Circles of Life Residential Care and Memory Care L

Based on documentation review, observation, and interview, the manager failed to ensure that the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety if a resident was left outside the facility and was unable to enter. Findings include: 1. Documentation review revealed the facility was licensed for the directed level of care. 2. The Compliance Officer observed ambulatory residents. 3. During an environmental inspection, the Compliance Officer observed a keypad lock on both the front door and back door. 4. The Compliance Officer observed through the back door window a resident in a wheelchair trying to get in. The resident was not able to reach the door to knock. The Compliance Officer was not able to open the door and looked for E2 to let the resident in. 5. In an interview, E2 reported that residents knock on the door to be let in. 6. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident. Findings include: 1. A record review of R1's, R2's, and R3's medical records revealed no incident reports. 2. In an interview, E1 reported that there were verbal altercations, not physical, between R3 and R4. R3 eventually had to be moved to another facility to have a private room. E1 also reported that there was no documentation regarding the altercations between R3 and R4.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. Findings Include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officers observed multiple ambulatory residents. 3. During an environmental inspection of the facility, the Compliance Officer observed that the back door had an alarm, but it was turned off. 4. In an interview, E1 acknowledged that the back door alarm was off and did not alert employees of the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure that a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer did not observe a thermometer placed inside the refrigerator. 2 . In an interview, E1 acknowledged that a thermometer had not been placed inside the refrigerator.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice poses a health and safety risk to residents. Findings include: 1. The Compliance Officers observed multiple ambulatory residents. 2. During an environmental inspection of the kitchen, the Compliance Officer opened a drawer to reveal a nail. 3. In an interview, E1 acknowledged that the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. This is a repeat deficiency from the compliance inspections conducted on March 14, 2024.

Based on observation, record review, and interview, the manager failed to ensure the manager designated, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present, as the manager's designee. The deficient practice posed a risk as E2 was not designated, in writing, to be present on the premises and accountable when the manager was not present on the premises. Findings include: 1. When the Compliance Officer arrived at the facility, the manager was not present. E2 was the only caregiver at the facility with eight residents. 2. A review of E2's personnel record revealed no designation for E2 to be present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. 3. During a joint interview, E2 was not aware of any sort of delegation of authority given and E1 acknowledged no such document was signed by E2.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of one resident reviewed accepted by the assisted living facility. 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 medical record revealed a determination letter. However, the determination was blank and did not indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged there was no completed documentation in R1's medical record to indicate if R1 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation, documentation review, 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 to provide access to an outside area from which a resident may exit to a location at least 30 feet away from the facility, 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. A review of Department documentation revealed the facility was licensed at the directed level of care. 2. During an environmental tour of the facility, the Compliance Officer observed two doors leading to the back yard. The backyard did not allow residents to be at least 30 feet away from the facility. The door leading out to the back yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 3. The Compliance Officer observed ambulatory residents walking around the facility and R1 was trying to exit the facility with R1 belongings during the time of the inspection. 4. In an interview, E1 acknowledged the residents did not have access to an outside area controlling or alerting employees of the egress of the resident.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of three caregivers reviewed. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. When the Compliance Officers arrived at the facility, the manager was not present. E2 and E3 were the only employees at the facility with seven residents. 2. Review of E2's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. Review of E3's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 4. Review of the azcg.tmutest.com website, revealed no documentation of a caregiver training certificate for E2 or E3. 5. In an interview, E2 and E3 reported they worked as assistant caregivers. 6. In an interview, E1 acknowledged E2 and E3 worked as assistant caregivers. E1 acknowledged E2 and E3 did not have documentation of completing a caregiver training program approved by the Department or the NCIA Board.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. The Compliance Officers observed E2 and E3 working at the facility at the time of the inspection. The Compliance officers observed no other employees on site. 2. A review of facility documents revealed a March 2024 personnel schedule. The personnel schedule revealed E4 was scheduled to work the day shift on the day of the inspection. 3. In an interview, E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on observation, record review, and interview, the manager failed to ensure that at least the manager or a caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. When the Compliance Officers arrived at the facility, the manager was not present. E2 and E3 were the only employees at the facility with seven residents. 2. Review of E2's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. Review of E3's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 4. Review of the azcg.tmutest.com website, revealed no documentation of a caregiver training certificate for E2 or E3. 5. In an interview, E2 and E3 reported they worked as assistant caregivers. 6. In an interview, E1 acknowledged the manager or a caregiver was not present at the assisted living home when a resident was present in the assisted living home.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of three residents reviewed. The deficient practice posed a TB exposure risk to residents. 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. A review of R1's medical record revealed documentation of freedom from infectious TB, however documentation of R1's Signs and Symptoms, and Risk Assessment, signed by a Registered Nurse or medical provider, was not available for review. 3. A review of R2's and R3's medical record revealed documentation of freedom from infectious TB was not available for review. Further, documentation of R2's or R3's Signs and Symptoms, and Risk Assessment, signed by a Registered Nurse or medical provider, was not available for review. 4. In an interview, E1 agreed R1's and R2's medical record did not contain documentation of freedom form infectious TB and R1's, R2's and R3's medical record did not contain documentation of each resident's Signs and Symptoms and Risk Assessment signed by a Registered Nurse or medical provider.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted which included the requirements in R9-10-807(B)(1-2) for one of three residents sampled. Findings include: 1. A review of R3's medical record revealed the medical record did not include documentation dated within 90 calendar days before the individual was accepted by the assisted living facility which included the requirements in R9-10-807(B)(1-2). 2. In an interview, E1 acknowledged R3's medical record did not include documentation dated within 90 calendar days before the individual was accepted by the assisted living facility which included the requirements in R9-10-807(B)(1-2).

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the March 2024 personnel schedule revealed that the facility operated on two shifts, 7am to 7pm and 7pm to 7am. 2. A review of documentation revealed a disaster drill was conducted on January 24, 2024 during the day shift. No other disaster plans were available for review. 3. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months.

Based on observation and interview the manager failed to ensure the premises at the assisted living facility was free from a condition or situation which may cause a resident or other individual to suffer physical injury. Findings include: 1. During a tour of the facility the Compliance Officers observed no fewer than two residents who were ambulatory with the assistance of a walker and no fewer than two residents who required assistance with a wheelchair. The backyard did not allow residents to be at least 30 feet away from the facility structure. There was a passageway on the west side of the facility which ran the length of the structure, and there was an unlocked gate at the end of the passageway which would allow residents to exit the back yard and be at least 30 feet away from the structure. However, the passageway was strewn with obstacles, such as wheel chairs, broken walkers, shower chairs, raised toilet seats, sheets of drywall and plywood, making passage through to the gate hazardous. 2. In an interview, E1 acknowledged the premises at the assisted living facility was not free from a condition or situation which may cause a resident or other individual to suffer physical injury.