Caring Angels Assisted Living Home

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. Findings include: 1 . A review of facility documentation revealed documentation of a policy and procedure review. However, the last time the policies and procedures were documented as reviewed was August 2021. 2 . In an interview, E1 acknowledged E1 failed to review the facility's policy and procedures every three years.

Based on observation and interview the manager failed to ensure poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the kitchen sink. The cabinet had magnetic locks. However, the magnetic locks were disengaged and the following chemicals were located in the cabinet: -A bottle of "Windex" glass cleaner; -A bottle of "Easy-off" cleaner and degreaser; -A bottle of "Pet Pro" stain destroyer; -A can of "Eliminator" wasp and hornet killer; and -A bottle of "Clorox" disinfecting mist. 2 . In an interview, E1 acknowledged the cabinets under the kitchen sink were not locked and inaccessible to residents.

Based on documentation review, observation, and interview, the manager failed to ensure a dog was licensed with Maricopa County. The deficient posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. Review of the Maricopa County Animal Care and Control website stated "all dogs three months of age and older are required to have a license..." 2. During an environmental inspection of the facility with E1, O1 was observed. 3. Review of O1's record revealed O1 was over three months of age. However, documentation of a license with Maricopa County was not available. 4. In an interview, E1 acknowledged documentation was not available showing O1 had a current Maricopa County license.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. In an interview, E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 3. Technical assistance was provided on this Rule during the compliance inspection conducted September 20, 2022.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for two of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed current written service plans for personal care services dated January 13, 2023 and July 23, 2023. However, these service plans did not include a signature and date from the resident or representative. 2. Review of R2's medical record revealed current written service plans for personal care services dated August 9, 2022, January 13, 2023, and July 23, 2023. However, these service plans did not include a signature and date from the resident or representative. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include a signature and date from the resident or representative.

Based on documentation review, observation, and interview, the manager failed to ensure there was a 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, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed exit doors on the north, east, south, and west side of the facility did not have a device that alerted employees to the egress of a resident to the outside area. 3. In an interview, E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.