East Shea II Assisted Living LLC

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. Arizona Revised Statutes (A.R.S.) \'a7 36-420.01. states: "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." 2. A review of the facility's policies and procedures revealed a policy dated June 17, 2022 titled "Duty of Care" which stated, "...12. This facility shall develop an initial training, conduct and administer continued competency training in Fall Prevention and Fall Recovery Program." Further review of facility policies and procedures revealed an undated policy titled "Falls Prevention and Falls Recovery Training." This policy included detailed descriptions of a fall risk assessment procedure, intervention strategies, and post fall management for residents. However, the policy did not include details about how and when initial training and continued competency training in fall prevention and fall recovery is administered for all staff. 3. A review of E2's, E3's, E4's, and E5's personnel records revealed certificates indicating E2, E3, E4, and E5 completed a two hour continued education unit on the topic of "Preventing Falls." The training certificates were issued by "ALTS - Assisted Living Training School." However, the description of items covered in the course did not include any training related to fall recovery. 4. In an interview, E1 reported E1 was unclear about the details of A.R.S. \'a7 36-421.01. E1 reported all staff are trained during orientation using the facility's "Falls Prevention and Falls Recovery Training" and also receive a two hour continued education unit in "Preventing Falls." However, E1 acknowledged the facility's training program did not include details on when and how staff receive initial training and continued competency training in fall prevention and fall recovery. E1 acknowledged the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. This is a repeat citation from the on-site complaint inspection conducted on December 22, 2022.

Based on record review, documentation review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services. However, documentation to demonstrate R1's service plan was reviewed and updated at least once every six months was not available for review. 2. A review of R3's medical record revealed a service plan which was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition was not available for review. 3. In an interview, E2 reported E2 had the aforementioned documents on E2's computer and would send them to the Compliance Officer during the inspection as E2 could not come on-site. However, E2 did not provide the documents until after the Compliance Officer had completed the inspection at 2:15 PM on June 13, 2023. 4. In an email, received by the Department on June 13 at 4:12 PM, E2 provided the requested updated service plan for R1. However, the documentation provided after the Compliance Officer had already exited from the facility. In the email, E2 acknowledged the documentation was not provided within two hours of a Department request as E2 had an emergency. 5. In an email, received by the Department on June 13 at 5:32 PM, E2 provided the requested updated service plan for R2. However, the documentation provided after the Compliance Officer had already exited from the facility. In the email, E2 acknowledged the documentation was not provided within two hours of a Department request as E2 had an emergency. 6. In an interview, E3 acknowledged the requested service plan updates for R1 and R3 were not provided to the Department within two hours of a Department request.

Based on observation, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for two of four caregivers sampled. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. The Compliance Officer observed E3 working alone on the premises for the duration of the inspection conducted on June 13, 2023. 2. A review of E3's personnel record revealed E3 was hired as a caregiver. E3's personnel record revealed a document titled, "Pre-Employment Questionnaire" dated February 1, 2019. The document contained a section titled "Work Experience" which was blank. Further review of E3's personnel record revealed a caregiver training certificate from "Ability Training and Services," dated November 2, 2012. 3. In an interview, the Compliance Officer asked E3 when E3 earned E3's caregiving certification. E3 reported to not remember when E3 earned E3's caregiver certification. E3 reported E3 was from another country and had moved to Arizona to begin working as a caregiver in June 2020. E3 reported E3 did not know where the caregiver training certificate from "Ability Training and Services" came from, as E3 was not in Arizona in November 2012. 4. A review of E5's personnel record revealed E5 was hired as a caregiver. E5's record revealed a document titled, "Pre-Employment Questionnaire" dated January 25, 2023. The document included a section titled "Work Experience." The work experience contained four employers, dated from March 2014 through November 1, 2012. The document showed E5 worked as an "Animal Technician" in another country from March 2014 to January 2017. E5 then worked in another country as a "Team Leader" at "Visaya Knowledge Process" from February 2017 to September 2022. The application indicated E5's first job in Arizona was from "October 30, 2022 to November 1, 2022" as a "Caregiver" at "Hilda Lood." Further review of E5's personnel record revealed a caregiver training certificate from"Ability Training and Services", dated September 12, 2012. 5. In an interview, E2 reported E2 did not verify E3's or E5's caregiving training certificates. E2 reported both E3 and E5 brought caregiver certificates with them from a previous assisted living facility and E2 assumed the certificates were valid. E2 reported E2 would ensure E3 and E5 attended a new caregiver training and obtained verifiable certificates.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for one of four caregivers sampled. Findings include: 1. A review of facility documentation revealed a staffing schedule dated May 2023 which indicated the facility utilizes two shifts from 7:00 AM to 7:00 PM (day), and 7:00 PM to 7:00 AM (night). The schedule revealed E5 was scheduled to the work day shift May 2-5, 9-13, 16-20, 23-27, and 30-31, 2023. 2. A review of facility documentation revealed a policy titled "Staffing Documentation and Recordkeeping" which stated, "Prior to a new employee providing services to the resident orientation training will be completed that is specific to the duties to be performed by the manager, caregiver or assistant caregiver. A. Orientation Training Checklist will be used to document the orientation progress. B. Verify employee's skills and knowledge per the job description." 3. A review of E5's personnel record revealed a document titled "Employee Orientation Acknowledge," which included a checklist for the manager to verify E5's skills and knowledge. The items listed on the first page of the checklist included a bracket and signature in the "signed off" column, however there was no date indicated, and the second page of the document was blank. E5's personnel record also included a document titled "Caregiver, Assistant Caregiver or Employee Skills Documentation." However, most of the items on the document were not marked as reviewed. 4. In an interview, E2 reported E2 began verifying E5's skills and knowledge, but had not yet completed the verification. E2 acknowledged E5's skills and knowledge were not verified and documented before E5 provided physical health services, and according to policies and procedures.

Based on observation, record review, documentation review, and interview, the manager failed to ensure an assisted living facility had a manager and caregiver with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. Findings include: 1. The Compliance Officer observed E3 working alone on the premises for the duration of the compliance inspection conducted on June 13, 2023. 2. A review of E3's personnel record revealed E3 was hired as a caregiver. E3's personnel record revealed a document titled, "Pre-Employment Questionnaire" dated February 1, 2019. The document contained a section titled "Work Experience" which was blank. Further review of E3's personnel record revealed a caregiver training certificate from "Ability Training and Services," dated November 2, 2012. 3. In an interview, the Compliance Officer asked E3 when E3 earned E3's caregiving certification. E3 reported to not remember when E3 earned E3's caregiver certification. E3 reported E3 was from another country and had moved to Arizona to begin working as a caregiver in June 2020. E3 reported E3 did not know where the caregiver training certificate from "Ability Training and Services" came from, as E3 was not in Arizona in November 2012. 4. A review of R1's medical record revealed a service plan dated February 4, 2023 for personal care services which stated the following: "Ambulation: Trained Caregiver assist, non ambulatory, Two person assist, bedbound/weelchair bound, Full Assist, Requires repositioning every 3 hours & PRN." 5. A review of facility documentation revealed a work schedule dated May 2023. The schedule revealed only one caregiver was scheduled to work from 7:00 PM to 7:00 AM every day in May 2023. 6. In an interview, E2 reported one caregiver was able to assist R1 with a hoyer lift, so E2 did not believe the facility required two caregivers to be scheduled for each shift. E2 acknowledged the facility may be unable to meet the needs of R1 and ensure the health and safety of R1 with only one caregiver scheduled.

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 completed orientation, for two of five personnel members sampled. Findings include: 1. A review of facility documentation revealed a policy titled "New Employee Orientation" which stated, "Before providing services by the assisted living facility to a resident, a manager, caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver or assistant caregiver based up the specific requirements in the policies and procedures as defined by the "Scope of Services"...The New Orientation Checklist will be used to document the orientation process." 2. A review of E1's personnel record revealed E1 was hired as an assisted living facility manager. E1's record revealed no documentation indicating E1 received orientation specific to the duties to be performed by a manager at the facility. 3. In an interview, E2 reported E2 was not aware that a manager needed to receive orientation. E2 acknowledged E1's personnel record did not include documentation of a completed orientation. 4. A review of E5's personnel record revealed E5 was hired as a Caregiver. E5's record revealed a document titled "Employee Orientation Acknowledge," which included a checklist of items to be covered during E5's orientation. The items listed on the first page of the checklist included a bracket and signature in the "signed off" column, however there was no date indicated, and the second page of the document was blank. No other documentation of a completed orientation for E5 was available for review. 5. In an interview, E2 acknowledged E5's personnel record did not include documentation of E5's completed orientation.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for three of five personnel records sampled. 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. A review of facility policies and procedures revealed a policy titled "Staffing Documentation and Recordkeeping" which stated, "During the time of whether to consider hire for an employee: a. Check references." 3. A review of E1's personnel record revealed no documented, good faith efforts to contact previous employers to obtain information or recommendations relevant to E1's fitness to work in a residential care institution. 4. A review of E4's personnel record revealed no documented, good faith efforts to contact previous employers to obtain information or recommendations relevant to E4's fitness to work in a residential care institution. 5. A review of E5's personnel record revealed no documented, good faith efforts to contact previous employers to obtain information or recommendations relevant to E5's fitness to work in a residential care institution. 6. In an interview, E2 reported good faith efforts to 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 were made for E1, E4, and E5. However, E2 acknowledged no documentation of these efforts was available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, for one of three residents reviewed. Findings include: 1. A review of R2's record revealed no written service plan. Based on R2's acceptance date, this documentation was required. 2. A review of R2's medical record revealed R2 received medication administration services. Review of R2's medical record revealed documents titled "Activity Log," which documented activities of daily living (ADLs) provided to R2 in May and June, 2023. The documents identified R2 received caregiver assistance with "bathing", "dressing", "combing hair", "skin care", "pericare", "wound care", and "nightly checks". 3. In an interview, E2 reported R2's service plan had not been completed as R2 was a "new resident." E2 acknowledged the manager failed to ensure R2 had a written service plan.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, or the nurse or medical practitioner who reviewed the service plan, when updated, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a personal care service plan which was reviewed and updated on August 10, 2022. However, the service plan update was not signed and dated by a registered nurse, the resident's representative, or the facility manager. 2. In an interview, E2 reported R1 had each updated service plan signed by a nurse, R1's power of attorney (POA), and the facility's manager. E2 reported E2 would email the Compliance Officer copies of the signed updates. However, the service plan E2 sent to the Compliance Officer did not include the aforementioned signatures for the service plan updated on August 10, 2022. 3. In an interview, E3 acknowledged R1's personal care service plan was not signed and dated by the resident's POA, the manager, or the nurse who reviewed the service plan when the plan was updated.

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 three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated February 4, 2023 for personal care services. The service plan indicated the following services to be provided for R1: -"Bathing: Trained Caregiver helps, Shower 2x weekly, Sponge bath 1x daily"; -"Nail Care: Trained Caregiver helps, finger nails cleaned, trimmed & file weekly & prn"; and -"Ambulation: Trained Caregiver assist, non ambulatory, Two person assist, bedbound/weelchair bound, full assist, Requires repositioning every 3 hours & PRN." 2. A review of R1's medical record revealed activities of daily living (ADL) sheets for May and June, 2023. R1's May and June ADL sheets revealed R1 received assistance with a "Bed Bath/Sponge Bath" from June 1-31, 2023 and on May 1-2, and 5-7, 2023. However, no documentation to indicate R1 received assistance with showering, nail care, or ambulation in May or June, 2023 was available for review. 3. In an interview, R1 reported R1 did not receive showers, and only received a bed bath "maybe once a week." R1 reported R1's room smelled like urine because R1 had not been bathed in several days. 4. In an interview, E2 reported all services were provided to R1 as outlined in R1's service plan. E2 reported R1 did receive bed baths every day, and was offered showers at least twice a week, although E2 reported R1 often refused to shower. E2 reported R1 had a traumatic brain injury and "was lying" to the Compliance Officer. However, E2 acknowledged caregivers did not document services provided to R1 in R1's medical record. 5. A review of R3's medical record revealed a service plan dated May 1, 2023 for directed care services. The service plan indicated the following services to be provided for R3: -"Bathing: Trained Caregiver helps, Sponge bath 2x daily"; -"Hair Cut & Other Hair Care Related Services: Trained Caregiver helps, Comb Hair, daily, assistance"; -"Oral Care: Trained Caregiver helps, brush teeth, daily, full assist"; -"Nail Care: Trained Caregiver helps, finger nails cleaned, trimmed & file weekly & prn"; -"Skin care: Trained Caregiver helps, apply lotion to bony areas daily, check pressure areas daily"; -"Dressing: Trained Caregiver helps, Assist in selecting clothes, Assist in putting on & removing clothes"; and -"Mobility Assistance: Assist out of bed in wheel chair, Assisted out of bed in recliner." 6. A review of R3's medical record revealed an ADL sheet for June 2023. R3's June ADL sheet revealed R3 received assistance with "Dressing" and "Comb Hair" on June 2, 6, and 9, 2023. However, no documentation to indicate R3 received assistance with sponge baths, oral care, nail care, skin care, dressing, or transfers at the frequency specified in R3's service plan in June 2023 was available for review. 7. In an

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a potential for psychological distress and physical injury. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-807(C)(5) states: "C. A manager shall not accept or retain an individual if: 5. The individual requires restraints, including the use of bedrails." 2. During the environmental inspection of the facility, the Compliance Officer observed R1's bed had bed rails on both sides of the bed. 3. A review of R1's medical record revealed a service plan for personal care services dated February 4, 2023. The service plan revealed R1 was non-ambulatory and required a two-person full assist. A review of R1's medical record also revealed a document titled "Pre-Determination" dated February 1, 2023 which stated, "Does this person require restraints (includes bedrails): No." 4. In an interview, R1 reported the facility put up the bedrails "several months ago" and R1 was unable to get out of the bed with the rails in place. R1 reported R1 was unable to raise and lower the rails. 5. In an interview, E2 reported the facility put the bed rails on to keep R1 in bed at night, and to prevent R1 from falling out of the bed. E2 reported R1 could not get out of bed without assistance, so E2 did not view the bed rails as a restraint. However, E2 acknowledged the bed rails were acting as a restraint for R1.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a posted food menu dated May 8-14, 2023. However, no current food menu was conspicuously posted. 2. In an interview, E2 reported the food menu was prepared and E2 planned to post it later in the day. E2 acknowledged the current menu was not posted at the time of the inspection.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. Findings include: 1. A review of facility documentation revealed a staffing schedule with the following two shifts: -1st Shift, 7:00 AM-7:00 PM; and -2nd Shift, 7:00 PM-7:00 AM. 2. A review of facility documentation revealed disaster drills were conducted on the following dates and times: -January 4, 2022 at 10:40 AM; -April 10, 2022 at 7:15 PM; and -July 1, 2022 at 10:22 AM. However, documentation indicating disaster drills were conducted on each shift at least once every three months was not available for review. 3. In an interview, E2 reported E2 thought the facility had conducted disaster drills after July 1, 2022, but E2 could not remember when and if the drills were conducted. E2 acknowledged a disaster drill was not conducted on each shift at least once every three months. This is a repeat citation from the previous on-site compliance inspection conducted on June 3, 2022.

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. Findings include: 1. A review of facility documentation revealed the most recent documented evacuation drill was conducted at 9:00 AM on June 5, 2021. No other documentation showing disaster drills were conducted at least once every six months was available for review. 2. In an interview, E2 reported E2 thought the facility had conducted evacuation drills after June 5, 2021, but E2 could not remember when and if the drills were conducted. E2 acknowledged an evacuation drill was not conducted at least once every six months.