Cold Spring Assisted Living

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the facility tour with E1, the Compliance Officer observed the following in an unlocked kitchen cabinet: -One container of "Raid Multi Insect" which stated "Caution: Keep out of reach of children"; -One container of "Ajax with Bleach" which stated "Caution: Keep out of reach of children"; and -One container of "Oxygen Orange" which stated "Caution: Keep out of reach of children". 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on March 24, 2023 and the compliance inspection conducted July 8, 2021.

Based on documentation review, record review, observation, and interview, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of three residents reviewed. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Opioid Administration". This policy and procedure stated "1. Identify the resident's pain before he opioid is administered by using the pain scale table. Ask resident to rate pain level (0= no pain to 10= worst pain possible). If a resident is unable to communicate, caregiver will document signs and symptoms that lead them to believe that resident was in need of the opioid medications[...] 3. Document is the Opioid MAR -Identification of the resident's pain before the opioid was administered and -effect of the opioid administered." 2. Review of R1's medical record revealed a September 2024 medication administration record (MAR). This MAR revealed Norco Tab 5/325MG was administered on an "as needed" basis on the follow dates and times: -September 3 "AM"; -September 4 "PM"; -September 5 "Noon"; -September 7 "PM"; -September 9 "AM"; -September 11 "AM" and "PM"; -September 13 "AM" and "PM"; -September 14 "Noon"; -September 15 "PM"; and -September 16 "AM". Documentation was not available showing the identification of R1's need for the opioid and the effect of the opioid administered. 3. Review of R1's medical record revealed no documentation stating R1 had an end-of-life condition or an active malignancy. 4. In an interview, E1 acknowledged the caregiver did not document in R1's medical record the identification of the need for the opioid and the effect of the opioid administered.

Based on record review, documentation review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the assistant caregiver provided physical health services, for one of one assistant caregivers sampled. The deficient practice posed a risk if the assistant caregiver was unable to meet a resident's needs. Findings include: 1. Review of E4's personnel record revealed E4 was hired as an assistant caregiver. 2. Review of the September 2024 work schedule revealed that E4 worked 7AM-7PM September 12-20. 3. Review of E4's personnel record revealed no documentation that E4's skills and knowledge were verified. 4. In an interview, E1 acknowledged that documentation was not available that showed E4's skills and knowledge were verified and documented before providing physical health services.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for one of four employees sampled. Findings include: 1. A review of E4's personnel record revealed the record did not include the starting date of employment. 2. Review of the September 2024 work schedule revealed that E4 worked 7AM-7PM September 12-20. 3. In an interview, E1 acknowledged E4's personnel record did not include the starting date of employment.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of three residents reviewed. Findings include: 1. Review of R2's medical record revealed a residency agreement. However, this residency agreement did not include the signature of the manager and date signed. Based on R2's acceptance date, this document was required to be signed. 2. In an interview, E1 acknowledged R2's residency agreement did not include the signature of the manager and date signed.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's medical record revealed the most recent written service plan for directed care services dated June 18, 2024. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged R1's service plan did not include a signature and date from the resident or representative.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was prepared at least one week in advance of the date the activity was provided. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed the posted activity calendar. The activity calendar was dated August 2024. 2. In an interview, E1 acknowledged a calendar of planned activities was not prepared at least one week in advance.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of three residents reviewed. The deficient practice posed a risk as required information could not be verified and the Department was unable to determine substantial compliance during the inspection. Findings include: A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider. 1. Review of Department documentation revealed a report dated September 17, 2024, which documented R3 received serviced at the facility. 2. The Compliance Officer requested to review R3's medical record; however, no medical record was provided for review. 3. In an interview, E1 reported that R3 had been a resident at the facility. E1 acknowledged that a medical record for R3 was not maintained for at least six years after the last date R3 received services from the facility.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of one residents receiving medication administration sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated June 28, 2024. This service plan indicated R1 received medication administration. 2. Review of R1's September 2024 medication administration record (MAR) indicated the following: -Hydralazine 25mg tab was administered twice a day September 1st-15th; -Meclizine 25mg tab was administered once a day September 1st-15th; -Norco Tab 5/325MG was administered on an "as needed" basis on the follow dates and times: -September 3 "AM"; -September 4 "PM"; -September 5 "Noon"; -September 7 "PM"; -September 9 "AM"; -September 11 "AM" and "PM"; -September 13 "AM" and "PM"; -September 14 "Noon"; -September 15 "PM"; and -September 16 "AM"; -Oxybutynin CHL ER 10mg tab was administered once a day September 1st-15th; -Seroquel 25mg tab was administered twice a day September 1st-15th; -Tamsulosin 0.4mg cap was administered once a day September 1st-15th; -Aspirin tab chewable 81mg was administered once a day September 1st-15th; and -Benzonatate 100mg cap was administered twice a day September 1st-15th. 3. Review of R1's medical record revealed no documentation of signed written or verbal medication orders for the listed medications. 4. In an interview, E1 reported the medications were administered per the MAR and acknowledged the medications were not administered in compliance with an available medication order. This is a repeat deficiency from the on-site compliance inspection conducted on March 24, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour with E2, the Compliance Officer observed a cabinet in the kitchen that held seven residents' medications unlocked. This cabinet had a lock, however the cabinet was not locked, and the key was in the lock. 2. The Compliance Officer observed the following medications on the shelves of the kitchen refrigerator, which did not have a lock: -8 unlabeled oral syringes containing what appeared to be morphine (E2 was unable to identify the medication); -a bottle of Humulin insulin isophane; -a 30ml bottle of Lorazepam Intensol; and -2 boxes of Insulin Degludec syringes. 3. Review of the facility policy and procedure documentation revealed a policy titled "Medication Services", which stated "6. All resident medications must be secured in a locked storage area. Only the manager and trained caregivers shall be in possession of the keys to the facility's medication storage area." 4. In an interview, E1 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. This is a repeat deficiency from the on-site compliance inspection conducted on March 24, 2023.

Based on observation, documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances, which posed a health and safety risk. Findings include: 1. During the facility tour, the Compliance Officer observed an unlocked medication cabinet containing seven residents' medications. 2. Review of the facility's policies and procedures revealed a policy titled "Storing, Inventorying and Dispensing of Controlled Medications", which stated "[...] 3. When a controlled medication is received from the pharmacy, the RN or other designated staff person should count the number of tablets/capsules and enter this number on the Narcotics Inventory Sheet[...] 4. Maintain Narcotic Inventory Sheets with the resident's current medication record. [...] 6. The number of each controlled medication on hand must be counted monthly, with this number compared to the last number in the "Amount Remaining" column on the Narcotic Inventory Sheet." 3. Review of R1's medical record revealed no documentation of a written or verbal medication order for the following medication: -Norco Tab 5/325MG 4. Review of R1's medical record revealed a September 2024 medication administration record (MAR). This MAR revealed Norco Tab 5/325MG was administered on an "as needed" basis on the follow dates and times: -September 3 "AM"; -September 4 "PM"; -September 5 "Noon"; -September 7 "PM"; -September 9 "AM"; -September 11 "AM" and "PM"; -September 13 "AM" and "PM"; -September 14 "Noon"; -September 15 "PM"; and -September 16 "AM". However, no Narcotic Inventory Sheet was provided. 5. During an interview, E1 acknowledged the policies and procedures were not implemented for inventorying controlled substances.

Based on interview and record reviewed, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E1 reported that R1 was transported to the hospital from the facility by emergency medical services on September 16, 2024. 2. Review of R1's medical record revealed no documentation for the incident. 3. In an interview, E1 acknowledged R1's medical record did not include documentation showing the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency, for two of two terminated residents sampled. Findings include: 1. A review of R1's medical record revealed R1's date of termination of residency was not available for review. 2. In an interview, E1 reported R1 was no longer a resident at this facility. 3. A review of R2's medical record revealed R2's date of termination of residency was not available for review. 4. In an interview, E1 reported R2 was no longer a resident at this facility. 5. In an interview, E1 acknowledged that R1's and R2's termination dates were not included in the medical record.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's record revealed a current written service plan for directed care services dated April 13, 2024. This service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. During an interview, E1 acknowledged R2's service plan did not include skin maintenance to prevent skin issues.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of two residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. A review of R1's medical record revealed a written service plan was not available for review. 2. In an interview, E1 acknowledged that R1's medical record did not contain a written service plan.