Gifted Hands Assisted Living, LLC

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental tour, the Compliance Officer observed laundry fragrance beads on a table outside. 2. During the environmental tour, the Compliance Officer observed Sani-Cloth wipes on the filing cabinet in the living room. 3 . During the environmental tour, the Compliance Officer observed the cabinet below the kitchen sink was unlocked and contained toxic cleaning products. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 5. This is a repeat deficiency from the inspection conducted on November 3, 2023.

Based on documentation review, record review and interview, the manager failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training, for two of two personnel sampled. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a "Staff Records" policy that stated "The manager shall ensure that a personnel record for each staff member or volunteer is initiated upon hire and maintained..." Procedure: Proof of the following employee requirements will be met; each employee will have an individual file that will contain the employee's: documentation of ongoing and annual requirement met." 2. A review of E1's and E2's personnel records revealed documentation of fall prevention and fall recovery training on June 30, 2022. However, documentation of fall prevention and fall recovery training after June 2022, was not available for review at the time of inspection. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information required in A.R.S. § 36-420.04, for two of two residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. Review of R1's and R2's medical records revealed no documentation of a standardized form to provide to emergency responders. 2. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Documentation review revealed a quality management report that was reviewed in 2019. However, there was no documentation that the quality management records were reviewed and evaluated at least once every 12 months after 2019. 2. In an interview, findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed a review page. However, the page was last signed March 1, 2021. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if the facility was unable to meet a resident's emergency needs. Findings Include: 1. In an environmental inspection, the Compliance Officer observed that R1's and R2's bedroom was not equipped with a bell, intercom, or other mechanical means to alert employees to the residents' needs or emergencies. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster plan included when, and how, residents would be relocated, how a resident’s medical record would be available to individuals providing services to the resident during a disaster, a plan to ensure each resident’s medication would be available to administer to the resident during a disaster, and a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of the facility’s documentation/policies and procedures revealed a disaster plan for the facility, however, the plan did not include the following: how a resident’s medical record would be available to individuals providing services to the resident during a disaster. a plan to ensure each resident’s medication would be available to administer to the resident during a disaster; a plan for obtaining food and water for individuals present in the assisted living facility or the assisted living facility’s relocation site during a disaster; 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months, and had a tag attached to the fire extinguisher that specified the date of the last servicing and the identification of the person who serviced the fire extinguisher. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During an environmental inspection, the Compliance Officer observed a fire extinguisher with no receipt of purchase or a tag attached identifying the last service date. 2. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of three sampled employees. The deficient practice posed a risk if the individual was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) states, "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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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. The Compliance Officer observed E3 arrive on-site at the facility during the inspection. 3. A review of E3's personnel record revealed no documentation of a current, valid fingerprint clearance card. 4. In an interview, E1 acknowledged E3's personnel record did not contain documentation of a fingerprint clearance card.

Based on record review and interview, the manager failed to ensure a resident's written service plan was developed with assistance and review from the resident or resident's representative, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate the residents' decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated October 10, 2023 for personal care services. The service plan was not signed by R1 or R1's representative. 2. A review of R2's medical record revealed a service plan dated October 10, 2023 for personal care services. The service plan was not signed by R2 or R2's representative. 3. In an interview, E1 acknowledged R1's and R2's service plans were not signed by R1 and R2 or their representatives.

Based on 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 as administered medication could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed medication administration records (MARs) dated October 2023 and November 2023. R1's October and November 2023 MARs reflected R1 was administered "Divalproex 125 mg (milligrams) one tablet twice daily" from October 18, 2023 through November 3, 2023. However, there was no documentation of a medication order for "Divalproex 125 mg" in R1's medical record. 2. In an interview, E1 reported R1's "Divalproex" medication was a verbal order, and acknowledged there was no documentation of the medication order.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medications. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked box inside the facility's kitchen refrigerator. The box contained "Novolog flex insulin", two bottles of "calcitonin nasal spray", "Humulin kwik pen", and "Haloperidol injection." 2. In an interview, E1 acknowledged the medications observed in the refrigerator were not stored in a locked area at the time of the inspection. This is a repeat citation from the previous compliance inspection conducted on June 22, 2022.

Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted on each hallway of each floor of the assisted living facility. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an evacuation path was not posted in the north hallway containing a resident bedroom and common bathroom. 2. In an interview, E1 acknowledged an evacuation path was not posted in each hallway of the assisted living facility.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked laundry room. The laundry room contained "Oxi clean" laundry detergent, "Ajax" cleaner, "Arm and Hammer", "Boca Laundry Detergent", and "Clorox bleach." 2. In an interview, E1 acknowledged the poisonous or toxic materials were not stored in locked areas and were accessible to residents. This is a repeat citation from the previous compliance inspection conducted on June 22, 2022.