Caring Angels Residential for Elderly II, LLC

Based on observation, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as a designated caregiver was not present on the premises and accountable when E3 was not present on the premises, and the Department was unable to determine substantial compliance as documentation designating E2 was not available during the inspection. Findings include: 1. The Compliance Officer observed E2 working alone when the Compliance Office arrived on the premises at approximately 11:30 AM. 2. The Compliance Officer observed a document titled "DELEGATION OF AUTHORITY" (dated April 1, 2022) posted by the front door. The document stated "I, [E3]...hereby delegate authority to...[E1]...[E4]..." 3. The Compliance Officer observed E1 arrive on the premises at approximately 12:30 PM. 3. A review of E2's (hired in 2023) personnel record revealed documentation designating E2 to be present on the premises and accountable for the assisted living facility when the manager was not present on the premises was not available for review. 4. In an interview, E1 acknowledged a designated individual was not present on the premises when the manager was not present on the premises, and E2 was not designated in writing to be present and accountable when E3 was not on the premises.

Based on observation, record review, documentation review and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(ix) for one of four employees sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs, and the required information could not be verified for E2. Findings include: 1. The Compliance Officer observed E2 on the premises and working alone when the Compliance Officer arrived on the premises. 2. A review of documentation provided by E1 revealed the following documentation for E2: -Name; -Date of birth; -Orientation; however, the orientation was undated; -Documentation of E2's caregiver certificate; -Evidence of freedom from infectious tuberculosis; -Cardiopulmonary resuscitation training; -First aid; and -Copy of E2's fingerprint clearance card. However, documentation of the following was not available for review: -E2's phone number; -E2's starting date of employment; -Documentation of E2's qualifications, including skills and knowledge applicable to E2's job duties; -E2's education and experience applicable to E2's job duties; and -Documentation of compliance with \'a7 A.R.S. 36-411(C)(1)(2). 3. In an interview, E1 acknowledge a personnel record for E2 to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i-iii)(ix) was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, 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 two of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's (accepted in April 2022) medical record revealed 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. However, the documentation was signed and dated by a physician fifteen calendar days after R1's date of admission. 2. A review of R2's (accepted in November 2022) medical record revealed 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. However, the documentation was signed and dated by a registered nurse 103 calendar days after R2's date of admission. 3. In an interview, E1 acknowledged documentation to include whether R1 and R2 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 was not submitted before or at the time of R1's and R2's acceptance.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after a resident's date of acceptance, for one of three residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident for 24 calendar days. Findings include: 1. A review of R2's (accepted in November 2022) medical record revealed a written service plan was completed 24 calendar days after R2's date of acceptance. 2. In an interview, E1 acknowledged a written service plan for R2 was not completed within 14 calendar days after acceptance.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the resident or resident's representative, for three of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a current service plan (dated in February 2023) for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 2. A review of R2's medical record revealed a current service plan (dated in May 2023) for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 3. A review of R3's medical record revealed a current service plan (dated in April 2023) for directed care services. However, the service plan was not signed and dated by the resident's representative. 4. In an interview, E1 acknowledged R1's, R2's, and R3's written service plans did not include a signature and date from the resident or resident's representatives.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the manager, for two of three residents sampled. Findings include: 1. A review of R2's medical record revealed a current service plan (dated in May 2023) for personal care services. However, the service plan was not signed and dated by the manager. 2. A review of R3's medical record revealed a current service plan (dated in April 2023) for directed care services. However, the service plan was not signed and dated by the manager. 3. In an interview, E1 acknowledged R2's and R3's service plans were not signed and dated by the manager.

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 two of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated in February 2023) for personal care services. The service plan stated the following services were to be provided to R1: -Bathing; -Oral Care; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Ambulation. 2. A review of R1's medical record revealed an activities of daily living document for June 1-30, 2023. However, the following services were not documented as provided on June 21, 2023 -Bathing; -Oral Care; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Ambulation. 3. A review of R2's medical record revealed a service plan (dated in May 2023) for personal care services. The service plan stated the following services were to be provided to R2: -Bathing; -Oral Care; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 4. A review of R2's medical record revealed an activities of daily living document for June 1-30, 2023. However, the following services were not documented as provided on June 21, 2023: -Bathing; -Oral Care; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 5. In a interview, E1 acknowledged services provided had not been documented in R1's and R2's medical records.

Based on record review, documentation review, observation and interview, the manager failed to ensure the resident's medical record included documentation of medication administration, for three of three residents sampled who received medication administration. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a service plan (dated in February 2023). The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed medication orders. 3. A review of facility documentation revealed a medication administration record (MAR) for R1 for June 1-30, 2023. However, documentation of medication administered to R1 from June 19, 2023 to June 22, 2023 was not available for review. 4. The Compliance Officer observed medications for R1 on the premises. 5. A review of R2's (admitted in 2022) medical record revealed a service plan (dated in May 2023). The service plan revealed R2 received medication administration. 6. A review of R2's medical record revealed medication orders. 7. A review of facility documentation revealed a medication administration record (MAR) for R2 for June 1-30, 2023. However, documentation of medication administered to R2 from June 19, 2023 to June 22, 2023 was not available for review. 8. The Compliance Officer observed medications for R2 on the premises. 9. A review of R3's (admitted in 2022) medical record revealed a service plan (dated in April 2023). The service plan revealed R3 received medication administration. 10. A review of R3's medical record revealed medication orders. 11. A review of facility documentation revealed a medication administration record (MAR) for R3 for June 1-30, 2023. However, documentation of medication administered to R3 from June 19, 2023 to June 22, 2023 was not available for review. 12. The Compliance Officer observed medications for R3 on the premises. 13. In an interview, E1 acknowledged R1's, R2's, and R3's medical record did not include documentation of medication administered to R1, R2, and R3. E1 reported the residents were receiving their medications.

Based on 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 the resident's primary care provider or other medical practitioner examining the resident at least once every six months throughout the duration of the resident's condition, reviewing the assisted living facility's scope of services, and signing and dating a determination stating the resident's needs were being met by the assisted living facility, for one of two residents sampled who was unable to ambulate even with assistance. Findings include: 1. A review of R1's (accepted in 2022) medical record revealed a current service plan for personal care services. The service plan stated " ...bed bound..." 2. A review of R1's medical record revealed documentation to include whether the resident's primary care provider or other medical practitioner examined the resident, reviewed the assisted living facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the assisted living facility was not available for review. 3. In an interview, E1 acknowledged the aforementioned documentation was not available for review.

Based on observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway to another sleeping area. The deficient practice posed a privacy rights risk to a resident. Findings include: 1. A review of Department documentation revealed the perpetual license for AL12184 was effective on April 5, 2022. 2. The Compliance Officer observed, and walked through the master bedroom (occupied by one resident) to the master bathroom and to the master bedroom closet. 3. The Compliance Officer observed a sleeping area, with a bed and personal belongings, in the master bedroom closet. 4. In an interview, E2 reported the master bedroom closet was used as a rest area for E2. 5. In an interview, E1 acknowledged a resident bedroom was used as a passageway to another sleeping area.