Crystal Cove Home Care II

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. In documentation review, the facility's disaster plan did not indicate the plan was reviewed at least once every 12 months, as required. 2. In an interview, E2 acknowledged the facility did not have documentation the disaster plan was reviewed at least once every 12 months. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

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 a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills conducted within the last 12 months. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency situation. Findings include: 1. A review of facility documentation revealed no documentation of evacuation drills conducted within the last 12 months. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1) through (9), for three of three sampled residents. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed standardized emergency responder forms were not available for review. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management". The policy stated, "...1. A plan is established, documented, and implemented for an ongoing quality management program...the documented report is submitted to the governing authority...". 2. The Compliance Officer requested to review the facility's quality management reports submitted to the governing authority. However, the reports were not provided for review. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three residents sampled. 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 R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview,the manager failed to ensure a resident had a written service plan which was signed and dated by the resident or resident's representative, the manager, and, if a review was required, by the nurse or medical practitioner who reviewed the service plan. This posed a health and safety risk if the resident or resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. A review of R1's medical record did not include documentation the resident's service plan was signed and dated by the resident or resident's representative for the service plan dated April 2, 2025. 2. A review of R3's medical record did not include documentation the resident's service plan was signed and dated by the resident or resident's representative for the service plan dated February 3, 2025. 3. In an interview, the findings were reviewed with E2 and no additional information was provided.

Based on record review and interview, the owner failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for three of three employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A.R.S. \'a7 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." 2. A review of E1's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 3. A review of E2's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 4. A review of E3's personnel record revealed an application for a fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C) was not available for review. 5. In an interview, E2 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C) for E1, E2, and E3 was not available for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of facility documentation revealed documents labeled "Crystal Cove Policy and Procedure Manual." However, there was no documentation to indicate the policies and procedures were reviewed at least once every three years and updated as needed. 2. In a interview, E1 acknowledged the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "1. The department shall: (d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1's medical record revealed no documentation of the notification of R1 of the availability of vaccination for influenza and pneumonia. Based on R1's acceptance date, this documentation was required. 3. A review of R2's medical record revealed no documentation of the notification of R2 of the availability of vaccination for influenza and pneumonia. Based on R2's acceptance date, this documentation was required. 4. During an interview, E1 acknowledged R1's and R2's medical records did not include current documentation showing the influenza and pneumonia vaccination was offered or received.