Arcadia Woods Assisted Living LLC

Based on record review and interview, the manager failed to ensure a resident had a written service plan that accurately included the amount, type, and frequency of assisted living services being provided to the resident, for three of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated May 17, 2024. R1's service plan stated R1 required assistance grooming and dressing daily. However, R1's service plan did not state the amount of services R1 was expected to receive. 2. A review of R2's medical record revealed a service plan dated July 5, 2024. R2's service plan stated R2 required assistance grooming and dressing daily. However, R2's service plan did not state the amount of services R2 was expected to receive. 3. A review of R3's medical record revealed a service plan dated July 22, 2024. R3's service plan stated R3 required assistance grooming and dressing daily. However, R3's service plan did not state the amount of services R3 was expected to receive. 4. In an interview, E1 acknowledged R1's, R2's, and R3's service plans did not reflect the amount of services R1, R2, and R3 were expected to receive.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a facility tour with E2, one of three patio doors leading to the backyard, did not have a alarm, alert, or control to notify an employee of a resident's egress from the facility. 3. In an interview, E2 acknowledged one of three patio doors did not alert employees of the egress of a resident from the facility at the time of inspection.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During the environmental inspection of the facility, the compliance officer observed R4 in a geriatric chair with an attached table. R4 was observed being wheeled to and from the kitchen area, and out of R4's bedroom while in the geriatric chair. . In an interview, E2 reported R4 could not get out of the chair unless the tray was removed. E2 reported R4 was ambulatory and could not remove the tray without staff's assistance. E2 reported could only walk around with staff supervision, and would speak with R4's family regarding another solution to monitor R4's whereabouts in the facility.

Based on record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for four of four sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E1's, E2's, E3's and E4's personnel records revealed documentation of freedom from infectious tuberculosis. However, documentation of a baseline symptom screening was not available for review. 2. In an interview, E3 acknowledged E1's, E2's, E3's, and E4's personnel records did not include all required documentation of evidence of freedom from TB.

Based on documentation review, record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. The deficient practice posed a health and safety risk as services could not be verified as provided against a service plan. Findings include: 1. A review of facility documentation revealed a policy titled "Provision of Services." The policy stated "A manager shall ensure that a caregiver or assistant caregiver provides a resident with the assisted living services in the resident's service plan; Documents the services provided in the resident's ADL (Activities of Daily Living), MAR (Medication Administration Record) or Service Notes..." 2. A review of R1's medical record revealed a service plan. The service plan indicated R1 required assurance checks daily and nightly every 30 minutes. However, documentation of assurance checks completed every 30 minutes for R1 was not available for review. 3. In an interview, E3 acknowledged R1's medical record did not include documentation of "assurance checks" provided to R1. This is a repeat citation from the compliance and complaint inspection conducted on August 11, 2023.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan dated July 19, 2022. The service plan did not indicate the level of service R2 was expected to receive. 2. In a joint interview E1, E3, and E4 acknowledged R2's service plan did not indicate the level of service R2 was expected to receive.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the signature and date from the resident or resident's representative, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed with assistance from the resident or resident's representative to articulate decisions and agreements. Findings include: 1. A review of R2's medical record revealed a service plan dated July 19, 2022. The service plan did not include a signature from R2 or R2's representative. 2. In a joint interview, E1, E3, and E4 acknowledged R2's service plan did not include a signature from R2 or R2's representative.

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 provided could not be verified against the service plans. Findings include: 1. A review of R2's medical record revealed a service plan dated July 19, 2022. The service plan stated the following service was to be provided to R2: "Required scheduled showers Tuesday and Saturday, 2x a week" and "requires full assist from caregivers with showers". 2. A review of R2's medical record revealed an activities of daily living (ADL) log for July 2023. However, R2's July 2023 ADL log did not indicate the aforementioned service was provided to R2 on July 21-31, 2023. 3. In an interview, E1 reported R2 received showers twice weekly but the caregivers forgot to document the service as provided on July 21-31, 2023.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R2's medical record revealed documentation of notification of the resident of the availability of vaccination for influenza and pneumonia in July 2022. However, the medical record did not contain current documentation of notification of the resident of the availability of vaccination for influenza and pneumonia. 2. In a joint interview, E1, E3, and E4 acknowledged R2's medical record did not contain current documentation of notification of the resident of the availability of vaccination for influenza and pneumonia.