Genuine Companionship

Based on observation, documentation review, and interview, the manager failed to ensure a qualified caregiver, who had been designated in writing, was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed E4 was the only personnel member present on the premises. E4 reported E4 was the cook at the facility. 2. The Compliance Officer observed a posting titled, "Delegation of Authority." However, E4 was not listed on this posting as a manager's designee. 3. A review of E4's personnel record revealed E4 was an assistant caregiver and not qualified to be designated as the manager's designee. 4. In an interview, E1 acknowledged the manager failed to ensure a qualified caregiver, designated in writing, was present on the premises and accountable for the assisted living facility when the manager was not present.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered by qualified individuals. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed E4 working on the premises. 2. A review of facility documentation revealed a policy titled, "Staff Scheduling and Back up employee Policy and Procedure." The policy stated, "This facility's work schedule will include the date, work hours and name of each person assigned to work." 3. A review of facility documentation revealed a July 2024 personnel schedule. The schedule indicated E3 was scheduled to work the day of the inspection; however, E3 was not on-site. E4, who was on-site, was not included on the schedule. In addition, the hours worked were not included on the schedule as required. 4. In an interview, E1 and E2 acknowledged documentation of the caregivers and assistant caregivers working each day, including the hours worked, was not maintained and accurate.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of four personnel sampled. The deficient practice posed a risk if E2 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, "CPR and First Aid." The policy stated, "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and that their certification is maintained and in [sic] current as long as they are employed by this facility...In order to keep First Aid and CPR training and skills up to date, it is required that each employee and volunteer to provide the following:...Method and contents of CPR training which includes the ability to perform and demonstrate Cardiopulmonary resuscitation..." 2. A review of E2's personnel record revealed current documentation of E2's CPR/First Aid training from the "National CPR Foundation," issued December 13, 2023 and valid for two years. However, the CPR training did not include a hands-on demonstration of techniques as required. 3. In an email exchange, a representative from the "National CPR Foundation" stated, "Our courses are online only." 4. In an interview, E1 and E2 acknowledged E2's personnel record did not include current CPR training with hands-on demonstration as required. E2 reported to have taken an in-person class but was unable to provide documentation for review.

Based on observation, interview, and record review, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assistant living home. The deficient practice posed a risk as the individual on-site was not qualified to provide the required assisted living services. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed the manager was not present. E4 was the only employee working at the facility with two residents. E4 reported E4 was the cook at the facility and was not a certified caregiver. E1 and E2 arrived approximately 45 minutes later. 2. In an interview, E1, E2, and E4 revealed E3 was at the facility earlier in the day, but left at some point via a ride-sharing service. 3. A review of R1's and R2's medical records revealed R1 and R2 required assisted living services, including medication administration. 4. A review of E4's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E4's record did not include documentation showing an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E4 was not qualified to be left alone with the residents based on the lack of caregiver training. 5. A review of the az.tmuniverse.com website revealed no documentation of a caregiver training certificate for E4. 6. In an interview, E1 and E2 reported E4 was not a caregiver and worked as an assistant caregiver. E1 and E2 acknowledged neither a manager or caregiver was present at the facility when the Compliance Officer arrived.

Based on documentation review, record 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 as required training could not be verified for E4. Findings include: 1. A review of the facility's polices and procedures revealed a policy titled, "CPR and First Aid Policy and Procedures." Under the heading, "Policy Statement," the policy stated, "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and their certification is maintained and in [sic] current as long as they are employed by this facility." 2. A review of E4's personnel record revealed no evidence that indicated E4 had completed any CPR or first aid training. 3. In an interview, E1 and E2 acknowledged E4's personnel record did not include documentation that indicated E4 had been trained in CPR or first aid.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know if a medication was administered. Findings include: 1. A review of R1's medical record revealed a written service plan dated March 5, 2024. The service plan indicated R1 received medication administration. 2. A review of R1's medical record revealed a signed medication list dated February 7, 2024 for the following medications: -Finasteride 5 mg, one tablet daily; -Metoprolol 25 mg, one tablet daily; -Pantoprazole 40 mg, one tablet daily; and -Pravastatin 20 mg, one tablet daily. 3. A review of R1's July 2024 medication administration record (MAR) revealed the aforementioned medications were typically administered at 7:00 AM. However, medication administration provided to R1 was not documented the morning of the inspection and before E3 left the facility. 4. A review of R2's medical record revealed a current written service plan dated May 22, 2024. The service plan indicated R2 received medication administration. 5. A review of R2's medical record revealed signed medication orders for the following medications: -Sertraline 50 mg, one tablet daily; -Albuterol small volume nebulizer (SVN) every 8 hours at 7:00 AM, 1:00 PM, and 7:00 PM; -Furosemide 20 mg, one tablet daily; -Hydrochlorothiazide 25 mg, one tablet daily; -Isosorbide 30 mg, one tablet daily; -Losartan 100 mg, one tablet daily; and -Metformin 500 mg, one tablet twice daily. 6. A review of R2's July 2024 MAR revealed the aforementioned medications were typically administered at 7:00 AM unless noted above. However, medication administration provided to R2 was not documented the morning of the inspection and before E3 left the facility. 7. In an interview, E1 and E2 acknowledged R1's and R2's medical record did not include documentation the aforementioned medications were administered. E4 reported E3 administered the medications before leaving the facility.