Firebird Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of four personnel members sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institution, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. 2. A review of facility documentation revealed a staffing schedule for July 2023. The staffing schedule revealed E3 was scheduled to work July 1, 2, 4, 5, 6, 12, 13, 19, 20, 26, 27, 2023, from 6:00 AM - 8:00 PM. 3. A review of E3's personnel record revealed a fingerprint clearance card with an expiration date of July 6, 2023. However, documentation of a current fingerprint clearance card for E3 was not available for review. 4. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E3's fingerprint clearance card status stated "Not Valid". 5. A review of E3's personnel record revealed a photograph of E3's fingerprint clearance card application. The fingerprint clearance card application was dated July 21, 2023. However, a current fingerprint clearance card was not available for review. 6. In an interview, O1 and E1 acknowledged E3 did not have a current and valid fingerprint clearance card.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance without meeting the requirements in R9-814(B)(2)(b)(iii), two of three residents sampled who received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: R9-10-814(B)(2) A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: b. The resident's primary care provider or other medical practitioner: iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility; 1. A review of R1's (admitted 2021) medical record revealed a service plan (dated in May 2023) for directed care services. The service plan stated "Mobility...Non-Ambulatory..." 2. A review of R1's medical record revealed documentation indicating R1's medical practitioner examined R1 every six months, signed and dated a determination stating R1's needs could be met by the facility, and reviewed the facility's scope of services was not available for review. 3. A review of R2's (admitted 2017) medical record revealed a service plan (dated in May 2023) for directed care services. The service plan stated "Mobility... Non-Ambulatory..." 4. A review of R2's medical record revealed documentation indicating R2's medical practitioner examined R2 every six months, signed and dated a determination stating R2's needs could be met by the facility, and reviewed the facility's scope of services was not available for review. 5. In an interview, O1 and E1 reported R1 and R2 were bedbound. O1 acknowledged R1 and R2 did not have documentation from R1's or R2's medical practitioners stating R1 and R2 were examined, R1's and R2's needs were met by the facility, and if R1's or R2's care was within the facility's scope of services, at least once every six months, was not available.

Based on documentation review and interview, the manager failed to ensure documentation of the disaster plan review included a critique of the disaster plan review. Findings include: 1. A review of facility documentation revealed a document titled "Disaster Plan - Annual Review" dated January 4, 2023. The document included the date and time of the disaster plan review and the name of each employee participating in the disaster plan review. However, a critique of the disaster plan review was not included. 2. In an interview, O1 acknowledged the disaster plan review did not include documentation of the critique of the disaster plan review.

Based on documentation review, observation, and interview, the manager failed to ensure a resident bedroom was not used as a passageway to another sleeping area. The deficient practice posed a privacy rights risk to a resident and the Department was unable to evaluate a potential modification to the licensed premises. Findings include: 1. A review of Department documentation revealed the perpetual license for AL7201 was effective on May 23, 2008. 2. The Compliance Officer observed and walked through the master bedroom (occupied by R1) to the master bathroom and to the master bedroom closet. 3. The Compliance Officer observed a sleeping area, with two mattresses, in the master bedroom closet. 4. In an interview, E1 and O1 reported E2 worked 24 hours shifts and used R1's bedroom closet as a rest area. 5. A review of Department documentation revealed the floor plan, provided to the Department in 2008 by the licensee, did not state the master bedroom closet was to be used as a sleeping area. 6. In an interview, E1 and O1 acknowledged a resident bedroom was used as a passageway to another sleeping area.