Avista Sun City West Memory Care

Based on record review and interview, the manager failed to ensure that a manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of five personnel sampled. Findings include: 1 . A review of E1's personnel record revealed documentation of a negative TB blood test. However, documentation of a completed risk assessment and signs and symptom screening was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure if an assisted living facility maintained residents’ medical records electronically, that safeguards exist to prevent unauthorized access. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a laptop on top of a medication cart in building C. The screen for the Medication Administration Record (MARs) was hidden from view. However, there was a second tab open that allowed the Compliance Officers to access resident medical records. This was also observed in buildings A and B. 2 . In an exit interview, the finding was discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of facility documentation revealed documentation of a fire inspection conducted by the local fire department on June 12, 2023. However, documentation of a fire inspection conducted by the local fire department before June 12, 2024 was not available for review at the time of inspection. 2. In an interview, E1 acknowledged a fire inspection was not conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of four employees reviewed, which required an employee to have a valid fingerprint card or submitted an application for a fingerprint card no more than 20 working days after the date of hire. 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 licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of November 22, 2023. The personnel record revealed no documentation of a fingerprint clearance card. However, a document printed from the Department of Public Safety's (DPS) website was available that showed an application was submitted to DPS dated November 20, 2023. The document showed the fingerprint clearance card was "In Process". 3. Review of E6's personnel record revealed E6 worked as an assistant caregiver and had a hire date of November 30, 2023. The personnel record revealed no documentation of a fingerprint clearance card. However, a document printed from the DPS website was available that showed an application was submitted to DPS dated January 16, 2024. The document showed the fingerprint clearance card was "In Process". 4. In an interview, O1, a DPS representative, reported a fingerprint application was received for E4 and E6, however E4's and E6's actual rolled fingerprints were not submitted. 5. In an interview, E1 and E2 acknowledged a fingerprint clearance card was not available for E4 and E6.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for two of four caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency and the Department was provided false and misleading information. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Maintaining Employee Records" that stated "Each employee or volunteer file will contain the following employment requirements:...3. Documentation of:...e. CPR training f. First Aid training..." 2. Review of the personnel records revealed the following: -E3's personnel record revealed E3 worked as a caregiver and had a hire date of May 2, 2023. The personnel record revealed a first aid card issued November 6, 2022 and a CPR card issued June 17, 2022. (This employee personnel record was reviewed during the compliant investigation conducted December 26, 2023. At that time, E3's personnel record included a CPR card from www.NationalCPRFoundation.com that was issued on September 19, 2023 and no other CPR training was available in the personnel record.) -E6's personnel record revealed E6 worked as an assistant caregiver and had a hire date of November 30, 2023. The personnel record revealed a first aid card issued November 6, 2022 and a CPR card issued June 17, 2022. -E3's and E6's first aid cards and CPR cards appeared falsified as they were not original, exactly the same (with the exception of the individuals name that was handwritten), and were photocopied. No additional documentation of first aid and CPR training was available for review. 3. Review of the January 2024 personnel schedule revealed the following: -E3 worked the 2pm-10:30pm shift January 3rd-5th and 10th, 11th, and 13th and the 10pm-6:30am shift January 3rd, 4th, 10th, 11th, and 13th. -E6 worked the 6am-2:30pm shift January 7th, the 2pm-10:30pm shift January 1st-4th, 7th-9th, and 11th, and the 10pm-6:30am shift January 13th. 4. In an interview, E1 and E2 acknowledged E3's and E6's first aid cards and CPR cards appeared falsified and current first aid and CPR training was not available. 5. This is an uncorrected deficiency from the complaint investigation conducted December 26, 2023.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a progress note dated December 25, 2023. This progress note stated "...resident was given (R2's) morning meds when resident stated (R2) was not feeling well then went unresponsive. Time resident was sent to the hospital: 9am ..." However, documentation was not available that showed R2's primary care provider was notified of this incident. 2. In an interview, E1 and E2 acknowledged R2's medical record did not include documentation that showed a caregiver immediately notified the resident's primary care provider. 3. This is an uncorrected deficiency from the complaint investigation conducted December 19, 2023.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a progress note dated December 25, 2023. This progress note stated "...resident was given (R2's) morning meds when resident stated (R2) was not feeling well then went unresponsive. Time resident was sent to the hospital: 9am ..." However, the documentation did not include any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 and E2 acknowledged R2's medical record did not include documentation of any action taken to prevent the incident from occurring in the future. 3. This is an uncorrected deficiency from the complaint investigations conducted December 19, 2023, and December 26, 2023.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services. The deficient practice posed a health and safety risk if the employee did not know how to properly perform CPR. Findings include: 1. Review of E2 's (hired May 2023) personnel record revealed a CPR card that was obtained from www.NationalCPRFoundation.com, which was an online course. E2's CPR online certificate was issued on September 19, 2023. There was no other current documentation of CPR training available for review that would document that E2 had attended an approved CPR training course that included hands on demonstration of the employee's ability to perform CPR. 2. The compliance officer contacted a representative from NationalCPRFoundation who stated "Our courses are online only." 3. During an interview, E1 and E2 acknowledged E2 did not have current documentation of CPR training that included hands on demonstration ability to perform CPR.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a progress note dated December 4, 2023 and December 6, 2023. The progress note for December 4, 2023 revealed 911 was called for "physically aggressive attempted to strike at caregiver". E1 reported 911 was called and transported R1 to the hospital and R1 was discharged returned to the facility the same day. The December 6, 2023 progress note revealed R1 assaulted R2. Documentation was not available that showed any action taken to prevent the incidents from occurring in the future. 2. In an interview, E1 and E2 acknowledged R1's medical record did not include documentation of any action taken to prevent the incidents from occurring in the future. This is an uncorrected deficiency from the complaint investigation conducted on December 19, 2023.

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 five 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 R1's medical record revealed a current written service plan dated December 11, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated April 11, 2023. These medication orders stated the following: "Lisinopril Tablet 10mg Give 1 tablet by mouth one time a day Hold for BP [Blood Pressure] SBP [Systolic Blood Pressure] below 110 Diastolic below 60" "Midodrine HCL Tablet 10mg Give 1 tablet by mouth every 8 hours as needed for Systolic blood pressure less than 110" 3. Review of R1's medical record revealed a December 2023 medication administration record (MAR). This MAR stated the following: "Lisinopril Tablet 10mg Give 1 tablet by mouth one time a day Hold for BP SBP below 110 Diastolic below 60" and indicated the following: -R1's SBP was recorded below 110 at 8am on December 4th, 5th, 10th, 11th, and 12th. -R1's Diastolic blood pressure was recorded below 60 at 8am on December 4th. "Midodrine HCL Tablet 10mg Give 1 tablet by mouth every 8 hours as needed for Systolic blood pressure less than 110" and indicated the following: -R1's SBP was recorded less than 110 at 8am on December 4th, 5th, 10th, 11th, and 12th. However, the MAR did not indicated the medication was administered. 4. During an observation of R1's medications, the following was observed: Lisinopril 10mg was not available. Midodrine HCL 10mg was available. 5. In an interview, E2 reported Lisinopril had been not available since November 12, 2023. E1 and E2 acknowledged the medications were not administered in compliance with the available medication orders.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of five residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R3's medical record revealed a current written service plan dated December 9, 2023. This service plan indicated R3 received medication administration. 2. Review of R3's medical record revealed signed medication orders dated April 11, 2023. These medication orders stated the following: "Atorvastatin 80mg Tablet Give 1 tablet orally one time a day" "Donepezil HCL 5mg Tablet Give 1 tablet orally one time a day" "Gabapentin 600mg Tablet Give 1 tablet orally three times a day" "Glipizide ER 5mg Tablet Give 1 tablet orally one time a day" "Levothyroxine 50mcg Tablet Give 1 tablet orally one time a day" "Pantoprazole DR 40mg Tab Give 1 tablet orally one time a day" "Tamsulosin HCL 0.4mg capsule Give 1 capsule orally one time a day" 3. Review of R3's medical record revealed a December 2023 medication administration record (MAR). This MAR stated the following: "Atorvastatin 80mg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8pm December 8th - present. "Donepezil HCL 5mg Tablet Give 1 tablet rally one time a day" however, did not include documentation the medication was administered at 8pm December 8th - present. "Gabapentin 600mg Tablet Give 1 tablet orally three times a day" however, did not include documentation the medication was administered at 9am December 9th - present and at 2pm and 8pm December 8th - present. "Glipizide ER 5mg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8am December 9th - present. "Levothyroxine 50mcg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 6am December 9th - present. "Pantoprazole DR 40mg Tab Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8am December 9th - present. "Tamsulosin HCL 0.4mg capsule Give 1 capsule orally one time a day" however, did not include documentation the medication was administered at 5pm December 8th - present. 4. During an observation of R3's medications, the following was observed: Atorvastatin 80mg was available. Donepezil HCL 5mg was available. Gabapentin 600mg was available. Glipizide ER 5mg was available. Levothyroxine 50mcg was available. Pantoprazole DR 40mg was available. Tamsulosin HCL 0.4mg was available. 5. In an interview, E2 reported the medications were administered per the medication orders and E1 and E2 acknowledged R3's medical record did not include documentation the medications were administered.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one resident reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a progress note dated December 11, 2023 at 02:01. This progress note stated "...Resident fell out of bed due to low blood sugar...Did the Resident require EMS due to any injuries or pain: yes...Was the Medical Practitioner notified...Will be contacting Doctor in the AM..." Documentation was not available that showed R4's primary care provider was immediately notified of this incident. 2. In an interview, E1 and E2 acknowledged R4's medical record did not include documentation that showed a caregiver immediately notified the resident's primary care provider of the incident.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a progress note dated December 11, 2023 at 02:01. This progress note stated "...Resident fell out of bed due to low blood sugar...Did the Resident require EMS due to any injuries or pain: yes..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 and E2 acknowledged R4's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.

Based on observation, documentation review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed O1 was no longer the manager of AL10432 on April 5, 2022. 2. The Compliance Officer observed E1's license, issued by the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), posted on the premises and was issued on November 12, 2008. 3. A review of E1's (hired in 2022) personnel record revealed E1 was hired as the licensed manager. However, documentation the Department was notified when there was a change in the manager was not available for review. 4. In an interview, E1 acknowledged the governing authority did not notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of E1's (hired in 2022) personnel record revealed E1 was hired as the licensed manager. However, documentation the Department was notified when there was a change in the manager was not available for review. 2. A review of E5's (hired in March 2023) personnel record revealed E5 a valid fingerprint clearance card in compliance with A.R.S. \'a7 36-411(A) was not available for review. 3. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed residency agreements. However, the residency agreements stated, "The Community may terminate this agreement as follows after providing 14 days written notice to Resident or Resident's responsible party if any of the following exist: a. Nonpayment of fees, charges, or deposits; b. The resident requires continuous medical services, nursing services (unless the community complies with A.R.S. \'a7 36-401(C), or behavioral health services; c. The assisted living services needed by the resident are not within the assisted living Community's scope of services; d. The assisted living community does not have the ability to provide the assisted living services needed by the resident; or e. The resident requires restraints, including the use of bedrails." However, the residency agreements did not include the correct provisions for an assisted living facility to terminate residency with a fourteen-day written notice. 4. A review of R1's medical record revealed a service plan for directed care services dated in February 2023. R1's service plan revealed R1 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R1 on multiple dates and shifts were not available for review. 5. A review of R2's medical record revealed a service plan for directed care services dated in April 2023. R2's service plan revealed R2 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R2 on multiple dates and shifts were not available for review. 6. A review of R3's medical record revealed a service plan for directed care services dated in March 2023. R3's service plan revealed R3 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R3 on multiple dates and shifts were not available for review. 7. A review of R4's medical record revealed a service plan for directed care services dated in February 2023. R4's service plan revealed R4 required assistance with activities of daily living. However, documentation to indicate activities of daily living were provided to R4 on multiple dates and shifts

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(A), for one of nine employees sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A.R.S. \'a7 36-411(A) states A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. 2. A review of facility documentation revealed a staffing schedule from April 30, 2023 - May 20, 2023. The staffing schedule revealed E5 worked the following dates: - April 30, 2023 - May 1, 2023, 2:00 PM - 10:00 PM; - May 4, 2023 - May 8, 2023, 2:00 PM - 10:00 PM; and - May 11, 2023 - May 15, 2023, 2:00 PM - 10:00 PM. 3. A review of E5's (hired in March 2023) personnel record revealed E5 was hired as an assistant caregiver. However, the personnel record did not include a valid fingerprint clearance card in compliance with A.R.S. \'a7 36-411(A). 4. In an interview, E1, E2, and E3 were unaware if E5 had applied for a fingerprint clearance card. E1, E2, and E3 acknowledged E5's personnel record did not include documentation of compliance A.R.S. \'a7 36-411(A).

Based on documentation review, record review, and interview, the manager failed to ensure the facility's residency agreements contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G). The deficient practice posed a risk if the resident was not informed of the terms of residency, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. R9-10-807(C): A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails. 2. A review of the facility's policies and procedures (October 2021) revealed a policy titled "Termination and Refunds." The policy stated, "The Community may terminate the agreement after providing 14 days written notice to a resident or the responsible party for one of the following reasons: a. The individual requires continuous: i. Medical Services; ii. Nursing services, unless the assisted living community complies with A.R.S. \'a7 36-401(C); or iii. Behavioral health services; b. The assisted living services needed by the individual are not within the assisted living community's scope of services; c. The assisted living community does not have the ability to provide the assisted living services needed by the individual; or d. The individual requires restraints, including the use of bedrails." 3. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed residency agreements. However, the residency agreements stated, "The Community may terminate this agreement as follows after providing 14 days written notice to Resident or Resident's responsible party if any of the following exist: a. Nonpayment of fees, charges, or deposits; b. The resident requires continuous medical services, nursing services (unless the community complies with A.R.S. \'a7 36-401(C), or behavioral health services; c. The assisted living services needed by the resident are not within the assisted living Community's scope of services; d. The assisted living community does not have the ability to provide the assisted living services needed by the resident; or e. The resident requires restraints, including the use of bedrails." 4. In an interview, E1, E2, and E3 acknowledged R1's, R2's, R3's,

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical records, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan (dated in February 2023) for directed care services. The service plan stated the following services were to be provided to R1: - Grooming; - Safety checks; - Ambulation; - Transferring; - Dressing; - Skin maintenance; and - Incontinence care. 2. A review of R1's medical record revealed an activities of daily living (ADL) log for May 2023. The ADL revealed the following: - Grooming services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. - Safety checks were not documented as provided on May 3 - 5, 2023; May 9, 2023; May 11, 2023; May 13, 2023; and May 16, 2023, during the 6:00 AM - 2:00 PM shift. May 2, 2023, during the 2:00 PM - 10:00 PM shift. May 7, 2023, May 11, 2023, and May 14, 2023, during the 10:00 PM - 6:00 AM shift. - Ambulation services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. May 7, 2023, May 11, 2023, and May 14, 2023, during the 10:00 PM - 6:00 AM shift. - Transferring services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. May 7, 2023, May 11, 2023, and May 14, 2023, during the 10:00 PM - 6:00 AM shift. - Dressing services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. - Skin maintenance services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. May 7, 2023, May 11, 2023, and May 14, 2023, during the 10:00 PM - 6:00 AM shift. - Incontinence care services were not documented as provided on May 9, 2023, and May 13, 2023, during the 6:00 AM - 2:00 PM shift. May 7, 2023, May 11, 2023, and May 14, 2023, during the 10:00 PM - 6:00 AM shift. 3. A review of R2's medical record revealed a service plan (dated in April 2023) for directed care services. The service plan stated the following services were to be provided to R2: - Grooming; - Safety checks; - Ambulation - Transferring; - Catheter care; - Dressing; - Incontinence care; and - Skin maintenance. 4. A review of R2's medical record revealed an ADL log for May 2023. The ADL revealed the following: - Grooming services were not documented as provided on May 15, 2023, during the 6:00 AM - 2:00 PM shift. - Safety checks were not documented as provided on May 3 - 6, 2023; May 10 - 12, 2023; and May 15, 2023, during the 6:00 AM - 2:00 PM shift. May 2, 2023, during the 2:

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the facility's license was effective on September 1, 2017. 2. A review of facility documentation revealed a staffing schedule, dated May 2023. The schedule revealed the facility maintained three shifts, 6:00 AM - 2:00 PM, 2:00 PM - 10:00 PM, and 10:00 PM - 6:00 AM. 3. A review of facility documentation revealed disaster drills were completed on the following dates and times: - May 31, 2022, (no time indicated); - September 30, 2022, at 1:09 PM; - November 30, 2022, (no time indicated); and - December 29, 2022, (no time indicated). However, additional documentation of disaster drills for employees conducted on each shift at least once every three months was not available for review. 4. In an interview, E1, E2, and E3 acknowledged disaster drills for employees were not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed the facility's license was effective on September 1, 2017. 2. A review of facility documentation revealed an evacuation drill for employees and residents was completed on October 31, 2022, at 2:16 PM. However, additional documentation of evacuation drills for employees and residents conducted at least once every six months was not available for review. 3. In an interview, E1, E2, and E3 acknowledged evacuation drills for employees and residents were not conducted at least once every six months.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were stored 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. The Compliance Officer observed three separate buildings on the facility's premises. The buildings were identified as building A, building B, and building C. 2. The Compliance Officer observed one ambulatory resident in building A. 3. The Compliance Officer observed an unlocked cabinet in the kitchenette in building A. The cabinet contained an odor eliminator and two disinfectant sprays. The materials contained warning labels. 4. The Compliance Officer observed an unlocked laundry room in building A. The laundry room contained a spray bottle of cleaner with bleach in an unlocked cabinet. The spray bottle contained warning labels. 5. The Compliance Officer observed one ambulatory resident in building B. 6. The Compliance Officer observed an unlocked cabinet in the kitchenette in building B. The cabinet contained glass cleaner, super concentrated pot and pan detergent, super concentrated dish machine chlorine, super concentrated rinse aid, and super concentrated dish machine soap. The materials contained warning labels. 7. The Compliance Officer observed one ambulatory resident in building C. 8. The Compliance Officer observed an unlocked cabinet in the kitchenette in building C. The cabinet contained a spray bottle of cleaner with bleach. The bottle contained warning labels. 9. The Compliance Officer observed an unlocked laundry room in building C. The laundry room contained a spray bottle of 'Oxi Clean' in an unlocked cabinet. The spray bottle contained warning labels. 10. In an interview, E1, E2, and E3 acknowledged the poisonous or toxic materials stored by the facility were not locked and were accessible to residents.