Faith Care Homes

Based on documentation and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1 . A review of facility documents revealed that the policies and procedures were not reviewed at least once every three years and updated. The last review date was August 10, 2021. 2 . In an interview, E1 acknowledged that the policies and procedures had not been reviewed at least once every three years and updated, as needed.

Based on observation and interview, the manager failed to ensure that there was 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 that had monitors or alerts 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 . During a tour of the facility, the Compliance Officer observed an alarm on the front entry door and the door to the back yard, both of which had the alarms set in the off position. 2 . In an interview, E1 acknowledged that the doors that allowed egress for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and had monitors or alerts employees of the egress of a resident from the facility, were turned off.

Based on record review and interview the manager failed to ensure that medication was administered to a resident as prescribed and cover the documentation of a resident's refusal to take prescribed medication in the resident's medical record. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1 . During a review of R1's medication administration record the Compliance Officer revealed medications not administered per medication orders and no documentation to indicate R1's refusal to take prescribed medications: Sennoside S - 50 milligram (mg) - 1 tablet twice a day - Not given August 1 - August 5, 2025 Ezetimibe - 10 mg tablet - 1 tablet daily in the evening - Medication was given in the morning and evening August 1 - August 5, 2025. 2 . In an interview, E1 acknowledged that medications were not administered as prescribed and no documentation to indicate refusal to take prescribed medications.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95 F and 120 F in areas of the facility used by residents. Findings include: 1 . During the environmental tour of the facility the Compliance Officer observed the hot water temperatures to not be within the range of 95 F - 120F: Water test in Resident bathroom was 93.2 F Water test in Kitchen was 90.1 F. 2 . In an interview, E1 acknowledged that the hot water was not maintained between 95 F and 120 F.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a caregiver had the qualifications, skills and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk if E1 was unable to meet a resident's needs during an emergency or an accident. Findings include: 1. The Compliance Officer observed E1 working alone on the premises upon arrival at 8:45 AM. 2. A review of E1's (hired in 2022) personnel record revealed a cardiopulmonary resuscitation (CPR) and first aid training card with an issue date of June 1, 2021 and expiration date of June 1, 2023. However, documentation of current CPR and first aid training was not available for review. 3. A review of facility documentation revealed E1 was scheduled to work alone 7AM-7PM throughout the months of June 2023, July 2023, and August 2023. 4. In an interview, E1 reported E1 had not renewed E1's CPR and first aid training. 5. In an interview, E3 acknowledged the facility did not have sufficient caregiver present with the qualifications, skills and knowledge necessary to ensure the health and safety of a resident.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of four employees sampled. The deficient practice posed a risk if E1 was unable to meet a resident's needs during an emergency or an accident. Findings include: 1. The Compliance Officer observed E1 working alone on the premises upon arrival at 8:45 AM. 2. A review of E1's (hired in 2022) personnel record revealed a CPR and first aid training card with an issue date of June 1, 2021 and expiration date of June 1, 2023. However, documentation of current CPR and first aid training was not available for review. 3. A review of facility documentation revealed E1 was scheduled to work alone 7AM-7PM throughout the months of June 2023, July 2023, and August 2023. 4. In an interview, E1 reported E1 had not renewed E1's CPR and first aid training. 5. In an interview, E3 acknowledged E1's personnel record did not include documentation of current CPR and first aid training.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2), for four of four employees sampled. Findings include: A.R.S. \'a7 36-411(C) Owners shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E1's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 2. A review of E2's (hired in 2020) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 3. A review of E3's (hired in 2020) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 4. A review of E4's (hired in 2020) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review. 5. In an interview, E3 acknowledged E1's, E2's, E3's, and E4's compliance with A.R.S. \'a7 36-411(C)(2) was not available for review.

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 and the manager, when updated, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated in June 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager. 2. A review of R2's medical record revealed a service plan dated in April 2023 for supervisory care services. However, the service plan was not signed and dated by the resident or the manager. 3. In an interview, E3 acknowledged the service plans for R1 and R2 had not been signed and dated by the resident or resident's representative, or the manager.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of two residents sampled. The deficient practice posed a risk as a resident did not receive the expected service. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services dated in June 2023. The plan revealed R1 was to receive the following service: -Bathing: Caregiver provide: Shower Daily 2-3x a week 2. A review of R1's medical record revealed a document (dated August 2023) titled "ACTIVITIES OF DAILY LIVINGS." The document indicated R1 received a "Partial Bath" on August 1-14, 2023. However, documentation R1 received a shower daily 2-3x a week was not available for review. 3. In an interview, E1 reported R1 received mostly bed baths since being admitted. 4. A review of R2's medical record revealed a current service plan for supervisory care services dated in April 2023. The plan revealed R2 was to receive the following service: -Bathing: Caregiver provide: Shower Daily 2-3x a week 5. A review of R2's medical record revealed a document (dated August 2023) titled "ACTIVITIES OF DAILY LIVINGS." The document indicated R2 received a "Partial Bath" on August 1-10, 2023. However, documentation R2 received a shower daily 2-3x a week was not available for review. 6. In an interview, E3 reported R2 was independent with bathing and acknowledged R2 had not received the assisted living service documented in R2's service plan. 7. In an interview, E3 acknowledged R1 had not received the assisted living service documented in R1's service plan.

Based on observation, record review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed the following medication bottles belonging to R2: -Glipizide 5mg tab; -Levocetirizine 5mg tab; -Tamsulosin HCL 0.4mg cap; and -Januvia 50mg tab. 2. A review of R2's medication administration record (MAR) dated in August 2023 revealed R2 received medication administration of the above mentioned medications on August 1-14, 2023. 3. A review of R2's medical record revealed medication orders were not available for review. 4. In an interview, E3 acknowledged medication orders for the observed medications belonging to R2 were not in the medical record.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed the following medication bottles belonging to R2: -Glipizide 5mg tab; -Levocetirizine 5mg tab; -Tamsulosin HCL 0.4mg cap; and -Januvia 50mg tab. 2. A review of R2's medication administration record (MAR) dated in August 2023 revealed R2 received medication administration of the above mentioned medications on August 1-14, 2023. However, medication orders were not available for review. 3. In an interview, E3 reported E3 requested R2's medication orders from R2's prescribing doctor, however, E3 had not received the medication orders. E3 acknowledged R2 received medication administration without medication orders.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked cabinet used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. The Compliance Officer observed a cabinet in the kitchen contained a magnetic lock. The Compliance Officer observed the magnetic lock accessible to residents. The Compliance Officer used the magnetic lock to open the cabinet. The cabinet contained medications belonging to current residents. 3. In an interview, E3 acknowledged the medications were not stored locked as all individuals had access to the key and were able to gain access to the medications.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include the date and time of the disaster plan review; the name of each employee or volunteer participating in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Emergency Disaster Plan" (dated August 10, 2021). The policy stated "...The disaster plan is reviewed and the review is documented at least once every 12 months." 2. The Compliance Officer requested to review the facility's disaster plan annual review at 9:10 AM. However, E3 reported E3 was unable to locate the requested documentation. 3. In the exit interview conducted at 10:45 AM, E3 provided the Compliance Officer with a document titled "Yearly Disaster review for Faith Care Homes 2023." However, the document provided for review did not include the date and time of the disaster plan review; the name of each employee or volunteer participating in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. 4. In an interview, E3 reported the documented provided to the Compliance Officer was the facility's disaster plan annual review. 5. In an interview, E3 acknowledged the disaster plan review did not include the date and time of the disaster plan review; the name of each employee or volunteer participating in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of Department documentation revealed the facility's license was effective on October 7, 2020. 2. A review of facility documentation revealed a staffing schedule, dated August 2023. The schedule revealed the facility maintained two shifts; 7 AM-7 PM and 7 PM-7 AM. 3. A review of facility documentation revealed disaster drills were completed on the following dates and times: -April 11, 2023 "AM"; and -July 19, 2023 at "PM". However, additional documentation of disaster drills for employees conducted on each shift at least once every three months was not available for review. 4. In an interview, E3 acknowledged the facility had not conducted disaster drills on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in areas of the assisted living facility used by residents. The deficient practice posed a burn risk to residents. Findings include: 1. The Compliance Officer observed the hot water temperature to be 135\'b0 F in the sink of a common bathroom used by residents, using a Department issued thermometer. 2. In an interview, E3 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F. The is a repeat deficiency from the compliance inspection completed on June 28, 2022.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a health and safety risk to residents. Findings include: 1. The Compliance Officer observed one ambulatory resident on the premises. 2. The Compliance Officer observed "LA's Totally Awesome Window Clean" in an unlocked cabinet in a common bathroom. The poisonous or toxic material contained a warning label. 3. The Compliance Officer observed the following poisonous or toxic materials in an unlocked cabinet under the kitchen sink: -"Fabuloso"; -"409" heavy duty oven cleaner; -"Pledge" expert care wood oil; and -"Pine-Sol" multi-surface cleaner. The poisonous or toxic materials contained a warning labels. 4. In an interview, E3 acknowledged the poisonous or toxic materials were left unlocked and were accessible to residents. The is a repeat deficiency from the compliance inspection completed on June 28, 2022.