Golden Years Assisted Living

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... 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... C. Owners shall make documented, good faith efforts to:...2. Verify the current status of a person's fingerprint clearance card..." 2. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of November 14, 2022. The personnel record revealed a fingerprint clearance card issued May 30, 2017. However, the record did not contain documentation that showed the card was verified with DPS. 3. Review of the Department of Public Safety (DPS) fingerprint clearance card database on November 6, 2023, revealed E2's fingerprint clearance card was valid. 4. In an interview, E1 acknowledged documentation was not available that showed E2's fingerprint clearance card was verified with DPS upon hire.

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 R1's medical record revealed a current written service plan dated October 30, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated October 25, 2023. These medication orders stated the following: "Ondansetron HCL 4mg tablet, Sig: 1 tablet orally every 6 hours" "Quetiapine Fumarate 25mg Tablet, Sig: 1 tablet at bedtime" 3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Ondansetron HCL 4mg tab 1 tab q6h PO" and indicated the medication was administered at 8am, 1pm, 5pm, and 9pm, not every six hours per the medication order. "Quetiapine 25mg Fumarate 1 tab BID PO" and indicated the medication was administered at 8am and 5pm, not at bedtime per the medication order. 4. During an observation of R1's medications, the following was observed: Ondansetron HCL 4mg was observed Quetiapine 25mg was observed 5. In an interview, E1 reported the medications were administered per the MAR and acknowledged R1's medications were not administered in compliance with the available medication orders.

Based on record review, observation, 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 risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated October 30, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated October 25, 2023. These medication orders stated the following: "Ondansetron HCL 4mg tablet, Sig: 1 tablet orally every 6 hours" "Pantoprazole Sodium 40mg tablet delayed release, Sig: 1 tablet orally twice a day" "Quetiapine Fumarate 25mg Tablet, Sig: 1 tablet at bedtime" "Metformin HCL 1000mg tablet, Sig: 1 tablet with a meal orally twice a day" "Donepezil HCL 5mg Tablet, Sig: 1 tablet at bedtime orally once a day" "Atorvastatin Calcium 40mg tablet, Sig: 1 tablet orally at bedtime" In addition, R1's medical record revealed a signed medication order dated October 28, 2023. This medication order stated "Pyridium 100 BID". 3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Ondansetron HCL 4mg tab 1 tab q6h PO" however, did not include the initials of the individual administering this medication at 1pm, 5pm, and 9pm November 3rd-present. "Pantoprazole Sodium 40mg 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd-present. "Quetiapine 25mg Fumarate 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Metformin HCL 1000mg 1 tab BID PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Donepezil HCL 5mg 1 tab PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Atorvastatin Calcium 40mg 1 tab HS PO" however, did not include the initials of the individual administering this medication at 5pm November 3rd. "Phenazopyridine PO 1 tab 100mg" however, did not include the initials of the individual administering this medication at 5pm November 3rd-4th. 4. During an observation of R1's medications, the following was observed: Ondansetron HCL 4mg was observed Pantoprazole Sodium 40mg was observed Quetiapine 25mg was observed Metformin HCL 1000mg was observed Donepezil HCL 5mg was observed Atorvastatin Calcium 40mg was observed Phenazopyridine 100mg was observed 5. Review of R2's medical record revealed a current written service plan dated May 16, 2023. This service plan indicated R2 received medication administration. 6. Review of R2's medical record revealed signed medication orders dated October 3, 2023. These medication orders stated the following: "Famotidine 20mg

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed an opened jar of Smucker's strawberry jam, an opened bottle of Kikkoman soy sauce, and an opened bottle of Sweet Baby Ray's barbecue sauce in the kitchen pantry. These containers stated "Refrigerate after opening". 2. In an interview, E1 and E2 acknowledged the foods were stored in the pantry and required refrigeration.

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. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed the hallway on the west side of the facility did not have a posted evacuation path. 2. In an interview, E1 acknowledged the evacuation path was not posted on each hallway of the assisted living facility.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed a rechargeable fire extinguisher. This fire extinguisher had a receipt attached that showed a purchase date of October 21, 2021. 2. In an interview, E1 acknowledged the rechargeable fire extinguisher was not serviced at least once every 12 months.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed four small oxygen tanks unsecured in the hallway. 2. In an interview, E1 acknowledged oxygen tanks were not secured.

Based on documentation review, observation, and interview, the manager failed to ensure a dog was licensed with Maricopa County. The deficient posed a risk if a dog allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. Review of the Maricopa County Animal Care and Control website stated "all dogs three months of age and older are required to have a license..." 2. During an environmental inspection of the facility with E2, O1 was observed. O1 appeared to be older than three months of age. 3. Documentation of a license with Maricopa County was not available for O1. 4. In an interview, E1 acknowledged documentation was not available that showed O1 had a current Maricopa County license.