Aloha Assisted Living Home, LLC

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked area. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed an unlocked cabinet above the kitchen counter. The Compliance Officer observed a padlock in a nearby container on the kitchen counter. Inside the cabinet, the Compliance Officer observed shelves containing all of the residents' medications in multi-dose containers. 2. In an exit interview with E1, the findings were reviewed 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 maintained in a locked area inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet below the kitchen sink had a lock. However, the cabinet had been left unlocked and the Compliance Officer was able to access the cabinet without the key. Inside the cabinet, the Compliance Officer observed two spray bottles of glass cleaner. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two personnel members sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A review of E2's personnel record revealed E2 was hired on July 14, 2023 as a caregiver. The record included a photocopy of a fingerprint clearance card, however the card indicated an expiration date of July 29, 2023. Evidence of verification of a current, valid fingerprint clearance card was unavailable for review. Further, evidence of documentation of good faith efforts to contact previous employers to obtain information or recommendations relevant to E2's fitness to work in a health care institution was not available for review. 2. In an interview, E1 agreed E2's personnel record did not contain evidence of verification of a current fingerprint clearance card. E1 acknowledged E2's personnel record did not contain evidence of good faith efforts to contact all prior employers.

Based on observation, documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident that covered orientation, for one of two employees sampled. Findings include: 1. When the Compliance Officer arrived at the facility, E2 was observed to be the only caregiver present, and was providing assisted living services to residents. 2. A review of the facility's policies and procedures revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy stated, "8. A caregiver is required to complete all new employee orientation, ongoing education and training as identified by the manager, fire and/or evacuations drills conducted while the caregiver is on the premises, and any mandatory meetings during his/her employment with this Assisted Living Facility." 3. A review of E2's personnel record revealed E2 was hired on July 14, 2023, as a caregiver. However, evidence of documentation E2 was oriented to the facility was unavailable for review. 4. In an interview, E2 advised they work part time at the facility, for a couple of hours each shift as a back-up caregiver. 5. In an interview, E1 acknowledged E2 works at the facility as a back up caregiver. E1 agreed E2's personnel record did not contain documentation of orientation to the facility as required per policy.

Based on observation, documentation review, and interview the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, for one of two caregivers sampled. The deficient practice posed a risk if employees were unable to meet the needs of residents. Findings include: 1. When the Compliance Officer arrived at the facility, E2 was the only caregiver present. The Compliance Officer observed E2 providing physical health services to residents at the facility. 2. A review of E2's personnel record revealed E2 was hired as a caregiver on July 14, 2023. However, evidence indicating E2's skills and knowledge were verified and documented before providing physical health services was unavailable for review. 3. A review of the facility's policies and procedures, updated March 1, 2022, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy read as follows: "1. A caregiver: ...d. Demonstrates the qualification, skills, and knowledge required to provide assisted living services and/or behavioral care to a population of adults with various levels of physical, functional, and cognitive needs;" 4. In an interview, E1 agreed evidence of documentation of verification of E2's skills and knowledge was unavailable for review.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of R2's medical record revealed an order dated May 22, 2024, for "Nystatin topical 100,000 units/g cream, 1 application applied topically 2X a day for (fungal infection peri/groin area). 2. A review of R2's medical record revealed a medication administration record (MAR) used for documenting administration of medications to R2 for the month of September. However, the record did not include an area for documentation of administration of Nystatin topical 100,000 units/g cream, 1 application applied topically 2X a day. 3. In an interview, E1 acknowledged R2 received medication administration and the September 2024 MAR did not include documentation of administration of Nystatin as required.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered by an individual under direction of a medical practitioner for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical record revealed a current service plan which indicated R1 and R2 received medication administration. R1's and R2's medical record reveled a medication administration record which indicated R1 and R2 were being administered medication as prescribed. However, R1's and R2's medical record did not contain evidence of documentation of an individual authorized by a medical practitioner to administer medication under the direction of the medical practitioner. 2. A review of facility policy and procedures revealed a policy regarding medication administration which stated: "A manager will...Obtain authorization from a medical practitioner...that allows qualified caregivers...to provide medication administration and treatments ordered by the resident's medical practitioner..." 3. In an interview E1 acknowledged R1 and R2 were receiving medication as ordered, however authorization to administer medication had not been obtained from R1's or R2's medical provider.