Gardens at Ocotillo Senior Living

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of eight residents sampled. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R4’s and R6's medical records revealed no documentation of TB test showing whether these residents tested positive or negative for TB. Based on the admission dates of R4 and R6, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's service plan included the level of service the resident was expected to receive for four of eight residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1’s, R2's, R4's, and R8's medical records revealed a service plan that did not include the level of service the resident was expected to receive. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two out of eight residents reviewed. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2's and R7's medical records revealed that documentation of the residents' orientation to exits from the assisted living facility was not available for review at the time of inspection. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of a resident's general or specific whereabouts. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environment tour of the facility, the Compliance Officer observed that a door that leads out to the yard in the memory care unit was unlocked and had no alerts on. 3. In an exit interview with E1, the findings were reviewed, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documents revealed no documentation to indicate the facility's disaster plan was reviewed at least once within the past 12 months that included the date and time of the disaster plan review, the name of each employee participating in the disaster plan review, a critique of the disaster plan review, and any recommendations for improvement. 2. In an interview, E1 acknowledged that documentation indicating that the facility's disaster plan was reviewed within the last 12 months was not available.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility evacuation drills revealed that no documentation of an evacuation drill was available for review. 2. In an exit interview with E1, the findings were reviewed, and no additional information was provided.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The Compliance Officer observed the facility's toxicology guide available for use by personnel members was the "Elsevier Toxicology Handbook 3rd Edition". 2. A review of the publisher's website revealed the "Elsevier Toxicology Handbook 4th Edition" was the most recent edition. 3. In an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure that frozen foods were stored at a temperature of 0\'b0 F or below. Findings include: 1. During a facility tour, the Compliance Officer observed the facility's freezer had a thermometer that registered 14\'b0 F. The freezer was tested with the Department issued thermometer and the temperature registered 17\'b0 F. 2. In an interview, E1 acknowledged that frozen foods were not stored at or below 0\'b0 F.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed the following unlocked on a cart in the hallway: -1 container of "Drano Max Gel" which stated "Danger: Keep out of Reach of Children and Pets. Harmful if swallowed. May burn eyes, skin, and muccous membranes on contact." 2. In an interview, E1 acknowledged poisonous or toxic material stored by the assisted living facility was not maintained in a locked area inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure that the health care institution did not have, establish or implement policies that prevent employees from providing appropriate first aid. Findings include: 1. A.R.S. \'a7 36-420.B.2 states "Each health care institution: Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services...to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently..." 2. Review of the facility's policies and procedures revealed a policy titled "Fall-Lift Assist", revised August 1, 2023, which stated "i. Call for an additional team member or ensure at least two team members are present to assist the resident. 1. If only one team member is available call 911 for lift assist." 3. In an interview, E1 acknowledged that the policy prevented employees from providing appropriate first aid.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.C , for one of six personnel records sampled. The deficient practice posed a risk if the personnel were a danger to a vulnerable population. 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. Verify the current status of a person's fingerprint clearance card." 2. A review of E5's personnel record revealed no documentation showing that the owner had made a good faith effort to contact previous employers to obtain information or recommendations or verified the status of E5's fingerprint clearance card. 3. Review of the caregiver schedule for September 1-21 revealed that E5 worked 2:30pm-10:30pm on September 17-21. 4. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411.C. for E5 was not available for review.

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk of a potential resident rights violation if the resident was subjected to abuse. Findings include: 1. A.R.S. \'a7 46-454(A) stated "...person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit ... All of the above reports shall be made immediately by telephone or online." 2. R9-10-101.111 stated "Immediate" means without delay. 3. Review of facility incident reports revealed a document titled "State Reportable Form". This document reported an incident when a staff member observed bruises on R4 which looked like fingerprints. The document stated "Date reported to the ED:9/3/24" and "Have the following been notified? APS: 9/6/24". A print out of the "Adult Protective Services Online Submission Form" showed a reported date of September 6, 2024. 4. In an interview, E1 acknowledged the suspected abuse was not reported according to A.R.S. \'a7 46-454.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every six months, for one of three residents reviewed receiving personal care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. Review of R2's medical record revealed a current written service plan for personal care services dated December 20, 2023. However, a service plan after December 20, 2023 was not available for review. 2. In an interview, E1 acknowledged R2 received personal care services and the service plan was not updated at least once every six months. This is a repeat deficiency from the on-site compliance inspection conducted on December 6, 2021.

Based on documentation review and interview, the manager failed to establish and document a policy and procedure to protect the health and safety of a resident that covered responding to and reporting an unexpected reaction to a medication. Findings include: 1. Review of the facility's policies and procedures showed no policy and procedure that covered responding to and reporting an unexpected reaction to a medication. 2. In an interview, E1 acknowledged that a policy and procedure that covered responding to and reporting an unexpected reaction to a medication had not been established and documented.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, including a demonstration of the employee's ability to perform CPR. The deficient practice posed a risk if E6 and E8 were unable to perform CPR. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation (CPR and First Aid Training - Arizona Specific" (dated December 2014). The policy stated "Upon hire and before providing any hands of care the team member will provide a copy of a current CPR card specific to adults that includes a demonstration of the caregiver's ability to perform CPR..." 2. A review of E6's (hired in 2022) personnel record revealed E6 was hired as a caregiver. The personnel record revealed documentation of CPR training from New Life CPR (issued January 29, 2022). 3. A review of the New Life CPR website revealed courses were conducted online. 4. A review of E8's (hired in 2021) personnel record revealed E8 was hired as a caregiver. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued August 17, 2022). 5. A review of the NationalCPRFoundation website revealed courses were conducted online. The NationalCPRFoundation website stated, "Help Save Lives Today with Your Online CPR Certification Training!" 6. In a joint interview, E1, E2, E3, and E4 acknowledged E6's and E8's online CPR training did not include a demonstration of E6's and E8's ability to perform CPR.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for one of five caregivers sampled. The deficient practice posed a risk if E11 was unable to meet a residents needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Team Member Training - Arizona Specific" (dated January 21, 2022). The policy stated "...All Resident Care team members knowledge and skills will be documented before they begin to provide direct care in the Community." 2. A review of E11's (hired in March 2023) personnel record revealed E11 was hired as a caregiver. A review of E11's personnel record revealed documentation of the verification of E11's skills and knowledge (dated in June 2023). 3. A review of facility documentation revealed a staffing schedule dated March 2023-June 2023. The staffing schedule revealed E11 was scheduled to work on the following dates: -March 9-10, 2023; -March 14, 2023; -March 16-18, 2023; -March 21-25, 2023; -March 28-31, 2023; -April 1, 2023; -April 4-6, 2023; -April 11-15, 2023; -April 18-22, 2023; -April 25-29, 2023; -May 2-6, 2023; -May 9-13, 2023; -May 16-20, 2023; -May 23-27, 2023; -May 30-31, 2023; -June 1-3, 2023; -June 6-10, 2023; -June 13-15, 2023; -June 16-17, 2023; and -June 20-24, 2023. 4. In a joint interview, E1, E2, E3, and E4 acknowledged E11's skills and knowledge were not verified and documented prior to E11 providing physical health services and according to the facility's policies and procedures.