Extended Family II Alh

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 evacuation drills had been conducted on January 4, 2023 and December 24, 2023 2. In an interview, E1 acknowledged an evacuation drill for employees and residents had not been conducted at least once every six months.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for two of two sampled staff regarding fall prevention and fall recovery. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Policy Topic: Fall Prevention & Fall Recovery Training" This policy stated, "Initial training in fall prevention and fall recovery will take place during orientation of new employment. Continued competency training in fall prevention and fall recovery will occur at each incident that occurs in the home with a resident." 2. A review of facility incident reports revealed the following incidents that had occurred in the home with a resident between January 2023 and May 2023: - January 7, 2023, 12:00 AM, "[R3] refused to use standing lift to transfer to the bathroom, started becoming verbally aggressive. [R3] was constantly reminded that it was for their safety as well as staff's. [E4] was present, [R3] started mocking [E4] saying [E4] should learn English because what [E4] was learning wasnt' good enough. Towards the end [R3] said [R3] didn't care if [R3] peed [themselves] to then, 'fine just do it.' [R3] was then notified that [R3] had no medication explaining why that was, but was angry the whole time, took the nighttime pills [R3] did have then threw the pull cup at me. Refused a shower and went to bed."; - January 25, 2023, 3 AM, "[R6] was confused, tried to open the front door. Left [R6's] walker and walked a few steps, lost [their] balance and fell on [their] right side, Injury: Cut above right eyeball, Action taken by to prevent reoccurence: Family was called earlier letting them know of [R6's] anxiety."; - January 25, 2023, 5 AM, "[R5] forgot to lock [R5's] wheelchair when [R5] tried to sit down on the chair it moved and [R5] fell. Injury: Skin tear on [left blank], Action taken by to prevent reoccurence: [Left blank]"; - January 27, 2023, 12:30 PM, "Caregiver found [R4] on the floor stating [R4] fell, injury: broken toenails, Action taken by to prevent reoccurence: put bed alarms on at all times when in bed."; - February 1, 2023, 5 PM, "[R6 representative] felt unhappy because the orders did not match the MAR. The orders and the medicine containers had different instructions, we wrote the orders as specified in the bottles. The Pharmacy confirmed that was the order they had on file. We will correct the MAR to match the order the on call hospice nurse clarified the order. [R6's representative] also complained because night shift caregiver administered morphine to resident. It was the only pain medication we had on hand and we have an order for it and [R6] was in pain, Action taken by to prevent reoccurence: Will call [R6's representative] before administering morphine."; - March 4, 2023, 2:30 PM, "I heard a thud towards [R5's] bedroom and found [R5] on the floor, Action taken by to prevent reoccurence: Reminded [R5] to use call button for help."

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented for discarding medication including expired medications. The deficient practice posed a health risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "R9-10-816 Medication Services." This policy stated, "Medications which are discontinued will be offered back to the resident's family only if they are over the counter medications. A discontinued medication form will be completed and signed by the resident manager. Medications which are not returned will be disposed of by the resident manager, Medications will be gathered and locked in administrative office until they are taken to a Federal Disposal Site (Walmart) by the manager. If a medication needs to be disposed of on site, a certified caregiver in the presence of a witness, by dissolving the medication in water in an enclosed zip lock in the microwave for 15-30 sec. and then flushed down the toilet. A medication disposal form will be completed and signed by the resident manager / certified caregiver and the witness." However, the policy did not cover expired medications. 2. During the facility tour, the surveyor observed boxes containing R2's current and active medications included the following: - A box of, "Albuterol Sulfate Inhalation Aerosol," with a marked expiration of February 14, 2023; - A box of, "Albuterol Sulfate Inhalation Aerosol," with a marked expiration of August 20, 2022; and - A box of, "Albuterol Sulfate Inhalation Solution," with a marked expiration of January 27, 2024. 3. During an interview, E1 acknowledged the manager had not established, documented, and implemented a policy and procedure for discarding medication including expired medication.

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 and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked two shifts per day, from 6 AM to 6 PM and from 6 PM to 6 AM. 2. A review of facility documentation revealed disaster drills during the previous 12 months had been conducted and documented as follows: 6 AM to 6 PM shift: - January 30, 2023; - May 23, 2023; - July 16, 2023; and - December 18, 2023. 6 PM to 6 AM shift: - January 5, 2023; - April 26, 2023; - September 27, 2023; and - October 27, 2023. 3. In an interview, E1 acknowledged a disaster drill for employees had not been conducted on each shift at least once every three months and documented.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of cardiopulmonary resuscitation training, to include a demonstration of the employee's ability to perform cardiopulmonary resuscitation, to include the qualifications for an individual to provide CPR training, and to include the time frame for renewal of CPR training, for one of two caregivers sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "R9-10-806. Personnel," which stated, "10. Before providing assisted living services to a resident, a manager or a caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training specific to adults...C. At extended family homes a personal (sic) record for each employee or volunteer will consist of: C.vi. CPR and First Aid Cards, verified by management." However, this policy did not cover the method and content of CPR training, and did not require a demonstration of the employee's ability to perform CPR, did not include the qualifications for an individual to provide CPR training, and did not specify the time-frame for renewal of CPR training. 2. A review of the facility's policies and procedures revealed a policy titled, "R9-10-803 A.R.S. Administration," which stated, "Policy Topic: CPR, First Aid...Extended family homes staff shall initiate CPR in accordance with its certified training for CPR before the arrival of emergency medical services...Staff who are certified in CPR shall be available at all times." However, this policy did not cover the method and content of CPR training, and did not require a demonstration of the employee's ability to perform CPR, did not include the qualifications for an individual to provide CPR training, and did not specify the time-frame for renewal of CPR training. 3. A review of E2's personnel record revealed E2 had been hired in August of 2022 as a caregiver. 4. A review of E2's personnel record revealed a full page CPR and First Aid certificate from the National Safety Council with a marked expiration of November 2022. However, this was not a card and management verification of the training had not been documented. 5. A review of E2's personnel record revealed a full page CPR and First Aid certificate from the Postgraduate Institute for Medicine dated June 27, 2023, seven months after the expiration of the previous certificate. The certificate indicated it was, "An internet based activity on 6/27/2023." However, this was not a card and management verification of the training had not been documented. 6. A review of E2's personnel record revealed a copy of a CPR and Firs

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. A review of E2's personnel record revealed a signed job description for, "Certified Caregiver." The job description had been signed by E2 on August 9, 2022 and the "hiring staff" on August 13, 2022. The job description required, "Certification as a caregiver as acknowledged by the state of Arizona (must have ALTP number on certificate)." 2. A review of E2's personnel record revealed a copy of a caregiver training certificate issued on October 27, 2023, 14 months after E2 was hired as a caregiver. 3. A review of a facility work schedule dated May 6 through May 19, 2023, prior to E2 becoming a certified caregiver. The work schedule indicated E2 worked as the only caregiver in the facility from 2 PM until 10 PM on May 6, from 6 PM until 10 PM on May 7, from 2 PM until 10 PM on May 11, from 6 AM until 10 PM on May 12, from 2 PM to 10 PM on May 13, from 2 PM until 10 PM on May 14, from 6 AM until 6 PM on May 18, and from 6 AM until 6 PM on May 19, 2023. 4. In an interview, E2 reported having direct care worker training and not knowing upon hire it was not the same as being a certified caregiver. E2 reported having become a certified caregiver upon learning the direct care worker certificate was not sufficient. 5. In an interview, E1 acknowledged E2 had not provided documentation of completion of a caregiver training program prior to being employed as a caregiver.

Based on record review, documentation review, and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility including whether the individual required continuous nursing services or restraints, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed a document titled "Authorization for Medication Administration/Services." This document was signed by a medical practitioner within 90 calendar days before admission and stated whether each resident would require continuous medical services or intermittent nursing services. However, the document did not state whether each resident required continuous nursing services or restraints. 2. In an interview, E1 acknowledged the admissions form provided by the facility for R1 and for R2 did not include the required verbiage stating whether the resident required continuous nursing services or restraints.

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, and included medication administration or assistance in the self-administration of medications, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed an order dated January 26, 2022 for, "New Compression Stocking to be applied upon awakening and removed at bedtime, not to exceed 12 hours of wear." 2. A review of R2's medical record revealed an order to discontinue compression stockings was not available for review. 3. A review of R2's medical record revealed a service plan, dated December 23, 2023, for directed care services. However the service plan did not include assistance with compression stockings. 4. In an interview, E1 reported R2 was not being provided assistance with compression stockings, however, E1 acknowledged an order to discontinue the compression stockings had not been provided for review and R2's service plan did not include the ordered service.

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, and the nurse or medical practitioner who reviewed the service plan, when initially developed and when updated, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's and R2's medical records revealed each resident had current and historical service plans. However, the service plans did not include all required signatures. R1's January 28, 2023 service plan had not been signed by a nurse or R1 or R1's representative, and R2's December 23, 2023 service plan had not been signed by R2 or R2's representative. Documentation of attempts to obtain a representative's signature on each service plan were not available for review. 2. In an interview, E1 acknowledged the service plans provided for R1 and R2 had not all been signed and dated by the resident or their representative or a nurse when initially developed and when updated.

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)(1-7), for one of one directed care residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated December 23, 2023, for directed care services. The service plan did not include the following: - the determination in R9-10-814(B)(2)(b)(iii), dated within six months of the on-site inspection; and - Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan 2. A review of R2's medical record revealed a document titled, "Physician Authorizations," which complied with the requirements in R9-10-814(B)(2)(b)(iii). However, the document was dated July 17, 2023, more than six months prior to the on-site inspection, and a current authorization was not available for review. 3. In an interview, E2 acknowledged R2's service plan did not include all of the requirements in R9-10-815(C)(1-7).

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, 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 documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a facility tour, the Compliance Officer observed the rear door of the facility did not have a door alarm and did not control egress of a resident from the facility. The rear door led to a fenced and secured outside area. 3. During a facility tour, the Compliance Office observed an exit door from resident bedroom #10 did not have a door alarm and did not control egress of a resident from the facility. This side door led to a fenced and secured outside area. 4. In an interview, E1 acknowledged a resident could egress through either the side or back door without alerting a caregiver to the egress of the resident.

Based on documentation review, record review, observation, and interview, the manager failed to implement a policy and procedure to protect the health and safety of a resident that covered assisting a resident in procuring medication for one of two sampled residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "R9-10-816 Medication Services." This policy stated, "To prevent medication errors, Extended Family Assisted Living Homes recommends the use of Salibas Pharmacy for all residents. Salibas delivers medication cards, properly labeled in amounts of 28-day increments. There is no additional cost and most if not, all insurance companies work with Salibas Pharmacy. If a family chooses not to utilize Salibas Pharmacy, all medications must be brought in bottles, each must be labeled properly. All medications should be in their originally labeled containers which contain the name of the resident, the name of the medication, the dose,time, and route of administration, and any special instructions. All medications (including over-the-counter medications) can be ordered through Salibas Pharmacy. If the family obtains the medication, then an order must be also on file. All medications (including over the counter medications) brought into this facility must be accompanied by written instructions from the physician which states the name of the resident, the name of the medication, and the dose, time, and route of administration. Special instructions and guidelines should also be included. At least once every 6 months a medication audit will be conducted either by PCP signed medication audit sheet or having PCP office e-mail or fax the monthly notes with all medications and Manager having PCP sign on the papers. To help ensure that the resident is receiving the best possible care. Hospice patients have a RN that reviews medication on a more frequent basis so this sheet may be used to consolidate the meds to one place unless the hospice provides a list of medications that can be audited to the current MARS." 2. A review of R2's medical record revealed a signed medication audit sheet, dated within the previous six months, was not available for review per facility policy. 3. A review of R2's medical record revealed an order, dated April 5, 2022, which included an order for, "Senna Oral Tablet 8.6 mg, Give 8.6 mg by mouth twice daily." 4. A review of R2's medical record revealed a signed medication list, dated February 19, 2022. The list included the following medication: - Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution Inhalation 2 puffs by INH Q6 hours for COPD." 5. The Compliance Officer observed R2's medications did not include Senna tablets. The Compliance Officer observed two boxes of Albuterol Sulfate inhalers were available. However, one box had a marked expiration of February 14, 2023, and the second box had a marked expiration of August 20, 2022. No other containers of Albuterol Sulf

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication, and false or misleading information was provided to the Department Findings include: 1. A review of R1's medical record revealed a service plan, dated June 28, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed an untitled Activities of Daily Living (ADL) document dated August 2023. The ADL indicated R1 was "Out" for dinner on August 22, 2023, and was at, "hospital" and did not receive any services on August 23, 2023. 3. A review of R1's medical record revealed a document titled, "Extended Family Homes Anatomical Diagrams-Skin Surface Assessment," dated August 24, 2023. The document stated, "Came back from hospital on 08/24/2023." 4. A review of R1's medical record revealed a medication administration record, (MAR) dated August 2023. The MAR indicated R1 had been provided the following medications at 8 PM on August 23, 2024, which was false and misleading because R1 was in the hospital at this time: - "Latanoprost 0.005% Instill 1 drop in both eyes once daily at bedtime"; - "Seroquel 25 mg, take 1 at by mouth at bedtime"; and - "Calmoseptine Ointment, Apply to buttocks 3 times daily." 5. A review of R2's medical record revealed a service plan, dated December 23, 2023, for directed care services including medication administration. 6. A review of R2's medical record revealed an order, dated April 5, 2022, which included an order for, "Senna Oral Tablet 8.6 mg, Give 8.6 mg by mouth twice daily." 7. A review of R2's medical record revealed a signed medication list, dated February 19, 2022. The list included the following medication: - "Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution Inhalation 2 puffs by INH Q6 hours for COPD"; - "Flovent HFA 110 MCG/ACT Aerosol Inhalation 1 puff inhaled orally 2 times per day for COPD"; - The list of orders did not include an order for Fluticasone. 8. During the on-site inspection. E1 contacted R2's medical provider and obtained a current list of medications, however, this list was not signed by a medical practitioner. The list included the following: - "Senna Oral Tablet 8.6 mg, Give 8.6 mg by mouth twice daily"; - "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Take 2 puffs by mouth every 6 hours"; - "Flovent HFA inhalation aerosol 110 MCG/ACT Take 1 puff by mouth twice daily at 8 AM and 8 PM"; - "Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 MCG/Dose Take 1 puff by mouth twice daily at 8 AM and 8 PM"; and - "Levothyroxine Sodium Oral Tablet 100 MCG, Take 100 mcg by mouth once daily at 8 AM." 9. A review of R2's medical record revealed a MAR dated March 2024. The

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cup on the counter in a shared, resident-accessible bathroom adjacent to the dining room. The cup contained two tubes of toothpaste, a toothbrush, and a tube of, "Calmoseptine" ointment with a prescription label for a resident which stated, "apply a thin layer topically to the rash on buttocks 3 times daily and with brief changes." 2. During an environmental inspection of the facility, the Compliance Officer observed an unlocked drawer in the kitchen containing objects such as batteries, altoids, tape, a vape, and a flashlight. Also in the drawer, the Compliance Officer observed a tube of "Hycrocortisone Cream 1%," with a prescription label for a resident which stated, "apply to affected area topically three times a day as needed." 3. During an environmental inspection of the facility, the Compliance Officer observed an unlocked refrigerator in a hallway near the shared bathroom. Inside the refrigerator, the Compliance Officer observed a clear plastic tote with a blue lid containing medications. The tote did not have a lock. Inside the tote, the Compliance Officer observed two containers of, "Lorazepam 2MG/ML intensol" with prescription labels for R2, and two boxes of, "Gentamicin Sulfate." 4. During an environmental inspection of the facility, the Compliance Officer observed the door to a resident bedoom was open and the bedroom was unoccupied at the time of the inspection. In the resident bedroom, marked "Master BDRM #1" on the facility map, the Compliance Officer observed the following medications on a counter adjacent to a handwashing sink: - Eye drops; - Chest Rub; and - Antacid tablets. 5. In an interview, E1 acknowledged medications stored by the assisted living facility had not been stored in a locked area.

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a risk as critical information needed in an investigation regarding a resident's urgent medical needs were not obtained as required. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "R9-10-818 Policy and Procedure: Emergency and Safety Standards," which stated, "B. Incident Report: When a resident has an incident, accident, emergency, or injury (even unexplained) that results in the resident needing staff assistance or medical services, staff is to ensure the following:...3. Documents the occurrence on an Incident Report thoroughly and puts the report in the red hanging bin with incident report manila folder. Each home will have its own." 2. A review of R1's medical record revealed an untitled Activities of Daily Living (ADL) form dated August 2023. The ADL was marked "Out" for dinner on August 22, 2023, and was marked, "Hospital" on August 23, 2023. 3. A review of R1's medical record revealed a form titled, "Extended Family Homes Anatomical Diagrams-Skin Surface Assessment," dated August 24, 2023. The form stated, "Came back from hospital 8/24/23." The skin assessment form had circled on both knees, the left shin, the right bicep, and the right wrist and hand, but no documentation to indicate the what the notations signified. 4. A review of R1's medical record revealed a form titled, "Extended Family Homes Anatomical Diagrams-Skin Surface Assessment," dated August 31, 2023. The form had a circle on the buttocks with a note, "tender, bleeding" and a circle on the left elbow with a note, "2 1/2 skin tear" 5. A review of R1's medical record revealed an untitled Activities of Daily Living (ADL) form dated September 2023. The ADL was marked, "Out" for dinner on September 6, 2023, and was marked, "Hospital" on September 7, 8, 9, and September 10, 2023. The form included the note, "Passed away 09/11/23" 6. A review of facility incident reports revealed incident reports for R1's hospitalizations in August 2023 and September 2023 were not available for review. 7. In an interview, E1 acknowledged R1's record did not include documentation showing the date and time of each incident; a detailed description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers and 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 drawer in the kitchen containing the following: - "Weiman Glass Cook Top Heavy Duty cleaner & polish"; and - "Cerama Bryte cooktop cleaner." 2. During an environmental inspection of the facility, the Compliance Officer observed an unlocked drawer in the dining room containing a bottle of, "Bic Wite-out." 3. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.