Avalon Cares of Arizona, LLC

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 five employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. 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..." 2. Review of E5's personnel record revealed E5 worked as an assistant caregiver and had a hire date of November 4, 2023. The personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E5's fitness to work in a residential care institution. 3. In an interview, E1 acknowledged documentation was not available that showed E5's work references were obtained upon hire at the facility. 4. Technical assistance was provided on this Rule during the compliance inspection conducted December 8, 2022.

Based on record review, documentation review, 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. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of September 1, 2021. 2. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of July 23, 2022. 3. Review of the November 2023 personnel schedule revealed E4 worked the 7pm - 7am shift alone November 4th - 7th. 4. In an interview, E3 reported E3 worked the 7pm - 7am shift with E4. E1 and E3 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by E3.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for one of one resident reviewed who required behavioral care. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. Review of R2's medical record revealed a service plan dated September 29, 2023. This service plan revealed R2 had a diagnosis of Alzheimer's, Dementia, Schizophrenia, Anxiety Disorder, and Bipolar. In addition, the medical record revealed R2 had a behavioral health professional and received administration of psychotropic medications including Haldol, Trazodone, Olanzapine, and Divalproex. However, R2's written service plan did not include the following required components: -the psychosocial interactions or behaviors for which the resident required assistance; -psychotropic medications ordered for the resident; -planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and -goals for changes in the resident's psychosocial interactions or behaviors. 3. In an interview, E1 reported R2 received services from Partners in Recovery on a monthly basis. E1 reported the caregivers often redirected R2 due to loud outbursts. E1 acknowledged R2 received behavioral care and the service plan did not include the required components.

Based on documentation review, record review, and interview, the manager failed to ensure a written service plan included the signature and date from a medical practitioner or behavioral health professional, for one of one resident reviewed who received behavioral care. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. Review of R2's medical record revealed a service plan dated September 29, 2023. This service plan revealed R2 had a diagnosis of Alzheimer's, Dementia, Schizophrenia, Anxiety Disorder, and Bipolar. In addition, the medical record revealed R2 had a behavioral health professional and received administration of psychotropic medications including Haldol, Trazodone, Olanzapine, and Divalproex. However, the service plan did not include a signature and date from a medical practitioner or behavioral health professional. 3. In an interview, E1 reported R2 received services from Partners in Recovery on a monthly basis. E1 reported the caregivers often redirected R2 due to loud outbursts. E1 acknowledged the service plan did not include a signature and date from a medical practitioner or behavioral health professional.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record included the correct strength of a medication administered to one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. Review of R2's medical record revealed a current written service plan dated September 29, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated May 6, 2023. This medication order stated "Levothyroxine 100 Microgram Oral Daily in the morning". 3. Review of R2's medical record revealed a November 2023 medication administration record (MAR). This MAR stated "Levothyroxine Sodium 125mcg Give one Tab PO Everyday" and indicated one tab was administered at 7am November 1st - present. 4. During a review of R2's medications, Levothyroxine 100mcg was observed. 5. In an interview, E1 reported Levothyroxine 100mcg was administered per the medication order and acknowledged R2's MAR did not include the correct strength of the administered medication.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu), according to A.R.S. \'a7 36-406(1)(d), to one of two residents reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R1's medical record revealed R1 refused the flu vaccination July 28, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1's medical record did not include current documentation that showed the flu vaccination was offered or received.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning; strategies to ensure a resident's personal safety; and coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan, for one of one resident reviewed who received directed care services. The deficient practice posed a health risk to the resident. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated September 17, 2023. This service plan revealed no documentation of cognitive stimulation and activities to maximize functioning; strategies to ensure personal safety; and coordination of communications with R1's representative. 2. In an interview, E1 acknowledged R1's service plan did not include documentation of cognitive stimulation and activities to maximize functioning; strategies to ensure personal safety; and coordination of communications with R1's representative.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated September 29, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed signed medication orders dated May 31, 2022. These medication orders stated the following: "Olanzapine 20mg give 1 tab po Q bedtime" "Trazodone 100mg give 2 tabs po Q bedtime" "Lorazepam 5mg give 1 tab po once daily PRN x anxiety or agitation" 3. Review of R2's medical record revealed a document titled "Incident Report Form" dated April 10, 2023 at "1210ish". This document stated "Resident pulled pantry cabinet by force, lock broken. This writer redirected to (R2's) room but get more agitated...Meds given Trazodone 200mg & Olanzapine 20mg..." 4. In an interview, E1 reported Olanzapine 20mg and Trazodone 200mg were given early not at bedtime due to R2's agitation. The Compliance Officers asked why the as needed Lorazepam was not administered per the medication order and E1 reported the medication was not available. E1 acknowledged R2's medications were not administered in compliance with the medication orders. 5. This is a repeat deficiency from the compliance inspection conducted December 8, 2022.