Carefree Manor 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. Arizona Revised Statutes (A.R.S.) \'a7 36-420.01. states: "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." 2. A review of facility policies and procedures revealed a policy titled "Fall Prevention" which stated, "All our residents upon admission will be assessed to minimize their risk of falling. These assessments will be documented in the service plan of such resident. Facility personnel will work to actively reduce the risk of falls by ensuring a safe physical environment and appropriate identification of at risk residents." However the policy did not include any documentation indicating a training program for fall prevention and fall recovery was developed. 3. A review of E1's personnel record revealed no documentation to indicate E1 received any training in fall prevention and fall recovery. 4. A review of E2's, E3's, and E4's personnel records revealed E2, E3, and E4 completed a two hour continued education unit in "Fall Prevention and Recovery" on April 24, 2023. 5. In an interview, E2 reported E2 was unaware of the statute. E2 acknowledged the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery.

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 one of three residents sampled. Findings include: 1. A review of R3's medical record revealed a service plan dated June 2, 2023 for directed care services. The service plan indicated R3 received medication administration. R3's medical record also revealed a medication order, dated August 27, 2023, for "busPIRone 5 mg (milligrams) Tab, 1 tablet orally 2 times per day." 2. Further review of R3's medical record revealed a medication administration record (MAR) for June 2023. R3's MAR indicated R3 received administration of "Buspirone HCl 5 mg" at 5:00 PM from June 1-21, 2023. However, the line for documenting administration of the medication at 8:00 AM was blank for R3's June 2023 MAR. No additional documentation indicating R3 received the medication two times per day as ordered was available for review. 3. In a joint interview, E2 and E4 reported E4 had administered "Buspirone" twice a day as ordered. E4 reported E4 forgot to document the administration of the first dose in June 2023. E2 and E4 acknowledged administration of medication to R3 in June 2023 was not documented in R3's medical record. This is a repeat citation from the previous on-site compliance inspection conducted on June 8, 2022.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of three caregivers sampled. Findings include: 1. The Compliance Officer observed E4 working on the premises and interacting with residents when the Compliance Officer arrived. E4 was the only staff member working in the facility's lower unit for the duration of the inspection. The Compliance Officer also observed E4 was the only personnel signing off on activities of daily living logs (ADLs) for the four residents living in the facility's lower unit. 2. A review of facility policies and procedures revealed a policy titled "Employees and Volunteers qualifications" which stated, "The hiring person or manager will ensure, check and document that each caregiver or assistant caregiver providing physical health services or behavioral health services have the required skills and knowledge before providing any services." 3. A review of E4's personnel record revealed E4 was hired as a caregiver. However, documentation of E4's qualifications, including skills and knowledge applicable to E4's job duties as a caregiver, were not available for review. 4. In an interview, E2 reported E4 had worked as a caregiver at the facility several times since 2015, so E2 knew E4 had the skills and knowledge required to perform E4's job duties as a caregiver. E2 acknowledged E4's personnel record did not contain documentation of E4's qualifications, including skills and knowledge.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for one of four personnel records sampled. Findings include: 1. A.R.S. \'a7 36-411(C) states: "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, nursing care institution or home health agency..." 2. A review of facility policies and procedures revealed a policy titled "Employees and Volunteers qualifications" which stated, "Employment Requirements: 4. Work experience and references (at least two work related and two personal references)...The hiring individual will check and document fingerprinting requirements for each employee...contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution." 3. A review of E4's personnel record revealed no documented good faith efforts to contact previous employers to obtain information or recommendations relevant to E4's fitness to work in a residential care institution. 4. In an interview, E2 reported E4 had worked as a caregiver at the facility several times since 2015, so E2 did not believe E2 needed to contact E4's other previous employers. E2 acknowledged E4's record contained no documentation of efforts to contact E4's previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution.

Based on record review and interview, the manager failed to ensure within 90 calendar days before or at the time of acceptance of an individual, the individual submitted documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services. However, R1's medical record contained no documentation to indicate whether R1 required continuous medical services, continuous nursing services, intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E2 acknowledged the medical record for R1 did not contain documentation to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant within 90 calendar days before or when R1 was accepted by the facility.

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 three residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan dated April 19, 2023 for directed care services. However, the service plan did not include a signature and date from the resident or resident's representative. 2. In an interview, E2 acknowledged R1's written service plans did not include a signature and date from the resident or resident's representative.

Based on record review, observation, and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated April 19, 2023 for directed care services. The service plan stated the following services were to be provided for R1: "Complete Bath 2 X week...Bathing: CG assist, Summary level of assistance needed: Max." 2. Further review of R1's medical record revealed documents titled "Activities of Daily Living Chart" (ADL) for May, 2023. R1's May 2023 ADL included a line which stated, "Bath: Full(F)/Partial(P)/BedBath(B)." R1's May ADL indicated R1 received assistance with "BedBath (B)" every day in May 2023. However no documentation indicating R1 received a complete bath two times per week as specified in R1's service plan was available for review. 3. In an interview, R1 reported facility caregivers provided R1 with a basic sponge bath "most mornings." However, R1 reported R1 had not received assistance with a full bath in May or June, 2023 as R1 was unable to get out of bed. 4. In an interview, E2 reported caregivers provided R1 with a bed bath every morning, but acknowledged R1 had not received a complete bath twice a week in May 2023. E2 reported caregivers could not give R1 a complete bath as R1 was bed bound. E2 reported when R1's service plan was created, it was expected R1 would recover quickly. However, E2 acknowledged R1 was not provided with all the assisted living services listed in R1's service plan. 5. A review of R2's medical record revealed a service plan created on June 9, 2022, and updated on December 2, 2022, and June 2, 2023, for personal care services. R2's service plan indicated R2 was to receive assistance with "foot care, daily &/or PRN." 6. The Compliance Officer observed R2's toenails were long, brown and cracking. R2's feet appeared dry and the skin on R2's toes was cracking. The Compliance Officer observed a large growth beneath R2's left big toenail. The toenail on R2's left big toe was protruding upward beneath the growth. 7. In an interview, R2 reported R2 used to receive foot care from a podiatrist who visited every month. However, R2 reported R2 had not received a visit from the podiatrist in "several months." 8. In an interview, E4 reported R2 received a monthly visit from a podiatrist. However, E4 reported R2's podiatrist had not come to the facility in May or June, 2023. E4 reported E4 had called the podiatrist "several times" but had not heard back. E4 acknowledged "foot care" as needed was not provided to R2 in May or June, 2023.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated April 19, 2023 for directed care services. The service plan stated the following services were to be provided for R1: -"Oral Care, Max CG Assist ...Brush teeth Daily &/or PRN"; -"Skin Care, Max CG Assist ...Apply lotions and creams to maintain skin integrity, thin/frail skin"; and -"Nutrition/Hydration: Fluids encourage 6 to 8 glasses per day." 2. Further review R1's medical record revealed an activities of daily living (ADL) log dated May 2023. R1's May 2023 ADL included lines titled, "Oral Care", "Skin Condition Check", and "Fluid Intake." However, the ADL revealed no documentation indicating the aforementioned services were provided to R1 in May 2023. 3. In an interview, E2 reported caregivers provided all of the aforementioned services indicated in R1's service plan. However, E2 acknowledged the services provided to R1 were not documented in R1's medical record. 4. A review of R3's medical record revealed a service plan dated March 3, 2023 for personal care services. The service plan stated the following services were to be provided for R3: "Nail Care, Max CG assist...Cleans nails prn, Clip Nails." 5. Further review of R3's medical record revealed ADLs for May and June, 2023. R3's May and June 2023 ADLs included no documentation indicating the aforementioned services were provided to R3 in May or June, 2023. 6. In an interview, E4 reported R3's nails were cleaned every day in May 2023. E4 also reported E4 clipped R3's nails "a few times" in May and June, 2023. E4 acknowledged the services provided to R3 were not documented in R3's medical record.

Based on documentation review, 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 vaccinations for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for two of three residents sampled. Findings include: 1. A.R.S. \'a7 36-406(1) states: "The department shall...(d) 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." 2. A review of R2's medical record revealed documentation indicating R2 was notified of the availability of vaccination for flu and pneumonia on October 20, 2021. However, no documentation to indicate R2 was notified of the availability of influenza and pneumonia vaccinations after October 20, 2021 was available for review. 3. 2. A review of R3's medical record revealed documentation indicating R3 was notified of the availability of vaccination for flu and pneumonia on October 20, 2021. However, no documentation to indicate R3 was notified of the availability of influenza and pneumonia vaccinations after October 20, 2021 was available for review. 4. In an interview, E2 reported E2 believed R2 and R3 were notified of the availability of the vaccinations for influenza and pneumonia in 2022. However, E2 acknowledged documentation of this notification was not available in R2's or R3's medical records.

Based on observation, record review, and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2), for one of one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A.A.C. R9-10-814(B)(2)(b) states: "The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility;" 2. During the environmental inspection of the facility, the Compliance Officer observed R1 lying in R1's bed. 3. A review of R1's medical record revealed a current service plan for directed care services. R1's service plan stated, "Transfer assistance, Bed Bound...1-2 persons assist for transfers and ambulation." 4. A review of R1's medical record revealed documentation meeting the requirements in R9-10-814(B)(2), dated upon R2's acceptance to the facility, was unavailable for review. 5. In an interview, E2 reported when R1 was admitted to the facility, it was expected R1 would recover quickly. However, E2 acknowledged documentation to demonstrate the requirements in R9-10-814(B)(2) were met for R1 was not available for review.

Based on documentation review, record review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R1's and R3's medical records revealed service plans indicating R1 and R3 received directed care services. 3. During the environmental inspection of the facility's upper unit, the Compliance Officer observed a sliding door leading from the dining area to the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the back yard of the upper unit allowed residents to be at least 30 feet away from the facility. The Compliance Officer observed an unlocked gate in the southeast corner of the back yard, which opened to the front yard. The Compliance Officer also observed a swimming pool which was accessible through an open gate in the back yard. 4. During the environmental inspection of the facility's lower unit, the Compliance Officer observed a sliding door leading from the facility's living room into the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the back yard of the lower unit allowed residents to be at least 30 feet away from the facility. 5. In an interview, E2 acknowledged the devices to alert employees of the egress of a resident from the facility to the outside area through the back doors of the upper and lower units were not in working order. E2 also acknowledged the gate in the back yard of the facility's upper unit did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan created on June 9, 2022, and updated on December 2, 2022, and June 2, 2023, for personal care services. The service plan indicated R2 received medication administration. R2's medical record also contained a medication order dated April 12, 2023 for "NIFEdipine ER Tab ER 24hr 90 mg (milligrams) sig: TAKE 1 TABLET BY MOUTH ONCE DAILY." 2. Further review of R2's medical record revealed medication administration records (MARs) for May and June, 2023. R2's May 2023 MAR contained a row which indicated "NIFEdipine ER 24 hr 30 MG" was administered to R2 at 8:00 AM on May 1-31, 2023. R2's June 2023 MAR contained a row which indicated "NIFEdipine ER 24 hr 60 MG" was administered to R2 at 8:00 AM on June 1-22, 2023. 3. The Compliance Officer observed a basket containing R2's medications. The Compliance Officer observed a pharmacy prepared multi-dose package of "Nifedipine ER 60 MG tablets." The label on the package stated, "Take 1 tablet by mouth once daily." The package originally contained 28 tablets, and 20 tablets were removed from the package. The fill date and other details on the package appeared to have been scratched off. 4. In an interview, E2 reported the documentation in R2's May and June MARs accurately represented the dosages of "Nifedipine" R2 received. E2 reported the facility was waiting on the order for "Nifedipine 90 MG" to arrive at the facility, and was using the rest of the lower dosage orders in the meantime. E2 reported E2 did not know why the details on the pharmacy prepared multi-dose package of "Nifedipine ER 60 MG" tablets was scratched off. E2 acknowledged R2 was not administered "Nifedipine ER Tab 90 mg" in compliance with the most recent medication order in R2's medical record.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a food menu dated May 21-27, 2023 was conspicuously posted in the facility's lower unit. The Compliance Officer observed no food menu was conspicuously posted in the facility's upper unit. The Compliance Officer observed neither unit had a current food menu conspicuously posted. 2. A review of facility documentation revealed a document titled "Weekly Menu" dated June 18-24, 2023. However, the menu was inside a binder and was not conspicuously displayed. 3. In an interview, E2 reported E2 planned to post the current food menu later in the day. E2 acknowledged the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served.

Based on observation and interview, the manager failed to ensure food was stored in a way to protect from potential contamination. Findings include: 1. During the environmental inspection of the facility's lower unit, the Compliance Officer observed an uncovered pot on the kitchen stove containing what appeared to be mashed up hard boiled eggs. The Compliance Officer also observed an uncovered pan containing what appeared to be macaroni and cheese. 2. In an interview, R2 reported R2 was not served macaroni, or any sort of "cheesy casserole" for breakfast the morning of the inspection. R2 reported R2 believed R2 ate some hard boiled eggs for breakfast. 3. In an interview, E4 reported the pot containaing eggs was left over from breakfast the morning of the inspection. E4 reported the pan contained a casserole which E4 also served for breakfast. E4 reported E4 had not yet had the time to clean up or cover the leftover food. E4 acknowledged the foods were not stored in a way to protect from potential contamination.

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. Findings include: 1. A review of facility documentation revealed a staffing schedule with the following two shifts: -1st Shift, 7:00 AM-7:00 PM; and -2nd Shift, 7:00 PM-7:00 AM. 2. A review of facility documentation revealed disaster drills were conducted on the following dates and times: -February 11, 2022 at 7:10 AM and 9:30 PM; -February 12, 2022 at 10:00 AM; -May 27, 2022 at 8:00 PM; -May 31, 2022 at 1:15 PM and 7:30 PM; -August 7, 2022 at 4:30 (AM/PM not specified); -August 30, 2022 at 7:00 PM; -November 20, 2022 at 11:00 AM; -November 22, 2022 at 7:00 PM and 1:00 AM; and -November 26, 2022 at 9:30 AM. However, documentation indicating disaster drills were conducted on each shift at least once every three months was not available for review. 3. In an interview, E2 reported the facility had scheduled disaster drills in 2023, but forgot to conduct them. E2 acknowledged a disaster drill was not conducted on each shift at least once every three months. This is a repeat citation from the previous on-site compliance inspection conducted on June 8, 2022.

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. Findings include: 1. A review of facility documentation revealed the most recent documented evacuation drill was conducted at 2:45 PM on November 26, 2022. No documentation of an evacuation drill conducted after November 26, 2022 was available for review. 2. In an interview, E2 reported the facility had scheduled an evacuation drill for May 2023, but forgot to conduct it. E2 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed five oxygen cylinders near the side entrance to the facility's garage. The oxygen cylinders were in an upright position, but were not secured. 2. During an interview, E3 reported E3 believed the cylinders were empty and did not know they needed to be secured. E3 acknowledged the five oxygen cylinders in the garage were not secured.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. Findings include: 1. The Compliance Officer observed four ambulatory residents on the premises. 2. During th environmental inspection of the facility, the Compliance Officer observed a bottle of "Leslie's Cartridge Cleaner", a bottle of "Jacuzzi Spa All Purpose Cleaner", a bottle of "Jacuzzi pH UP", a bottle of "Clorox Spa All-In One Sanitizer & Shock," and other assorted pool and spa cleaning products, sitting out on a table on the back patio of the facility's upper unit. The Compliance Officer observed the table was close to the sliding glass door leading from the facility's dining area to the patio. The Compliance Officer also observed a jug of "Fabuloso" multipurpose cleaner, and a jug of "Ultra Joy Lemon Scent Dishwashing Liquid" in an unlocked cabinet under the kitchen sink in the facility's lower unit. The Compliance Officer observed the cabinet door under the sink had a lock, however the locking mechanism on the right door of the cabinet appeared to be broken. 3. In an interview, E2 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use. Findings include: 1. The Compliance Officer observed a swimming pool in the back yard of the facility's upper unit. The Compliance Officer observed the swimming pool was enclosed by a fence with a latching gate. However, the gate to the pool was open during the environmental inspection. The Compliance Officer observed no lock for the pool gate. 2. In an interview, E3 reported the lock for the swimming pool gate must have gotten "misplaced" while E3 was cleaning the back yard. E3 reported the pool was not in use, and the pool gate is usually locked. However, E3 acknowledged the swimming pool gate was not closed or locked at the time of inspection.