Celestial Care Homes, LLC

Based on record review, documentation review, and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered infection control. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. A record review of R2's medical records contained no verification of a negative TB test. Further review revealed a document titled, "Resident PPD Record" that was dated for May 10, 2024 and read, "given @ Chan rehab prior to admit." No lot number, expiration date, site, given by, nor results were listed on the form. 2. A documentation review of the facility's Policies and Procedure titled, "Residency and Residency Agreements" stated " The manager shall ensure that the resident provides evidence from freedom of infectious Tuberculosis, taken within three months from date of admission. 3. In an interview, E1 acknowledged that the manager failed to ensure that a resident provided documentation of freedom from infectious Tuberculosis (TB) and that the facility's Policies and Procedures were not implemented as required.

Based on record review, documentation review, and interview, the manager failed to ensure that an employee and/or resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for one of three residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of R2's medical records contained no verification of a negative TB test. Further review revealed a document titled, "Resident PPD Record" that was dated for May 10, 2024 and read, "given @ Chan rehab prior to admit." However, no lot number, expiration date, site, given by, nor results were listed on the form. 2. A documentation review of the facility's Policies and Procedure titled, "Residency and Residency Agreements" stated " The manager shall ensure that the resident provides evidence from freedom of infectious Tuberculosis, taken within three months from date of admission. 3. In an interview, E1 acknowledged that the manager failed to ensure that a resident provided documentation of freedom from infectious Tuberculosis (TB) and that the facility's Policies and Procedures were not implemented as required. This a a repeated deficiency from the on-site Complaint inspection conducted on September 4, 2024.

Based on observation, record review, documentation review, and interview, the manager failed to ensure the means of exiting the facility for a resident who does 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. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide Directed care services. 2. Prior to the start of the inspection, the Compliance Officer rang the door bell to enter the facility. R2 unlocked the door and let the Compliance Officer into the facility. 3. During the environmental inspection, the Compliance Officer could hear the alert notifying the caregivers when the doors were open. However, staff were not alerted to the front door opening, as E2 was unaware the Compliance had entered the facility. 4. In an interview, E2 acknowledged that the means of exiting the facility for a resident who does 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.

Based on observation and interview, the manager failed to ensure that food is obtained, prepared, served, and stored in a refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During the environmental inspection, the Compliance Officer observed two refrigerators that contained food for the residents. A thermometer was not contained in either refrigerator. 2. In an interview, E2 acknowledged that a refrigerator used by the facility to store food or medication did not contain a thermometer.

Based on record review and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver provided documentation of first aid (FA) training. The deficient practice posed a health and safety risk to residents if caregivers did not have FA training. Findings include: 1. In record review, E4's personnel record (hired on January 24, 2024, as a caregiver) included "Basic Life Support" training; however, did not indicate E4 provided documentation of FA training. 2. During an interview, E1 and E4 acknowledged E4 did not provide documentation of current FA training, as required.

Based on record review and interview, for one of four employees reviewed, the manager failed to ensure a personnel record included the individual's starting date of employment. Findings include: 1. In record review, E1's personnel record did not include the individuals' starting date of employment. 2. During an interview, E1 acknowledged the personnel record did not include the employee's date of hire.

Based on record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. In record review, the personnel records for E2 (hired as a caregiver on August 29, 2024), E3 (hired as a caregiver on March 7, 2024), E4 (hired as a caregiver on January 24, 2024), and E5 (hired as a caregiver on October 21, 2023), did not include documentation the caregivers received training on fall prevention and fall recovery, as required. 2. During an interview, E1 acknowledged the personnel records did not include documentation the caregivers received training on fall prevention and fall recovery.

Based on record review, interview, and documentation review, the manager failed to ensure if a manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse had occurred on the premises, the manager complied with all the requirements in R9-10-803(J). The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. In record review, R1's medical record included two documents of incidents where O1 independently provided services for R1, without staff knowledge, which appeared to cause R1 discomfort, and presented a potential risk of harm to R1. 2. During an interview, E1 reported at least two incidents occurred, E1 was a witness, and E6 reported the two incidents to Adult Protective Services (APS). 3. In documentation review, the facility did not have documentation, as required by R9-10-803.J, which included documentation of the facility's report according to (A.R.S.) \'a7 46-454, documentation an investigation was initiated within five working days after the report, and included a description of any injury to the resident related to the suspected abuse or neglect and any change to the resident ' s physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse, neglect, or exploitation; and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. 4. During an interview, E1 and E6 acknowledged the incidents occurred, and reported O1 sometimes bullied R1. E1 and E6 acknowledged the requirements of R9-10-803.J. were not documented by the facility, as required.

Based on record review, documentation review, and interview, for one of four caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services according to policies and procedures. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. In record review, the personnel record for E2 (hired as a caregiver on August 29, 2024), did not include documentation the caregiver's skills and knowledge were verified. 2. In documentation review, a facility policy, titled, "Staffing, Hiring, Orientation and In Service Training," on page 55, documented, "PROCEDURE: Upon being hired by the facility the applicant must: Complete an Application and Application Addendum I & 2 for employment to include the individual's name, date of birth, and contact telephone number. The starting date of employment or volunteer services and, if applicable the ending date. 2 Professional/Work References (references to be verified by the facility manager). Verification of three months of Health Related experience. Verification of qualifications, knowledge, and skills to perform the duties of the job hired for. Verification of the individual's education and experience applicable to the individual's job duties..." 3. In documentation review, the facility's policy and procedure manual had a document titled, "Caregiver Skills and Knowledge Documentation," page 64. This document was not found in E2's personnel record. 4. During an interview, E1 reported E2 worked the night shift alone on August 29, 2024. E1 acknowledged E2's skills and knowledge were verified and documented according the facility's policies and procedures, before E2 provided services for residents.

Based on record review, documentation review, and interview, for four of four caregivers reviewed, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver was not oriented, as required. Findings include: 1. In record review, the personnel records for E2 (hired as a caregiver on August 29, 2024), E3 (hired as a caregiver on March 7, 2024), E4 (hired as a caregiver on January 24, 2024), and E5 (hired as a caregiver on October 21, 2023), did not include documentation the caregivers received orientation specific to the duties to be performed by the caregiver. 2. In documentation review, a facility policy, titled, "Orientation and In Service," on page 56, documented, ".. 1. It is required that each employee and volunteer receive orientation before providing assisted living services to a resident.... Employee Orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the residents. The orientation is completed within 48 hours from the employment started day. The orientation to include but not limited to: The facilities philosophy and goals; Facility Rules and regulations, Characteristics and needs of resident's.\'b7Promotion of resident dignity, independence, self-determination, privacy, choice, and resident rights. The significance and location of resident service plans, how to read, interpret, and implement a service plan. Facilities policies and procedures manual, infection Control Practices/ Covid 19 Protocols. Food preparation, storage, and Food services, Abuse, neglect, and exploitation prevention and reporting requirements. Accident, Incident and injury reporting Fire, Safety and emergency procedures and Disaster Relocation Procedures of assisting, administering, and documenting residents with medications Location and use of Drug Book and First Aid kit Documentation of ADL's, obtaining and recording of vital signs, Medical emergencies and DNR status, Training for Fall Prevention and Recovery." 3. During an interview, E1 reported E2 was provided orientation for two hours on August 29, 2024, before E2 worked the night shift alone on August 29, 2024; however, the orientation was not documented. E1 acknowledged the caregivers worked shifts at the facility, and acknowledged the personnel records for the caregivers did not include documentation the caregivers received orientation, according to the facility's policy and procedures.

Based on documentation review, record review, and interview, for one of four caregivers reviewed, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1). The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E2 was fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: 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. In record review, E2's personnel record did not include documentation the facility made a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 3. During an interview, E1 reported E2 worked at the facility on August 29, 2024, on the night shift. E1 acknowledged E2's personnel record did not include documentation the facility made a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 4. This is an uncorrected deficiency from the Compliance and Complaint inspection conducted on April 10, 2024.

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a direct health and safety risk of or potential TB exposure, to residents and staff. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. In record review, R1's medical record included documentation of a negative TB skin test; however, did not include documentation of a risk assessment of prior exposure to infectious TB, or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. During an interview, E1 acknowledged R1's medical record did not include documentation of a risk assessment of prior exposure to infectious TB, or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 4. This is an uncorrected deficiency from the Compliance and Complaint inspection conducted on April 10, 2024.

Based on record review and interview, for one resident reviewed, who received directed care services, the manager failed to ensure a written service plan was updated, signed and dated, at least once every three months. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. In record review, R1's medical record (received directed care services), included a service plan dated June 1, 2024. The service plan was not signed and dated by the resident's representative and the manager, as required. 2. During an interview, E1 acknowledged the resident's service plan was not signed and dated, as required, by the resident's representative and the manager.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented that covered medication administration. The deficient practice posed a risk as the standards in the policies and procedures were not followed. Findings include: 1. A review of the facility's policies and procedures (dated March 9, 2023) revealed a policy titled, "Medications Services Policy and Procedure." The policy stated, "... 11. Only a trained and certified caregiver will administer medications from the medication organizer to the resident by placing the medication in the resident's hand, transferring the medications to a medicine cup and handing the cup to the resident or by placing the medications directly in the resident's mouth." 2. A review of E6's personnel record revealed a certificate from the "Pharmacy Technician Certification Board." The certificate stated, "... [E6] has met all requirements for certification and merits the designation of Certified Pharmacy Technician (CPhT), dated May 6, 2022. Further review of E6's personnel record did not reveal documentation that E6 was a certified caregiver. 3. A review of R1's, R2's, and R3's medication administration records (MAR) revealed E6 frequently administered medications to R1, R2, and R3 as evidenced by E6's initials, indicating E6 provided medication administration. 4. In an interview, E2 acknowledged E6 was not a certified caregiver. E2 believed E6 was qualified to provide medication administration due to E6's pharmacy technician certificate.

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk as the facility did not immediately report suspected abuse of a resident by a personnel member. Findings include: 1. A.R.S.\'a7 46-454(A) "... other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.110 "Immediate" means without delay. 3. A review of the facility's policy and procedures (dated March 9, 2023) revealed a policy titled, "Abuse, Neglect, and Exploitation Policy and Procedure." Under the heading, "Procedure" the document stated, "... If a manager has a reasonable basis to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall: ... immediately report to (APS) Adult Protective Service or local law enforcement of suspected or alleged abuse, neglect, or exploitation as required by ARS 46-454." 4. A review of facility documentation revealed an incident report dated November 6, 2023 at 11:30 PM. In the report, under the title, "Incident Type" the box that read "Abuse or Neglect" was checked. The incident report stated E11 "grabbed [R1] forcibly to get [R1] off the bed to the bathroom." The report indicated the incident took place on November 6, 2023 and the facility reported to APS on November 8, 2023. 5. In an interview, E2 acknowledged the facility did not immediately report the suspected abuse to APS as required. 6. A review of facility documentation revealed an incident report dated November 6, 2023 at 10:00 PM. In the report, under the title, "Incident Type" the box that read "Abuse or Neglect" was checked. The incident report stated, "Caregiver was trying to move [R4] from recliner to wheelchair. E11 grabbed [R4's] gaitbelt incorrectly telling [R4] to "get up" & then had to put [R4] down on the floor. After. [sic] E11 grabbed [R4] by [R4's] left forearm close to [R4's] elbow to pull [R4] help [sic] & said "get up". E11 then forcely [sic] (with caregiver's own strength) got [R4] up & resident did cry out "ouch". Caregiver did give resident a very bruised/bloody skin tear." 7. In an interview, E2 reported R4's certified nursing assistant (CNA) made the initial report to APS and E2 reported to APS on November 8, 2024. E2 acknowledged the facility did not immediately report the suspected abuse to APS as required. 8. Further review of facility documentation revealed an incident report dated August 29, 2023 reporting R5 was experiencing severe leg pa

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for eight of ten employees sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E3, E4, E5, E6, E7, E8, E9, and E10 were fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: 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 E3's, E4's, E5's, E6's, E7's, E8's, E9's and E10's personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers was made to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an interview, E2 acknowledged E3's, E4's, E5's, E6's, E7's, E8's, E9's and E10's personnel records did not include the documentation required in A.R.S. \'a7 36-411(C)(1).

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113., for three of three residents sampled. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a Mantoux skin test that was less than 12 months old. However, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 2. A review of R2's (admitted in 2023) medical record revealed a Mantoux skin test, that was less than 12 months old. However, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 3. A review of R3's (admitted in 2023) medical record revealed a Mantoux skin test, that was less than 12 months old. However, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 4. In an interview, E2 acknowledged R1's, R2's, and R3's medical records did not include a baseline symptom screening signed by a registered nurse, medical practitioner or local health department as required.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for a resident receiving directed care services, for two of three residents sampled. The deficient practice posed a risk if services provided to a resident's current needs were not being met. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. R1's medical record revealed one service plan dated July 10, 2023 and one service plan dated January 10, 2024. R1's medical record did not reveal a service plan was completed between July 10, 2023 and January 10, 2024 as required. 2. A review of R2's medical record revealed R2 received directed care services. R2's medical record revealed service plans dated August 19, 2023 and November 19, 2023. However, subsequent reviewed or updated service plans were not available for review. 3. In an interview, E2 acknowledged R1's and R2's service plans were not reviewed and updated at least once every three months as required.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for three 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 January 10, 2024. The service plan indicated R1 received directed care services and required assistance with the following activities of daily living: -Bathing; -Hygiene/Grooming; -Dressing; -Toileting; -Ambulating; and -Transfers. 2. A review of R2's medical record revealed a service plan dated November 19, 2023. The service plan indicated R2 received directed care services and required assistance with the following activities of daily living: -Bathing; -Hygiene/Grooming; -Dressing; -Foley catheter care; and -Reposition every 2 hours and as needed during awake hours. 3. A review of R3's medical record revealed a service plan dated January 29, 2024. The service plan indicated R3 required directed care services and required assistance with the following activities of daily living: -Bathing; -Dressing; -Hygiene/Grooming; -Toileting; -Ambulating; and -Transfers. 4. A review of R1's, R2's, and R3's medical record did not reveal documentation of the services provided to R1, R2, and R3. 5. In an interview, E2 acknowledged the caregivers did not document the services provided to the residents as required. E2 reported the facility does not currently document the assisted living services provided to the residents. E2 reported the facility would start documentation of services provided as soon as possible.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication list dated November 6, 2023. The medication list included the following: -Amlodipine Besylate 5 milligrams (mg), one tablet every day; -Atorvastatin 40 mg, one tablet every day; -Clopidogrel Bisulfate 75 mg, one tablet every day; -Losartan Potassium 100 mg, one tablet every day; -Memantine 10 mg, one tablet every night; -Mirtazapine 7.5 mg, one tablet every night; and -Venlafaxine 37.5 mg, one capsule every day. 2. A review of R1's medical record revealed R1 received medication administration. The medical record revealed a signed medication order dated July 13, 2023 for Amlodipine Besylate 5 milligrams (mg), take one tablet by mouth daily, with an additional comment to hold the medication if R1's systolic blood pressure measured below 110 mmHg. 3. A review of R1's medications revealed Amlodipine 5 mg was available for use. The Compliance Officer observed the medication bottle also included instructions to hold the medication if R1's systolic blood pressure measured below 110 mmHg. 4. In an interview, the Compliance Officer requested blood pressure documentation for review. E2 reported R1's blood pressure did not get taken or documented daily. 5. In an interview, E2 acknowledged the Amlodipine 5 mg was not administered in compliance with a medication order as R1's blood pressure was not getting taken prior to medication administration.