Heaven Can Wait

Based on observation and interview, the governing authority failed to designate, in writing, a manager who either had a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) \'a7 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. \'a7 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an expired manager's license for O1 conspicuously posted on the facility's wall. 2. A review of Department documentation revealed O1 notifed the Department on March 31, 2024 to indicate O1 would no longer be the manager of the facility. 3. In an interview, O1 reported not being the manager of the facility. 4. In an interview, E1 reported O1 was no longer the manager of the facility, and there was no certified manager currently designated.

Based on documentation review, observation, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. During the environmental inspection of the facility, the Compliance Officer observed R2 sitting in a wheel chair with a white strap wrapped around R2's waist. 3. In an interview, E1 reported R2 was a fall risk and the straps prevented R2 from walking.

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented any action taken to prevent the accident from occuring in the future, for one of two sampled residents. The deficient practice posed a potential risk of re-injury. Findings include: 1. A review of R1's medical record revealed a document titled "Incident Report" dated February 26, 2024. The report did not document any action taken to prevent the incident from occuring in the future. 2. In an interview, E1 reported R1 fell on February 25, 2024 and went to the hospital the following day. E1 acknowledged the incident report in R1's medical record did not document any action taken to prevent the incident from occuring in the future.

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk if facility staff were 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 fall prevention and fall recovery training program. However, the program did not include initial training and continued competency training. 2. A review E1's personnel record revealed no documented evidence to indicate E1 completed fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program failed to address initial and continued compentency training. E1 provided no documentation to indicate E1 completed fall prevention and fall recovery training.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk if no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a posted document titled "Delegation of Authority" dated June 17, 2023. The document listed E2, E5, and E6 as manager's designees. E3 and E4 were not listed on the "Delegation of Authority" document. 2. A review of facility documentation revealed a document titled "November 2023 Work Schedule". The schedule reflected E3 was scheduled to work the evening shift alone on November 2, 3, 8, 10, 12, 15, 17, 19, 22, 24, and 26, 2023, and E4 was scheduled to work the evening shift on November 4, 11, 18, and 25, 2023. 3. In an interview, E1 reviewed the "Delegation of Authority" document and reported E3 and E4 would be added as designees.

Based on record review, observation, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of four caregivers sampled. The deficient practice posed a health and safety risk to the residents if the caregiver was not informed of the duties that needed to be performed. Findings include: 1. A review of E1's personnel record revealed the personnel record did not contain documentation of orientation specific to E1's job duties before E1 provided assisted living services. 2. In an interview, E1 acknowledged E1's personnel records did not include documentation of orientation.

Based on record review and interview, the manager failed to obtain the signature of a resident's representative on the documented residency agreement within five working days after the resident's acceptance, for one of three residents sampled. The deficient practice posed a risk if the resident, the resident's representative, the resident's legal guardian, or another individual designated by the individual under Arizona Revised Statutes (A.R.S.) \'a7 36-3221 was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement did not include the signature of R1 or R1's representative. Based on R1's date of admission, the signature was required. 2. In an interview, E2 acknowledged the residency agreement for R1 was not signed by R1 or R1's representative. This is a repeat citation from the previous compliance inspection conducted on July 11, 2022.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for one of three residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R3's current service plan dated October 13, 2023 revealed it did not include the level of service R3 was expected to receive. 2. In an interview, E2 acknowledged R3's service plan did not include the level of service R3 was expected to receive.

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 three 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 R3's medical record revealed a medication order dated June 28, 2023 for "Quetiapine 50 mg (milligrams) take one tablet by mouth in the morning and two tablets at bedtime." 2. A review of R3's medical record revealed a medication administration record (MAR) dated November 2023. R3's November 2023 MAR reflected R3 was administered one tablet of "Quetiapine 50 mg" at 8:00 AM and one tablet at 5:00 PM from November 1, 2023 through November 16, 2023. 3. In an interview, E2 reviewed R3's "Quetiapine" medication order and R3's November 2023 MAR and acknowledged the MAR did not reflect R3's "Quetiapine" medication was administered according to R3's medication order.