Golden Springs Senior Living, LLC

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of three sampled personnel members. The deficient practice posed a risk if an employee did not possess the skills and knowledge to meet the needs of residents. Findings include: 1. A review of E2's and E3's personnel record revealed documentation of verification of skills and knowledge was not available for review at the time of inspection. 2. In an interview, E1 acknowledged E2's and E3's personnel record did not include documented verification of E2's and E3's skills and knowledge at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of three sampled personnel members. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter...obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 2. A review of E3's personnel record revealed documentation of a negative TB skin test. However, documentation of a second TB skin test and TB screening was not available for review at the time of inspection. 3. In an interview, E1 acknowledged E3's personnel records did not contain documentation of a second TB skin test and TB screening at the time of the inspection.

Based on documentation review, observation, and interview, the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed an alert and control on the front door and an alert on the door leading to the backyard. However, the alerts were not turned on, and the control was not locked. 3. In an interview, E1 acknowledged the front and back door had no functioning control or alert. This is a repeat deficiency from the compliance inspection conducted on July 18, 2023.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two 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. In an interview, E1 reported all residents receive medication administration. 2. A review of R1's medical record at approximately 10:30 AM revealed signed medication orders for the following medications: -Levetiracetam 500 MG 1 tablet by mouth twice a day; -Gabapentin 800 MG 1 tablet by mouth three times a day; and -Midodrine 5 MG 1 tablet by mouth three times a day. However, a review of R1's Medication Administration Record (MARs) for September 2024 revealed the following medications marked as administered: -Levetiracetam on September 24, 2024 at 8:00 PM ; -Gabapentin on September 24, 2024 at 12:00 PM and 5:00 PM ; and -Midodrine on September 24, 2024 at 12:00 PM and 5:00 PM. 3. A review of R2's medical record at approximately 10:30 AM revealed signed medication orders for the following medications: -Levetiracetam 500 MG 1 tablet by mouth twice a day; -Gabapentin 800 MG 1 tablet by mouth three times a day; -Elequis 5 MG 1 tablet by mouth twice a day; -Amitriptyline 10 MG 1 1/2 tablets at bedtime; -Tamsulosin .4 MG 1 cap by mouth daily; -Simvastatin 10 MG 1 tablet by mouth at bedtime; and -Mitrazapine 45 MG 1/2 tablet by mouth at bedtime. However, a review of R1's Medication Administration Record (MARs) for September 2024 revealed the following medications marked as administered: -Levetiracetam on September 24, 2024 at 8:00 PM; -Gabapentin on September 24, 2024 at 12:00 PM and 5:00 PM; -Elequis on September 24, 2024 at 8:00 PM; -Amitriptyline on September 24, 2024 at 8:00 PM; -Tamsulosin on September 24, 2024 at 8:00 PM; -Simvastatin on September 24, 2024 at 8:00 PM; and -Mitrazapine on September 24, 2024 at 8:00 PM. 4. In an interview, E1 acknowledged medication was not administered to residents in compliance with a medication order.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed an orientation form signed on February 2, 2024. However, neither date was within 24 hours after acceptance. 2. In an interview, E1 acknowledged documentation was not completed showing R1 was oriented to the facility's evacuation routes and plans 24 hours after acceptance.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and 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 an environmental inspection of the facility, the Compliance Officer observed a container of "Comet" bleach cleaning powder and a container of "Ultimate Clean" dishwasher packets in an unlocked cabinet under the sink. The Compliance Officer also observed a can of "Lysol" disinfectant spray on the countertop in the master bedroom. 2. During an environmental inspection of the facility, the Compliance Officer observed a door leading to the garage. The control for the door was not locked, and the door had a stopper which was able to be disengaged. When the door was opened, the Compliance Officer observed multiple cans of "Lysol" disinfectant spray, "Resolve" urine destroyer, and "Odoban" disinfectant spray sitting on a shelf. 2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked area and inaccessible to residents at the time of the inspection. This is a repeat citation from the compliance inspection conducted on July 18, 2023.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored 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 an environmental inspection of the facility with E3, the Compliance Officer observed Pinesol and Oxi Clean total bathroom cleaner unlocked in a hall closet. This closet was not capable of locking. 2. During an observation, the caregivers were not accessing the toxic materials at the time of arrival. 3. In an interview, E1, E2, and E3 acknowledged toxic materials were stored unlocked.

Based on documentation review, observation, and interview, the manager failed to ensure there was 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 provided access to an outside area and controlled or alerted 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E3, the Compliance Officer observed an exit door on the south side of the facility did not have a device that alerted employees to the egress of a resident to the outside area. 3. In an interview, E1, E2, and E3 acknowledged there was a means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated May 14, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated April 27, 2023. This medication order stated "Levothyroxine 100mcg Tab PO 1 tab QD". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated "Levothyroxine 100mcg Tab 1 tab by mouth daily" and indicated one tab was administered at 8am July 1st - present. 4. During an observation of R2's medications, Levothyroxine 125mcg was observed and one tab was observed prefilled in the "Morn" slot of R2's medication organizer. 5. In an interview, E1 and E2 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with the available medication order.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E3, the Compliance Officer observed Fluticasone, Calcium Carbonate, and Hydrocortisone cream unlocked in a cabinet in R2's shared bathroom. This cabinet was not capable of locking. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E3 reported R2 did not self administer the medications. E1, E2, and E3 acknowledged medications were stored unlocked.