Crocus AL LLC

Based on record review, documentation review, and interview, for one of five caregivers reviewed, the manager failed to ensure before providing assisted living services to a resident, 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 to the facility and the residents, as required. Findings include: 1. In observation, E6 was observed working at the facility, with seven residents. 2. During an interview, E6 reported [E6] filled in as a caregiver, when needed by the facility. 3. In record review, E6's personnel record did not include documentation E6 completed orientation. 4. During an interview, E1 acknowledged the orientation documentation, for E6, was not completed.

Based on record review and interview, for one of seven employees reviewed, the manager failed to ensure a personnel record included the individual's starting date of employment. Findings include: 1. In observation, E6 was observed working at the facility. 2. In record review, the personnel record for E6 did not include E6's starting date of employment. 3. During an interview, E6 reported [E6] filled in at the facility, when needed. 4. During an interview, E1 acknowledged E6's personnel record did not include E6's starting date of employment.

Based on observation, documentation review, record review and interview, for one of six employees reviewed, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411. A.R.S. \'a7 36-411(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 (FP) card. Findings include: 1. In observation, E6 was working at the facility, with seven residents present. 2. In record review, E6's personnel record (no hire date documented), did not include documentation the previous employers were contacted to obtain information or recommendations relevant to the person's fitness to work in the facility, and did not include documentation E6's FP clearance card was verified (FP card issued on January 31, 2022). 3. In documentation review, the FP clearance website revealed E6's FP card was valid. 4. During an interview, the findings were reviewed with E1, who acknowledged the facility did not document efforts to check the references, or the status of E6's FP card.

Based on observation, record review, and interview, for one of five caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident. Findings include: 1. In observation, E6 was observed working at the facility, with seven residents. 2. During an interview, E6 reported [E6] filled in as a caregiver, when needed by the facility. 3. In record review, E6's personnel record did not include documentation E6's skills and knowledge were verified. 4. During an interview, E1 acknowledged the caregiver's skills and knowledge were not verified and documented, which was required before E6 provided services for residents.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a written service plan included the signature and date from the resident or resident's representative. The deficient practice posed a health and safety risk if the resident or the resident's representative did not acknowledge the services that were to be provided. Findings include: 1. In record review, a review of the medical records for R1 and R2, revealed the records did not include an updated service plan, as required. 2. During an interview, the Compliance Officer informed E1 a current service plan was not found in the residents' medical records. 3. E1 provided a service plan for R1, dated April 2, 2024, (received personal care services), and a service plan for R2, dated April 30, 2024, (received directed care services). The service plans did not include the signature and date from the resident or resident's representative. 4. During an interview, E1 acknowledged the residents' service plans were not signed and dated by the resident or the resident's representative.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a written service plan included the signature and date of the manager. The deficient practice posed a health and safety risk if the manager did not acknowledge the documentation on the service plan, and the services to be provided for a resident. Findings include: 1. In record review, a review of the medical records for R1 and R2, revealed an updated service plan was not in the residents' records. 2. During an interview, the Compliance Officer informed E1 a current service plan was not found in the residents' medical records. 3. E1 provided a service plan for R1, dated April 2, 2024, (received personal care services), and a service plan for R2, dated April 30, 2024, (received directed care services). The service plans did not include the signature and date of the manager. 4. During an interview, E1 acknowledged the residents' service plans were not signed and dated by the manager.

Based on observation, documentation review, and interview, for the facility which provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents as an unlocked door provided access to the outside and street area, without alerting employees. Findings include: 1. In documentation review, the facility was licensed at the directed level of care. 2. In observation, the Compliance Officer observed an unlocked door in the common area, which exited to an outside patio. The door did not control or alert employees of the egress of a resident. A resident was observed walking outside on the patio. The bedroom for R3 was observed to have a door leading to an outside patio, which did not control or alert employees of the egress of a resident. 3. During an interview, E1 and E5 acknowledged the doors exiting the facility to the outside, did not control or alert employees of the egress of a resident from the facility, as required.

Based on observation, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked area used only for medication storage. The deficient practice posed a health and safety risk, if medications were accessible to residents. Findings include: 1. During an environmental inspection with E6, the compliance officer observed an unlocked metal box in the kitchen refrigerator. The box was observed to contain resident medications, which included Lorazepam (a controlled substance) medications x 2, and Lantus Insulin medications x 3. 2. During an interview, E1 and E6 acknowledged resident medications were stored in an unlocked manner in the refrigerator, and were accessible to residents. E1 reported [E1] had to break the lock to access the medications, and was going to buy a new container.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. The deficient practice posed a health and safety risk if medications, including narcotics, were not disposed of, as required. Findings include: 1. During a review of resident medication, the Compliance Officer observed R1's medications included the following: - Diphenhydramine 25 mg, 30 capsules dispensed on October 27, 2022 and expired October 21, 2023, with 30 capsules remaining. - Ondansetron 4 mg, 20 tablets, dispensed on October 27, 2022, and expired on October 21, 2023, with 20 capsules remaining. - Cetirizine 50mg, 31 capsules dispensed on October 27, 2022, and expired on October 21, 2023, with 31 capsules remaining. 2. In documentation review, a facility policy, titled, "... Medication Disposal," documented "A manager shall ensure that a residents medication shall be disposed of according to state and federal regulations and established procedure... Prescription medications must be disposed of when it becomes contaminated or damaged, outdated (i.e., expired, or is discontinued by the resident's Medical practitioner. Depending upon the situation, destroy the medication at the facility or return it to the pharmacy. 2. Check the expiration dates for all medications... on a regular basis to ensure that all medications are current..." 3. During an interview, E1 reported the medications were unused and should have been discontinued and discarded.

Based on observation, documentation review, record review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R1 had Percocet 5-325 mg medication (a schedule II controlled substance), and Pregabalin medication (a schedule V controlled substance) stored by the facility. The Percocet medication (120 tablets) was dispensed on April 3, 2024, and the container had 88 tablets remaining. The Pregabalin medication (56 tablets) were dispensed on April 3, 2024, and the container had 69 tablets remaining. 2. In documentation review, a facility policy, titled "... Medication Services," on page 56, documented, "... A narcotic inventory sheet (NIS) is provided for every controlled medication. These forms are usually provided by the pharmacy... Count the number of tablets... available and put the number in the "Amount on Hand" on the form... Write the number of tablets... taken ... by the resident in the "Amount given" column. Subtract that number from the "Amount on Hand" and the result should be placed in the "Amount Remaining" column..."- Page 64 documented, "... Upon the receipt of medications to the facility, personnel shall visually assess the delivery receipt or labels... The information must be written on the NARCOTIC CONTROLLED LOG and attached together with the resident's MAR. 2. The NARCOTIC CONTROLLED LOG will be used to track the cycle of medications administered and determine when inventory needs to be and reordering when there is less than three days of that medication left..." 3. In record review, R1's medical record (received personal care and medication administration services), included documentation R1 received the medications; however, did not include documentation of an inventory of the medications. 4. During an interview, E1 reported the Pregabalin medication tablets exceeded the amount dispensed because a caregiver may have added tablets from a prior medication container into the current prescription medication container. E1 reported the caregivers were trained to document an inventory of controlled substances; however, acknowledged an inventory of R1's controlled substances was not maintained.

Based on observation, record review, and interview, for three of six employees reviewed, the chief administrative officer failed to implement tuberculosis (TB) infection control activities; including baseline screening consisting of assessing risks of prior exposure to infectious TB, and determining if the individual had signs or symptoms of TB. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. The Compliance Officer observed E6 working on the premises of the facility, with seven residents present. 2. In record review, the personnel records for E3, E4, and E7 did not include documentation of a baseline screening consisting of assessing risks of prior exposure to TB, and determining if the individual had signs or symptoms of TB. 3. During an interview, E1 acknowledged the personnel working at the facility did not have the required documentation of a screening and risk assessment for TB, as required by R9-10-113.

Based on observation, record review, documentation review, and interview, for one of two residents reviewed, and receiving opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual, authorized to administer opioids, documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if a resident's pain was not identified, monitored and documented, as required. Findings include: 1. In observation, R1 had Percocet 5-325 mg medication (a schedule II controlled substance), stored by the facility. The Percocet medication (120 tablets) was dispensed on April 3, 2024, and the container had 88 tablets remaining. 2. In record review, R1's medical record (received directed care and medication administration services) included documentation R1 received the opioid medication as ordered; however, did not include documentation of an identification of the resident's need for the opioid, and the monitoring of the effect of the opioid administered. 3. In documentation review, a facility policy, titled "... Medication Services," on page 60-61, documented, "...Upon administration, the designated trained caregiver should: a. Monitor the pain of the resident by listening to resident's self report using a pain scale. b. Identify and document the resident's pain by assessing the amount of pain the resident is experiencing... c. Monitor the response of the resident towards the opioid medication. d. After two.. hours of ... administration assess and document the effectiveness of the opioid medication to the residents..." 4. During an interview, E1 reported the resident received opioid medication. E1 acknowledged the caregivers did not identify and document the resident's need for the opioid before the opioid was administered, and monitor and document the effect of the opioid administered, according to the facility's policies and procedures.

Based on record review, documentation review, and interview, the manager failed to ensure personnel provided appropriate first aid before the arrival of emergency medical services to a resident who had fallen, appeared to be uninjured, and was unable to recover independently. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-420(B)(2) states "Each health care institution:...2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times." 2. A review of R1's medical record revealed a service plan for personal care services dated May 23, 2023. R1's service plan stated, "Transferring, Requires total care...Mobility, Bed Bound, Wheel Chair, Chair Bound, Fall Risk...Transfer Assistance: Yes, 2 Person(s)." 3. A review of facility documentation revealed a document titled "Incident Report" dated July 15, 2023. The incident report stated, "Where did it happen? Bedroom...Date and Time of Occurence: 07/15/2023 5:26 AM...Incident Type: Fall...Describe what happened: [R1] was found on the floor...Did Injury Occur? No...Was ambulance called? Yes...Was the resident sent to the hospital? No...What did the resident say happened? Resident couldn't remember how [R1] fell out of bed...Describe other actions (first aid, etc.) and by whom: Caregiver, paramedics Resident was checked and put back in bed." 4. A review of facility policies and procedures revealed a policy titled "Report of Unusual Occurrence without injury" which stated "1. Do not move a resident who has fallen until examined by the caregiver or manager. 2. If there is no apparent injury, report the occurrence to the manager, resident representative and medical practitioner. 3. Complete the Report of Unusual Occurrence within 24 hours. 4. Closely monitor the resident for 8 hours, and continue to monitor for 72 hours or as directed by the Physician or Nurse." 5. In an interview, R1 reported R1 accidentally rolled out of bed on July 15, 2023 and was unable to get up without assistance. R1 reported R1 called facility night staff for assistance. R1 reported R1 believed E1 was working the night shift on July 15, 2023. R1 reported R1 explained to E1 that R1 was uninjured and was experiencing no pain. R1 reportedly told E1 that R1 just wanted help back into bed, but that E1 was unable and unwilling to assist R1, and called 911 instead. R1 reported E4 lives at the facility and would also have been available to assist E1 and R1, but E4 sleeps at night and was not called to assist. R1 reported R1 was lying on the ground until paramedics arrived "about 20 minutes later," and assisted R1 off of the floor and back into

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's education and experience applicable to the individual's job duties, for one of five personnel records sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Staffing" which stated, "1. Facility must maintain personnel records for each staff member that includes...Documentation of the individual's:...Job experience related to job duties..." 2. A review of facility documentation revealed a staff schedule. The schedule indicated E3 was scheduled to work from 7:00 AM to 7:00 PM on the following dates in 2023: May 1-4, 6-11, 13-18, 20-25, and 27-31; June 1, 3-8, 10-15, 17-22, and 24-29; and July 1-6, 8-13, and 13-16. 3. A review of E3's personnel record revealed an "Application for Employment" which indicated E3 was hired as a caregiver. The personnel record contained a section titled "Work Experience" which stated, "Please list the last five years of work history...Caregiver must...have a minimum of 3 months health-related experience." However, the section included no documentation of work experience applicable to E3's job duties. 4. In an interview, E2 acknowledged documentation of experience applicable to E3's job duties was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated May 25, 2023. The service plan listed the following services to be provided for R1: -"Oral Care, Requires assistance, Twice daily and as needed"; -"Nail Care, Requires assistance, Nails checked daily and trimmed as needed"; and -"Hair Care, Requires assistance, Daily and as needed". 2. Further review of R1's medical record revealed an activities of daily living (ADL) log for June 2023. R1's June 2023 ADL log indicated R1 received assistance with "Hand Nail Care" on June 1, 2023. However no, documentation indicating R1 received daily assistance with nail care was available for review. R1's June 2023 ADL log also included lines to document "Shampoo" and "Oral Care" assistance provided to R1. However, documentation to indicate R1 received assistance with these services in June 2023 was not available for review. 3. In an interview, E2 reported all services were provided to R1 according to the frequency specified in R1's service plan every day in June 2023. E2 reported R1's hair was usually shampooed by caregivers twice a week, or when R1 would allow caregivers to assist. E2 acknowledged oral care, nail care, and hair care services provided to R1 in June 2023 were not documented in R1's medical record. 4. A review of R2's medical record revealed a service plan for personal care services dated April 19, 2023. The service plan listed the following services to be provided for R2: -"Nail Care, Requires assistance, Nails checked daily and trimmed as needed"; -"Hair Care, Requires assistance, Daily and as needed"; -"Dressing, Requires assistance, Twice daily and as needed"; and -"Toileting, Requires assistance, daily as needed". 5. Further review of R2's medical record revealed an ADL log for May 2023. R2's May 2023 ADL log revealed no documentation to indicate the aforementioned services were provided on May 8-9, 13-14, or 21, 2023. 6. In an interview, E2 reported R2 was in the hospital from May 26, 2023 to June 23, 2023, but was at the facility from May 1-25, 2023. E2 reported all services in R2's service plan were provided to R2 according to the frequency specified from May 1-25, 2023, and acknowledged the services provided to R2 were not documented in R2's medical record.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of facility policies and procedures revealed a section titled, "VI. Medication Services" with a "Revision Date" of February 14, 2021. The last page of the section contained a policy titled, "R. Endorsement of Approval, Medication Administration and Treatments" which stated, "As required by AZDHS, if the facility provides medication administration services...a manager shall ensure that the policies and procedures for medication administration are reviewed and approved by a Medical Practitioner, Pharmacist or Registered Nurse and every three years thereafter." Beneath the policy were six blank spaces labeled with "endorsement of approval...date." There was no documented evidence to indicate the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. In an interview, E1 acknowledged the facility's policies and procedures for medication administration were not documented as reviewed and approved by a medical practitioner, registered nurse, or pharmacist.