Catalina Springs Memory Care

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one resident sampled. Findings include: 1. A review of department documentation provided by the Adult Protective Services (APS) revealed a nurse from Mercy Care reported medication was not given to R1 in compliance with a medication order. 2. A review of R1's medical record revealed a medication order dated April 22, 2024. The Compliance observed the following medications "Glipizide 50 MG TAB, Take 1 TAB by mouth every day for diabetes", and "Levetiracetam 500 MG TAB Take 1 Tablet by mouth 2 times daily". 3. A review of R1's medication record revealed on March 20, 21, 22, 23, and 24, 2024, "Glipizide" was not given. The medication was unavailable for the following reason: "medication not in the facility, waiting on delivery". 4. A review of R1's medication record revealed on February 15, 2024, "Levetiracetam" was not given for the following reason: "waiting on delivery". 5. A review of policy and procedures titled "Medication Availability" revealed the following "Policy: It is expected that medications will be given and documented as ordered. This is required by law and is a community expectation". 6. In an interview, E1 acknowledged the medication was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for one of four directed care residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of service plan dated May 10, 2024, indicating R1 was receiving directed care services. However, the service plans did not contain the following: - Offering sufficient fluids to maintain hydration, and - Encouragement to eat meals and snacks. 2. In an interview, E1 and E2 acknowledged the service plan for R1 did not contain all of the requirements for directed care residents.

Based on record review, documentation review, and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of four residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. A review of R2's medical record revealed a current written service plan for directed care services dated May 10, 2024. However, a service plan after August 10, 2024 was not available for review. 2. In an interview, E1, and E2 acknowledged R2 was receiving directed care services and the service plan was not updated at least once every three months.

Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of five employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population. 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. Findings include: 1. A review of E2's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E2's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 2. A review of E3's personnel record revealed a valid fingerprint clearance card and an application listing four prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E3's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 3. A review of E5's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, the Compliance Officer observed on a document titled "References" there was only one professional/Employment reference was listed. On the document was "Telephone" circled and the initials of the business officer personal. There were no good faith efforts to contact previous employers for information or recommendations that may be relevant to E5's fitness to work in a residential care institution, nursing care institution or home health agency. No other documents were available for review during the survey. 4. In an interview, E1, acknowledged the personnel records provided for review had not included documentation of compliance with all subsections of A.R.S. \'a7 36-411.

Based on record review, documentation review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for five of five directed care residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of a service plan dated October 3, 2023. The service plan indicated R1 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 2. A review of R2's medical record revealed documentation of a service plan dated October 18, 2023. The service plan indicated R2 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 3. A review of R3's medical record revealed documentation of a service plan dated November 8, 2023. The service plan indicated R3 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 4. A review of R4's medical record revealed documentation of a service plan dated October 27, 2023. The service plan indicated R4 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Cognitive stimulation and activities to maximize functioning; - Strategies to ensure a resident's personal safety; and - Encouragement to eat meals and snacks. 5. A review of R5's medical record revealed documentation of a service plan dated November 15, 2023. The service plan indicated R5 was receiving directed care services. However, the service plans did not contain the following: - Incontinence care that ensures that a resident maintains the highest practicable level of independenc

Based on documentation review, record review, and interview, the manager failed to ensure a written notification was provided to the Department within two working days after a resident inflicted self-injury which required immediate intervention by an emergency services provider. Findings include: A.A.C. R9-10-101(67) states danger to self "has the same meaning as A.R.S. \'a7 36-501." A.R.S. \'a7 36-501(8) states danger to self "a. Means behavior that, as a result of a mental disorder: i. Constitutes a danger of inflicting serious physical harm on oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out. ii. Without hospitalization will result in serious physical harm or serious illness to person." 1. A review of Merriam-Webster.com revealed it indicated that "injury" was a synonym for "harm." 2. A review of the Department's documentation revealed on January 18, 2023, a self report by E1 was sent to the department. The document revealed R1 had inflicted self-injury which required immediate intervention by an emergency services provider. 3. On further review of this document the date of the incident was January 4, 2023, however, E1 did not notify the department within two working days. 4. In an interview, E2, and E3 acknowledged E1 did not report the R1's self-injury resulting in immediate intervention by an emergency services provider within two working days.