Ahadi Care Home

Based on record review and interview, the manager failed to maintain a standardized form for each resident to be provided at the time the emergency responder (EMS) was contacted, for four of four records sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1, R2, R3 and R4's medical records revealed no standardized EMS documentation. 2. In an exit interview, the findings were reviewed with E2, E3, and E4, no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB, for three of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. A review of E1, E2, and E3's personnel records revealed no documentation of training and education related to recognizing the signs and symptoms of TB to individuals employed by or providing volunteer services for the health care institution. 3. Documentation review revealed the facility's policy on infection control, page 88. Item 3 reads, "Therefore, infection control will be practiced according to the procedures listed below. Conducting tuberculosis risk assessments, conducting tuberculosis screening testing, screening for signs or symptoms of tuberculosis, and providing training and education related to recognizing the signs and symptoms of tuberculosis, and...". 4. In an interview, findings were discussed with E2, E3 and E5, and no additional information was provided.

Based on record review, interview, and documentation review, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1, R3 and R4 medical records revelaed service plans. Each service plan outlined the services the residents required including the frequency levels for bathing (complete or partial), shampooing, oral care, nail care, shaving, combing hair, dressing, room maintenance, laundry, bladder, toileting, incontinent check, undergarments, catheter care, transfer to bed or chair, bed mobility assistance, and ambulation assistance. 2. When the Compliance Officer requested documentation of the services provided, E1, E2 and E5 reported that the documentation was in electronic format. E2 used the tablet to pull up records for the Compliance Officer to review. 3. Review of the electronic documentation for R1, R3, and R4 revealed the records were not updated and maintained in the electronic system. R3 shower logs were 60 days past due. R1's food log for the last 60 days included four meals, breakfast and lunch on September 23, breakfast on September 30 and Breakfast on October 15. R1's show log for the past 60 days did not include any documentation. 4. In an exit interview, findings were reviewed with E2, E3 and E5, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure an assisted living facility authorized to provide directed care services provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Documentation review revealed that the facility was licensed at the directed care level. 2. During an environmental inspection, the Compliance Officer observed a non-operational door alert on the sliding back door of the facility. E4 asked E2 why the door was not fixed. E2 did not respond. 3. In an exit interview, the findings were discussed with E2, E3, and E4 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked, self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection, the Compliance Officer observed the kitchen cabinet closest to the refrigerator had two locking mechanisms and both were unlocked. This cabinet stored resident medication. The magnetic keys were stored directly on the side panel of the refrigerator. 2. During an environmental inspection, the Compliance officer observed several old medication bottles in an unlocked kitchen cabinet. Some bottles had labels removed and other medications observed were prescribed for current residents. 3. In an exit interview, findings were reviewed with E2, E3 and E4, and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on April 26, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure an installed fire alarm was in working order. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During an environmental inspection, the Compliance Officer observed a fire alarm system. 2. The fire alarm panel had a service tag showing the fire alarm was last serviced in December of 2020. 3. In an exit interview, findings were reviewed with E2, E3 and E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection, the Compliance Officer observed Ajax dishwashing liquid detergent on the kitchen counter near the sink. 2. During the environmental inspection, the Compliance Officer observed the cabinet under the kitchen sink was unlocked. The cabinet contained Windex glass cleaner, Fabuloso multipurpose cleaner, Clorox spray cleaner, and Lysol spray. 3 . During the environmental inspection, the Compliance Officer observed the cabinet below the bathroom sink was unlocked and contained Lysol disinfecting wipes. 4. In an exit interview, the findings were reviewed with E2, E3, and E5 and no additional information was provided.

Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E2 and E3 were the only personnel members working at the facility. 2. During the environmental tour, the Compliance Officer observed there was a personnel work schedule posted for the month of September. However, E3 was not on the personnel work schedule posted. 3. In an interview, E4 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for two of three personnel sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E2 and E3 were fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 2. A review of E2's and E3's personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an interview, E4 acknowledged E2's and E3's, personnel records did not include the documentation required in A.R.S. \'a7 36-411(C)(1). E3 acknowledged the reference checks were not done.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of two residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services dated May 26, 2024. However, a service plan after May 26, 2024 was not available for review. 2. In an interview, E4 and E5 acknowledged R2 received directed care services and the service plan was not updated at least once every three months.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the July 2024 personnel schedule revealed three shifts; 6 AM - 6 PM and 6 PM - 6 AM. 2. A review of the facility's employee disaster drills revealed the following drills; - July 10, 2024, at 3:00 PM - June 28, 2024, at 11:50 AM - March 10, 2024, at 3:00 PM - January 10, 2024, at 3:00 PM - October 02, 2023, at 6:45 AM - September 10, 2023, at 6:46 PM - April 15, 2023, at 10:00 AM 3. In an interview, E4 and E5 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.

Based on observation, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present as the manager's designee. Findings include: 1. When the surveyor arrived at the facility, the manager was not present. The conspicuously posted assigned manager's designee list did not include E2's and E3's names who were the only caregivers working at the facility at the beginning of the inspection. Review of E2's and E3's personnel records revealed both employees were caregivers. E2 was hired on April 1, 2023 and E3 was hired on March 1, 2023. 2. In an interview, after E1, E4, and E5 arrived to the facility, they acknowledged E2 and E3 were not included on the manager's designee posted list nor any place else. This is a repeat deficiency from the compliance inspection conducted on May 2, 2022.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During a facility tour, E4 and the compliance officer observed in the facility's unlocked kitchen refrigerator in the bottom drawer of the refrigerator there was a plastic container with a rubber band around it containing flextouch insulin. Also in a ziplock bag on top of this plastic container there was stored flextouch insulin. Also an insulin flextouch pen was laying loose on top of the ziplock bag, There were twenty-one flex pens of Novolog insulin and three flex pens of Levemir insulin stored unlocked. 2. In an interview, E1 and E4 acknowledged the unlocked medications that were not stored in a self-contained unit.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in a closed container, which posed a health risk. Findings include: 1. During a facility tour, E4 and the compliance officer observed in the facility's laundry room there was a pile of soiled linen laying on the floor of the laundry room. 2. In an interview. E4 reported the linen was soiled and acknowledged it was not being stored in a closed container.