Haven of Camp Verde Alf, LLC

Based on observation, record review and interview, the governing authority failed to designate a certified manager. Findings include: 1. During an interview, E1 stated that E1 was the facility administrator, but was not a certified manager. E1 further stated that there had not been a certified manager overseeing the facility since O1 left. 2. Record review revealed that O1's last day as the facility manager was June 30, 2024. 3. During an interview, E1 acknowledged that no certified manager had been designated.

Based on documentation review and interview, the manager failed to ensure that a plan is established, documented, and implemented for an ongoing quality management program that, includes a method to make changes or take actions as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. Review of the monthly facility quality management reports revealed that the reports did not implement a method to make changes or take actions as a result of the identification of a concern about the delivery of services related to resident care. 2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management reports.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza. Findings include: 1. The record belonging to R1 contained documentation indicating that the resident was last notified of the availability of the influenza vaccination on October 18, 2022. No additional documentation indicating when the resident had been offered, refused, or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 2. The record belonging to R2 contained documentation indicating that the resident was last notified of the availability of the influenza vaccination on October 18, 2022. No additional documentation indicating when the resident had been offered, refused, or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 3. During an interview, E1 acknowledged that the record did not contain the required documentation.

Based on record review and interview for two of two sample personal care resident records, the manager failed to obtain documentation reflecting that the resident or resident's representative requested that the resident remain in the facility. Findings include: 1. During an interview, E1 indicated that R2 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 2. The resident's record did not contain a request from the resident or their representative to remain in the facility. Based on the resident's date of acceptance this documentation was required. 3. During an interview, E1 indicated that R3 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted. 4. The resident's record did not contain a request from the resident or their representative to remain in the facility. Based on the resident's date of acceptance this documentation was required. 5. During an interview, E1 acknowledged that the required documentation was not in the resident's records.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill included an identification of residents needing assistance for evacuation Findings include: 1. Review of 12 months of facility evacuation drill documentation revealed that the documentation failed to identify the residents needing assistance for evacuation. 2. During an interview, E1 stated, "We do have non-ambulatory and directed care residents here who would need assistance." 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a quality management plan was implemented for an ongoing quality management program. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Quality Assurance Program Review". The procedure stated "... An overall review and evaluation will be conducted yearly to ensure effectiveness and compliance. All findings and recommendations with be reported and discussed with our Governing Authority prior to change and implementation yearly...". 2. The Compliance Officer requested the annual report submitted to the governing authority. However, documentation of the annual report was not available for review. This is a repeat deficiency from the compliance inspection conducted on August 30, 2022.

Based on observation, record review, and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include if an individual was requesting or expected to receive supervisory care services, personal care services, or directed care services; and whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of two current residents sampled, and was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection. Findings include: 1. A review of R1's medical record revealed a three page document titled, "Physician Plan of Care." The document stated "...Diagnosis and Significant Findings of a Physical examination done within the past 90 days...". However, the document did not indicate whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. This document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 2. A review of R2's medical record revealed a three page document titled, "Physician Plan of Care." The document stated "...Diagnosis and Significant Findings of a Physical examination done within the past 90 days...". However, the document did not indicate whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. This document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 3. In a joint interview, E1 and E2 acknowledged R1's and R2's documentation did not indicate whether R1 or R2 required continuous medical services, continuous or intermittent nursing services, or restraints.

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 of two residents sampled. The deficient practice posed a risk to residents ability to familiarize themselves with exit locations, understand evacuation procedures, and stay alert to ensure their well-being and that of others in emergency situations. Findings include: 1. A review of R1's medical record revealed documentation of R1's orientation to exits from the assisted living facility was not available for review. Based on the resident's date of acceptance, this documentation was required 2. A review of R2's medical record revealed documentation of R2's orientation to exits from the assisted living facility. However, the document was not filled out. Based on the resident's date of acceptance, this documentation was required 3. In a joint interview, E2 reported being unaware of the rule that specified the residents needed to receive orientation to the exits from the assisted living facility. E1 and E2 provided a document from the resident handbook titled "safety and security" however, the document did not include a statement that residents received orientation to the exits.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration, for two of two residents reviewed receiving personal care services, which posed a health risk to the residents. Findings include: 1. A review of R1's medical record revealed a current written service plan for personal care services dated May 29, 2023. This service plan did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. 2. A review of R2's medical record revealed a current written service plan for personal care services dated January 9, 2023. This service plan did not include offering sufficient fluids to maintain hydration. 3. In a joint interview, E1 and E2 acknowledged R1's service plan did not include documentation of skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. E1 and E2 acknowledged R2's medical record did not include offering sufficient fluids to maintain hydration.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of facility documentation revealed a binder titled "ALF Fire Disaster Evacuation Log Book", the binder was provided to the Compliance Officer for review of the facility disaster drills. However, the binder did not contain documentation that a disaster drill was conducted for employees on each shift at least once every three months. 2. In a joint interview, E1 and E2 requested clarification on the frequency of disaster drills and how they are conducted. E1 reported only being familiar with fire drills and evacuation drills. 3. In a joint interview, E1 and E2 acknowledged the facility had not conducted disaster drills on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk to the health and safety of residents if employees were unable to implement a disaster plan in the event of a disaster. Findings include: 1. A review of facility documentation revealed a document identifying a "Evacuation drill" was conducted on October 14, 2022. However, documentation demonstrating an evacuation drill being conducted at least 6 months after this drill was not available for review. 2. In a joint interview, the Compliance Officer provided education of an evacuation drill to clarify and determine compliance to R9-10-818(A)(6)(a-e). E1 reported E1, E2, E7 and E8 remember participating in an evacuation drill conducted in December of 2022. However the evacuation drill was not documented in the facility's records.