Country Estates Assisted Living Home

Based on documentation review, record review, and interview, the manager failed to accurately document the actions taken to prevent an alleged incident of abuse from occurring in the future, according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for a resident who resided in the assisted living facility. Findings include: 1. A review of Department documentation revealed an incident that stated "[R1] told [O1] [R1] is afraid of the caregiver, [E1] and that [E1] hit [R1] and pushed [R1] up against the wall. During the conversation with [R1], [E2], Country Estates Group Home Manager, [O1] and [E1] [...] were all present. [E1] became very angry with [R1's] accusations and "got in [R1's] face" calling [R1] a "liar" and then hit [R1] several times to 'demonstrate' [E1] did not hit [R1]. 2. A review of R1's medical record included an incident report dated July 25, 2024, which documented R1 telling E2 that E1 had hit R1. In the "Follow Up Actions Taken" section of the document, E2 documented "[E1] is very hurt by the situation and is staying with other residents. R1 is cared for by other staff." 3. Review of the staff schedule for July 2024 revealed that E1 was the only caregiver on site July 27th 6:30pm-6:30am, July 28th 6:30pm-6:30am, July 29th 6:30pm-6:30am, and July 30th 6:30pm-6:30am. 4. In an interview, E1 reported that E1 had not provided care for R1 on July 25th or July 26th, but resumed providing care for R1 on July 27th. 5. During an interview, E1 acknowledged that the facility did not accurately document actions taken by the manager to prevent the suspected abuse from occurring in the future.

Based on documentation review, record review, and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. A review of Department documentation revealed an incident that stated "[R1] told [O1] [R1] is afraid of the caregiver, [E1] and that [E1] hit [R1] and pushed [R1] up against the wall. During the conversation with [R1], [E2], Country Estates Group Home Manager, [O1] and [E1] [...] were all present. [E1] became very angry with [R1's] accusations and "got in [R1's] face" calling [R1] a "liar" and then hit [R1] several times to 'demonstrate' [E1] did not hit [R1]. 2. A review of R1's medical record included an incident report dated July 25, 2024, which documented R1 telling E2 that E1 had hit R1. The document stated "[E1] became hurt and devastated at the accusation, and called [R1] a liar." 3. In an interview, E1 reported calling R1 a liar, raising E1's voice at R1, and slapping R1's leg during the incident. 4. In an interview, the Compliance Officer asked R1 if R1 felt that staff treat residents with respect and dignity, R1 stated "no". 5. In a telephone interview, E2 acknowledged R1 was not treated with dignity, respect, and consideration.

Based on documentation review, record review, and interview, the health care institution failed to develop 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 developed. Findings include: 1. A review of the facility's policies and procedures (dated November 11, 2022) revealed a training program for all staff regarding fall prevention and fall recovery was not available for review. 2. In an interview, E1 acknowledged a training program for all staff regarding initial training and continued competency training in fall prevention and fall recovery was not available for review.

Based on observation, documentation review, and interview, the governing authority failed to designate, in writing, a manager who has either a certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. The Compliance Officer observed E6's managers (ALM) license posted on the premises. However, the license expired June 30, 2023. 2. A review of the facility's policies and procedures (dated September 30, 2022) revealed a policy titled "Staffing and Record Keeping." The policy stated "The manager must be at least 21 years of age and must have completed the core training requirements by the Arizona Board of Nursing Care Institution Administrators and Assisted Living Managers (NCIA)." 3. In an interview, E1 reported E6 (hired in 2023) was the assisted living facility manager. 4. A review of https://elicense.az.gov/ARDC_LicenseSearch revealed E6's ALM license had expired effective June 30, 2023. 5. A review of staffing schedules dated July 3, 2023-July 16, 2023; and July 31-2023-January 28, 2024 revealed E6 was not scheduled to work during those time periods. 6. In an interview, E1 reported E6 was on-site frequently to check the status of the facility, and E1 reported to be unaware E6 had not renewed E6's ALM license.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who 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 the designated caregiver was not on-site to act on behalf of the governing authority in the on-site management of the assisted living facility when the manager was not present. Findings include: 1. The Compliance Officer (CO) observed E3, E4, and E5, on the premises and working when the CO arrived on February 9, 2024 at approximately 10:15 AM. 2. In an interview, E3 reported E1 was the designated caregiver. E3 reported to have called E1 and E1 would arrive at the facility within 30 minutes. 3. A review of a documention revealed a "Delegation of Authority" dated November 22, 2022 and signed by E6. The document stated "The following caregiver has been delegated the responsibility of this facility when I am not present [E1]..." 4. In an interview, E1 acknowledged having the responsibility for the facility when E6 was not present on the facility's premises. E1 reported to have been away from the facility for only a short period of time.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee included the individual's starting date of employment, for two of six employees sampled. Findings include: 1. The Compliance Officer observed E5 working at the facility upon arrival at 10:15 AM. 2. A review of E4's personnel record revealed a starting date of employment was not available for review. 3. A review of E5's personnel record revealed a starting date of employment was not available for review. 4. In an interview, E1 verbally provided E4's and E5's starting dates of employment to the Compliance Officer.

Based on record review and interview, the manager failed to ensure a personnel record for each personnel member included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties; the individual's education and experience applicable to the individual's job duties; and the individual's completed orientation required by policies and procedures, for two of seven personnel members sampled. The deficient practice posed a risk as the required information could not be verified for E3 and E5. Findings include: 1. The CO observed E3 and E5 providing direct services to residents during the inspection. 2. A review of E3's and E5's personnel records revealed documentation of qualifications, including skills and knowledge; documentation of education and experience; and documentation of completed orientation was not available for review. 3.In an interview, E1 reported to be unaware of the missing documentation in E3's and E5's personnel records.

Based on observation, interview and record review, the manager failed to ensure a personnel record for each employee was maintained throughout the individual's period of providing services in or for the assisted living facility. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer observed E2's manager certificate conspicuously posted on a wall near the facility's ADHS license. 2. In an interview, E1 reported E2 was the facility's day to day manager and E6 was the facility's official assisted living manager. 3. The Compliance Officer requested to review E2's and E6's personnel records. However, personnel records were not available for review. 4. In an interview, E1 reported E2 and E6 had personnel records, however, E1 was unable to locate the requested personnel records.

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 dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of three residents sampled. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R2's date of admission. However, the documentation was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 acknowledged R2's above mentioned documentation was not signed and was not dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. E1 indicated the document was signed by R2's power of attorney.

Based on record review and interview, the manager failed to ensure a residency agreement included the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G), for three of three residents sampled. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed residency agreements. The residency agreements stated "...The residency agreement may be terminated by the home upon 14-calendar-day written notice for: a. Documented failure of the resident to pay fees or charges. b. Care and service needs exceed our license/scope of services and is not able to provide the services needed by the individual. c. The individual requires restraints, including the use of bedrails." However, documentation to indicate the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G) was not available for review. 2. In an interview, E1 acknowledged R1's, R2's, and R3's residency agreements did not include the correct provisions for an assisted living facility to terminate residency.

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 to include the manager's signature and date signed, for two of three residents sampled. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed a documented residency agreement. However, the residency agreement was not signed and dated by the facility's manager. 2. A review of R3's (admitted in 2021) medical record revealed a documented residency agreement. However, the residency agreement was not signed and dated by the facility's manager. 3. In an interview, E1 acknowledged R2's and R3's residency agreements did not include the manager's signature and the date signed.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a review by a nurse or medical practitioner, for three of three residents sampled who required medication administration. Findings include: 1. A review of R1's medical record revealed a service plan dated in March 2023. The service plan indicated R1 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner. 2. A review of R2's medical record revealed an undated service plan. The service plan indicated R2 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner. 3. A review of R3's medical record revealed a service plan dated in April 2023. The service plan indicated R3 received medication administration. However, the service plan did not contain documentation of a review by a nurse or medical practitioner. 4. In an interview, E1 reported R1, R2, and R3 received medication administration and acknowledged the service plans were not signed by a nurse or medical practitioner.