Amenity Home Assisted Living LLC

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. A review of facility documentation revealed a fall prevention and fall recovery training program was not available for review. 2. A review of E1's and E2's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported a fall prevention and fall recovery training had not been implemented. E1 reported E1 and E2 had not received initial training or continued competency training in fall prevention and fall recovery. 4. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on observation, documentation review, and interview, the manager failed to establish and document policies and procedures to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for volunteers. Findings include: 1. The Compliance Officer observed E3 answer the front door when the Compliance Officer arrived on premises. The Compliance Officer observed E3 was wearing scrubs. 2. The Compliance Officer observed a bed and personal belongings in the master bedroom closet. The Compliance Officer observed E3 sitting on a chair in the master bedroom closet. The Compliance Officer observed E3 had changed to plain clothes. 3. In an interview, E1 reported E3 was a visitor. 4. In an interview, E3 reported E3 was a visitor. 5. In an interview, R1 reported E3 had provided services to R1. 6. In an interview, R4 reported E3 had provided services to R4. 7. In an interview, E3 reported E3 changed diapers, helped with feeding, setting up and giving toothbrushes to residents, and other household tasks. 8. In an interview, E3 later reported E3 was a volunteer. E3 reported E3 was not a caregiver and does not have documentation of completion of a caregiver training program. 9. A review of the facility's policies and procedures revealed a policy and procedure to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for volunteers was not established and documented. 10. In an interview, E1 acknowledged policies and procedures were not established and documented to cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for volunteers.

Based on 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 one of two personnel records sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(C)(1) Owners shall make documented, good faith efforts to: 1. 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. 1. A review of E2's (hired in 2022) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review. 2. In an interview, E1 reported E2's previous employers were contacted but this information was not documented. 3. In an interview, E1 acknowledged E2's documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) were not available for review. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on March 30, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure a personnel record for each volunteer was maintained throughout the individual's period of providing services in or for the assisted living facility, for one of one volunteer sampled; and one of one backup caregiver. Findings include: 1. The Compliance Officer observed E3 answer the front door when the Compliance Officer arrived on premises. The Compliance Officer observed E3 was wearing scrubs. 2. The Compliance Officer observed a bed and personal belongings in the master bedroom closet. The Compliance Officer observed E3 sitting on a chair in the master bedroom closet. The Compliance Officer observed E3 had changed to plain clothes. 3. In an interview, E1 reported E3 was a visitor. 4. In an interview, E3 reported E3 was a visitor. 5. In an interview, R1 reported E3 had provided services to R1. 6. In an interview, R4 reported E3 had provided services to R4. 7. In an interview, E3 reported E3 changed diapers, helped with feeding, setting up and giving toothbrushes to residents, and other household tasks. 8. In an interview, E3 later reported E3 was a volunteer. E3 reported E3 was not a caregiver and does not have documentation of completion of a caregiver training program. 9. The Compliance Officer requested to review E3's personnel record. However, a personnel record for E3 was not provided for review. 10. In an interview, E1 reported E3 does not have a personnel record. 11. In an interview, E1 reported E1 and E2 were not working from July 29-July 31, 2023. E1 reported a backup caregiver, E4 worked when E1 and E2 were not working. E1 reported E4 worked from July 29-31, 2023. 12. In an interview, E3 reported E1 and E2 were not working during the weekend. E3 reported another caregiver worked with E3 during the weekend. 13. The Compliance Officer requested to review E4's personnel record. However, a personnel record for E4 was not provided for review. 14. In an interview, E1 acknowledged personnel records for E3 and E4 were not maintained throughout the individual's period of providing services in or for the assisted living facility.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one 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 R2's medical record revealed a service plan for personal care services (dated in May 2023). The service plan stated the following services were to be provided to R2: -"Shower ... 2 Times Weekly;" -Partial Bath On Days When Complete Bath Is Not Given;" -Oral Care Daily;" -Comb Hair Daily;" and -Incontinent Checks Every 2 Hours Change Garments And Cleanse Skin If Soiled." 2. A review of R2's medical record revealed an activities of daily living (ADL) sheet for July 2023 and August 2023. The ADL sheet revealed the aforementioned services were not documented on the following dates: -July 30-31, 2023; and -August 1, 2023. 3. In an interview, E1 reported the aforementioned services were provided to R2. E1 acknowledged a caregiver or assistant caregiver did not document the services provided in R2's medical record.

Based on record review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet resident's needs. Findings include: 1. A review of R1's (accepted in 2022) revealed a service plan for personal care services (dated in July 2023). The service plan stated " ... unfortunately can't bearly [sic] weight due hips fractured from the past." 2. A review of R1's medical record revealed documentation to include whether the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility (dated upon acceptance). The document was unclear if "Unable to direct self-care" or "Confined to a bed or chair because of the inability to ambulate even with assistance" was checked. However, current documentation to include whether the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility was not available for review. 3. In an interview, E1 reported R1 was unable to ambulate. 4. In an interview, E1 reported documentation to include whether the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility was not available for review. 5. A review of R2's (accepted in 2022) revealed a service plan for personal care services (dated in April 2023). The service plan stated "Patient can't bearly [sic] weight assist one caregiver for transfer to wheelchair." 6. A review of R2's medical record revealed a document titled "Determination For Admission" (dated upon acceptance). The document stated "Is this Person confined to a chair or bed and is unable to ambulate on their own? YES" with a checkmark next to "YES." 7. A review of R2's medical record revealed documentation to include whether the residen

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration, for two of two residents sampled who received personal care services. The deficient practice posed a risk as the service plan did not include services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services (dated in July 2023). However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. 2. A review of R2's medical record revealed a service plan for personal care services (dated in May 2023). However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services (dated in July 2023). The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication administration record (MAR) for July 2023. The MAR documented R1 received medication administration on the following dates: -July 30-31, 2023. However, the initials appeared to be different, and written in different ink, than the initials for July 1-29, 2023. 3. In an interview, E1 reported E1 and E2 were not working from July 29-July 31, 2023. E1 reported a backup caregiver, E4 worked when E1 and E2 were not working. 4. In an interview, E3 reported E1 and E2 were not working during the weekend. E3 reported another caregiver worked with E3 during the weekend. 5. In an interview, E1 reported the initials on R1's MAR for July 30-31, 2023 were E1's initials and not E4's initials. E1 reported E4 worked from July 29-31, 2023. 6. In an interview, E1 reported E1's initials on R1's MAR for July 30-31, 2023 were a mistake. 7. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings. 7. A review of R2's medical record revealed a service plan for personal care services (dated in May 2023). The service plan revealed R2 received medication administration. 8. A review of R2's medical record revealed medication orders (dated November 12, 2022) for the following medications: -"Aspirin 81 mg 1 tab PO QD;" -"Tamsulosin 0.4mg 1 cap PO QD;" -"Furosemide 20mg 1 tab PO QD;" -"Gabapentin 300mg 1 cap PO QD;" -"Colchicine 0.6mg 1 tab PO QD;" -"Pantoprazole 40mg 1 tab PO BID;" -"Memantine 10mg 1 tab PO BID;" -"Rivastigmine 1.5mg 1 cap POD BID;" and -"Simvastatin 40 mg 1 tab PO QHS." 9. A review of R2's medical record revealed a MAR for July 2023. However, R2's aforementioned medications were not documented as administered on the following dates: -July 30-31, 2023. 10. A review of R2's medical record revealed a MAR for August 2023 was not available or review. 11. In an interview, E1 reported R2 received medication administration for R2's aforementioned medications but this information was not documented. 12. In an interview, E1 acknowledged medication administered to R2 was not documented in the resident's medical record.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. The Compliance Officer observed an unlocked resident bedroom, occupied by R2. The Compliance Officer observed a medication cup containing various pills of size and color on R2's bedside table. 3. The Compliance Officer observed another unlocked resident bedroom, occupied by R3. The Compliance Officer observed one bottle of "Acetaminophen 500mg" and one bottle of "Chlorhexidine Gluconate Oral Rinse USP, 0.12%" in R3's bedroom. 4. The Compliance Officer observed one bottle of "Tylenol 500mg" in an unlocked cabinet in the kitchen. 5. The Compliance Officer observed a small refrigerator with a child safety latch. The refrigerator contained a lockable box, however, the box was not locked. The Compliance Officer observed one box of "Lorazepam Intensol Oral Concentrate USP 2mg per mL" and one box of "Morphine Sulfate Oral Solution 100mg per 5mL" in the unlocked box. 6. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation, documentation review, and interview, the administrator failed to ensure a resident bedroom was not used as a passageway to another sleeping area and common bathroom. Findings include: 1. The Compliance Officer walked through the master bedroom and then through the master bathroom to arrive at the master bedroom closet. 2. The Compliance Officer observed a bed and personal belongings in the master bedroom closet. The Compliance Officer observed E3 sitting on a chair in the master bedroom closet. 3. The Compliance Officer observed two beds in the master bedroom. The Compliance Officer observed two residents, R4 and R5, each occupying the beds in the master bedroom. 4. A review of Department documentation revealed AL10265 was licensed effective January 26, 2017. 5. In an interview, E3 reported E3 was a visitor. E3 reported the personal belongings in the master bedroom closet belonged to E1 and E1's family. 6. In an interview, E1 reported E3 was a visitor. E1 reported R4, R5, E1, E1's family, and E3 used the master bathroom. 7. In an interview, E1 acknowledged a resident bedroom was used as a passageway to another sleeping area and common bathroom.