Citrus Canyon Care

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver 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 no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival at the facility, the Compliance Officer was greeted by E3. E3 was an unlicensed caregiver working without the supervision of a licensed caregiver that was designated as the manager. The Compliance Officer observed a list of caregivers listed as designated manager in the absence of E1. 2. Documentation review of the manager designation form listed E2 designated manager in the absence of E1. E2 was not initially present at the facility. 3. In an interview, E2 acknowledged that no manager or designee 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.

Based on documentation review and interview, the manager failed to ensure Policies and Procedures were established, documented, and implemented to protect the health and safety of a resident. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. During the inspection, the Compliance Officer requested the facility's Policies and Procedures manual. However, the facility's Policies and Procedures were not provided for review. 3. In an interview, E2 acknowledged the manager did not ensure Policies and Procedures were established, documented, and implemented to protect the health and safety of a resident.

Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of compliance with the requirements in A.R.S. § 36-411(C). The deficient practice posed a risk as required information could not be verified for all employees. Findings include: 1. A.R.S. § 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. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A record review of E3's personnel record, revealed an APS Central Registry check was not available for review. 3. A record review of E3's personnel record revealed, a Arizona Department of Public Safety (DPS) Fingerprint Clearance Card was not available for review. 4. In an interview, E2 acknowledged that the manager failed to ensure that a personnel record for E3 included documentation of compliance with the requirements in A.R.S. § 36-411(C).

Based on record review and interviews, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for one of two sampled employees. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the personnel file for E3 revealed, Cardiopulmonary resuscitation (CPR) and First Aid (FA) certification was not available for review. 2. In an interview, E2 checked with E3 and verified that the employee did not have a current CPR/FA certification. 3. In an interview, E2 acknowledged that E3 did not have current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Based on record review, documentation review, and interview, the manager failed to ensure that a manager, a caregiver, assistant caregiver, or a volunteer provide documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E3’s personnel record revealed, no documentation indicating that the employee completed the two-step TB process was available for review. 2. In an interview, E2 acknowledged documentation of freedom from infectious Tuberculosis (TB) was not provided for E3.

Based on observation, record review, and interview, the manager failed to ensure at least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. Upon entering the facility, the Compliance Officer was greeted by E3. No other employees were present at the time. 2. During the inspection, the Compliance Officer observed the manager designee list hanging on the wall. 3. During the inspection, E2 (a designated manager) arrived at the facility. 4. A record review of E2’s personnel record revealed, E2 was listed as a manager designee. 5. In an interview, E2 revealed that E3 was not a licensed caregiver and had no personnel record available for review. 6. In an interview, E2 acknowledged a manager or a caregiver was not present at an assisted living home when residents were present in the assisted living home.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation required by this rule, for one of three personnel sampled. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. Upon entering the facility, the Compliance Officer was greeted by E3. No other employees were present at the time. 2. A record review of personnel records revealed that a record for E3 was not available for review at the time of the inspection. 3. In an interview, E2 acknowledged no personnel record for E3 was available that contained the requite components.

Based on record review and interview, the manager failed to verify and document an assistant caregiver's skills and knowledge before the assistant caregiver provided physical health services. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A record review of E3's personnel file revealed, the employee was missing the requite components for an assistant caregiver. 2. In an interview, E2 acknowledged the manager did not verify the skills and knowledge for an assistant caregiver prior to the employee providing services for a resident.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident has a service plan that is established, documented, and implemented that: when initially developed and when updated, is signed and dated by: the resident or resident’s representative. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of the medical records for R1, revealed the resident received Personal Care services per the resident’s service plan. 2. A review of the medical records for R2, revealed the resident received Directed Care services per the resident’s service plan. 3. A review of R1's medical records revealed, the resident's service plan dated May 25, 2025, was not signed by the resident or resident's representative. 4. A review of R2's medical records revealed, the resident's service plan dated June 27, 2025 was not signed by the resident's representative. 5. In an interview, E2 acknowledged the manager did not obtain the signature of R1 or R1’s representative and R2's resident's representatives on the service plans as required.

Based on record review, documentation review and interview, the manager retained a resident confined to a bed or chair without meeting the requirements in R9-10-814.B.2.a.b.i-iii., including documentation of the resident's or the resident's representative's request the resident remain in the facility; documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A Department review of the facility's license revealed, the facility was authorized to provide Supervisory, Personal, and Directed Care services. 2. A Department review of R9-10-814.B.2.a.b.i-iii. stated, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 1. The condition is a result of short-term illness or injury; or the following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. the resident's representative request the resident remain in the facility; b. the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility." 3. A record review of R1's service plan stated, "Bed bound or wheelchair if out of bed." No initial physician recommendation nor continuation of care physician statement was available for review. 4. In an interview, E1 acknowledged that the manager failed to obtain documentation to demonstrate R1's primary care provider or other medical practitioner examined the bedbound resident at least once every six months throughout the duration of the resident's condition.

Based on observations, 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. During the environmental inspection, the Compliance Officer observed that when the patio door was opened, no alarm sounded to alert employees that a person was entering or exiting the facility. The alert was switched to the off position. 3. In an interview, E2 acknowledged that 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.

Based on observation and interview, the manager failed to ensure that a disaster plan was developed, documented, maintained in a location accessible to caregivers and assistant caregivers. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. During the inspection process, the Compliance Officer requested a documentation review of the facility's Disaster Plan. However, the Disaster Plan policy was not available for review. 2. E2 acknowledged a disaster plan was not developed, documented, maintained in a location accessible to caregivers and assistant caregivers.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted once every six months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A documentation review of the facility’s "Evacuation Drill” revealed that the last evacuation drill was completed on October 04, 2024. There was an orange sticky note with writing that read, "Next Drill 4/4/25". 2. The facility's Disaster Plan policy was not available for review. 3. In an interview, E2 acknowledged the manager failed to ensure an evacuation drill for employees and residents was conducted once every six months and documented.