [R2] to the hospital..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. A review of facility documentation revealed a document titled "Report of Unusual Occurrence," dated May 21, 2023. The documentation detailed an incident which resulted in R3 needing medical services. However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. A review of facility documentation revealed a document titled "Report of Unusual Occurrence," dated May 7, 2023, which detailed an emergency involving R5. The report stated, "Caregiver just finished giving the resident a change and was lowering [R5] onto [R5's] bed with the lift, then the caregiver noticed the resident's eyes turning upwards and [R5] wasn't responding/looking at caregiver when [R5's] name was called. Caregiver contacted emergency response, manager, and the resident's representative. Emergency personnels came, assessed the resident and said [R5's] vitals were ok but wanted to take the resident to hospital for better evaluation." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 4. A review of facility documentation revealed a document titled "Report of Unusual Occurrence," dated May 28, 2023, which detailed an emergency involving R6. The report stated, "Caregiver notices [sic] that the resident elbow is swollen the day after [R6] had a fall...Resident was taken to the hospital..." However, the report did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 5. A review of facility documentation revealed a document titled "Report of Unusual Occurrence," dated May 11, 2023, which detailed an accident involving R8. The report stated, "Resident was being lowered onto [R8's] bed with the lift when [R8] let go of the handle and stiff [R8's]-self out [sic], causing [R8] to hit [R8's] head on the wall which resulted in small swelling on the back of [R8's] head. Emergency personnels was call [sic] and they assessed [R8] and [R8's] vitals were

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-420.01. states: "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." 2. A review of facility policies and procedures revealed a policy titled "Fall Prevention" which stated, "All our residents upon admission will be assessed to minimize their risk of falling. These assessments will be documented in the service plan of such resident. Facility personnel will work to actively reduce the risk of falls by ensuring a safe physical environment and appropriate identification of at risk residents. Fall prevention and Recovery training is required upon hire and at least every 12 months thereafter." 3. A review of E1's and E4's personnel records revealed no documentation of initial training and continued competency training in fall prevention and fall recovery was available for review. 4. A review of E3's personnel record revealed documentation of orientation completed upon E3's hire. The orientation documentation for E3 revealed E3 was oriented in "Fall Prevention" upon hire. However, the document did not include any mention of E3's training in fall recovery. 5. In an interview, E1 acknowledged the manager failed to ensure the health care institution administered its training program for E1, E3, and E4 regarding fall prevention and fall recovery.

Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training and first aid training, for one of four personnel members sampled. Findings include: 1. A review of facility policies and procedures revealed an undated policy titled "First Aid and CPR training" which stated, "In order to keep First Aid and CPR training and skills up to date it is required that each employee and volunteer provide the following: 1. Documentation that verifies that the employee or volunteer has received CPR training. 2. Documentation that verifies that the employee or volunteer has received First Aid training...4. Timeframe for renewal of training for CPR and first aid...Each employee or volunteer will present proof of training in First Aid and CPR in the form of an unexpired card...The time frame of retraining is determined by the expiration date shown on the card or 24 months whichever occurs first. The hiring person has to be current in First Aid and CPR certification..." 2. A review of E1's personnel record revealed documentation of CPR and First Aid training certification. However, the certification card on record listed an expiration date of April 15, 2023. No documentation of current CPR and first aid training for E1 was available for review. 3. In an interview, E1 reported E1 would check for updated documentation. However, E1 reported E1 was unable to locate updated documentation. E1 acknowledged E1's personnel record did not contain documentation of current CPR and first aid training.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed no documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant. 2. In an interview, E1 acknowledged documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individuals required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant was not submitted by R1.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed three oxygen cylinders in the closet of R1's bedroom. The three cylinders were stored in an upright position, and one of the cylinders was secured in a portable oxygen cylinder cart. However, the other two oxygen cylinders were not secured. 2. During an interview, E1 acknowledged two of the oxygen cylinders in R1's closet were unsecured.