Dempsey's Adult Care Home

Based on record review and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of three resident records reviewed. The deficient practice posed a risk as R1's primary condition was not a physical health issue and the facility is not authorized to provide behavioral health services. Findings include: Arizona Administrative Code (A.A.C.) R9-10-101.32. states "Behavioral health issue" means "an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors." 1. A review of R2's medical record revealed a service plan for supervisory care services, initiated on July 15, 2019, with updates. The most recent service plan update stated R2 received personal care services. 2. Further review of R2’s service plan revealed R2 had a guardian and the only diagnosis listed in R2’s service plan was schizophrenia. The service plan included R2 was independent for mobility, showering, grooming, oral care, and toileting. R2 received no daily medication, and received a once per month injection of “paliperidone”, received at “Community Partners Healthcare”. 3. In an interview, E1 reported R2 did need assisted living services though was unable to verbalize the need, and agreed the service plan did not identify a primary physical health reason for assisted living services. 4. In an interview, E1 agreed the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and 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 records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a resident bedroom which included a sliding glass door that led to the backyard. The Compliance officer observed the door did not have an alert and was able to be opened without a key or special knowledge. 3. During an environmental inspection of the facility, the Compliance Officer observed a living room with a sliding glass door that led to the backyard. The door did not have an alert and was able to be opened without a key or special knowledge. 4. In an interview, E1 and E2 acknowledged there was a means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility. E1 found unused door alarms, which would be installed on the exit doors immediately.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked laundry room. The Compliance Officer observed two bottles of glass cleaner, a bottle of Listerine, two cans of furniture polish, and a bottle of laundry detergent, stored unsecured on a shelf. 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area and were accessible to residents.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled, "Fall Prevention and Fall Recovery." This policy contained information on fall prevention, fall recovery, and staffing training. 2. A review of E1, E2, and E3's personnel records revealed E1, and E2 had fall prevention and fall recovery training initially and annually, however, E3 did not have documentation indicating that E3 had reviewed or received the fall prevention and fall recovery training. 3. In an interview, E2, acknowledged E3 did not have documentation they reviewed or received the fall prevention and fall recovery training.

Based on documentation review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future. The deficient practice posed a health and safety risk to residents. Findings include: 1. A review of documentation provided by E1 revealed the following: - R2 had an incident resulting in the resident needing medical services on January 13, 2024. The documents did not include "any action taken to prevent the incident from occurring in the future". 2. During an interview, E2 acknowledged that R2's incident report did not include documentation showing any action taken to prevent the incident from occurring in the future.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed a form titled, "Determination for Admission," which was designed to provide documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. However, the form was signed and dated twenty two days after R2's date of admission. 2. A review of R3's medical record revealed a form titled, "Determination for Admission," which was designed to provide documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. However, the form was signed and dated three days after R3's date of admission. 3. In an interview, E1 acknowledged R2 and R3's admission forms were completed after R2, and R3's date of admission.

Based on record review, documentation review, and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections, and offering sufficient fluids to maintain hydration for one of one residents sampled receiving personal care services. Findings include: 1. A review of R1's medical records revealed documentation of a current written service plan for personal care services did not contain the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 2. A review of R2's medical records revealed documentation of a current written service plan for personal care services did not contain the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and - Offering sufficient fluids to maintain hydration. 3. In an interview, E1 acknowledged R1, and R2's service plans did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for one of one directed care residents sampled. Findings include: 1. A review of R3's medical record revealed documentation of service plans indicating R3 was receiving directed care services. However, the service plans did not contain the following: - Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; - Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; - Encouragement to eat meals and snacks; and - Documentation of the resident's weight, or from a medical practitioner stating that weighing the resident is contraindicated. 2. In an interview, E1 acknowledged R3's service plan did not contain all of the requirements for directed care residents.