Azalea Assisted Living LLC

Based on record review and interview, the manager failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for one of one resident sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A request for the facility's standardized emergency responder patient information form for R1, R2, R3, and R4 reveals no standardized emergency responder patient information form was available for review. 2. In an interview, E2 acknowledged the information required in A.R.S. § 36-420.04, a standardized emergency responder patient information form, was not available for review.

Based on observation, record review, and interview, the manager failed to ensure a medical record included all required information for three of three sampled residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1, R2, and R3 at the facility on the day of inspection. 2. The Compliance Officers requested the medical records for R1, R2, and R3. However, R1, R2, and R3 medical records were not available for review at the time of inspection. 3. In an interview, E2 acknowledged no medical records were available for review for R1, R2, and R3 before the end of the inspection.

Based on documentation review and interview, the manager failed to ensure policies and procedures were available to employees and volunteers of the assisted living facility. Findings include: 1. A request of facility documentation for policy and procedure manual revealed policy and procedure manual were unavailable for review. 2. In an interview, E2 acknowledged the policy and procedure manual were unavailable for review at the time of inspection.

Based on observation, documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee, which included the items required by this rule, for four of four employees sampled. The deficient practice posed a risk as required information could not be verified for an employee. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E2, E3, and E4 working at the facility on the day of inspection. 2. A request for the facility staff schedule revealed no staff schedule were available for review. 3. A request for the facility personnel records revealed no personnel records for E1, E2, E3, and E4. 4. In an interview, E2 acknowledged no personnel records were available for review for E1, E2, E3, and E4 before the end of the inspection.

Based on documentation review and interview, the manager failed to ensure documentation of monthly smoke detector tests were maintained. Findings include: 1. During the on-site inspection, the Compliance Officer requested documentation of monthly smoke detector testing. However, documentation of monthly smoke detector testing was not available for review. 2. In an interview, E2 acknowledged documentation of monthly smoke detector tests had not been provided for review.

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 health and safety risk to residents and employees, if the employees were unable to implement the evacuation plan. Findings include: 1. A request for facility documentation, evacuation drill for employees and residents, which is conducted at least once every six months, revealed no documentation was available for review. 2. In an interview, E2 acknowledged no documentation for evacuation drills for employees and residents were available for review.

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 and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A request for facility documentation, staff schedules revealed no staff schedules were available for review. However, E2 reported the facility has two shifts: 6:30 am to 7:00 pm and 7:00 pm to 6:30 am. 2. A request for facility documentation disaster drills revealed no documentation for disaster drills for the last 12 months. 3. In an interview, E2 acknowledged no documentation for disaster drills were available for review.