Heritage at Carefree Senior Living

Based on record review, observation, and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. Findings include: 1. A review of R2's medical record revealed R2 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the following toxic materials stored in a cabinet above the toilet in R2's room: - Dove Women's Deodorant; - AirWick Air Freshener; - Top Value Denture Cleanser Tablets; - Destin Maximum Strength Diaper Cream; and - AmLactin Ultra Smoothing Body and Hand Cream. The cabinet was equipped with a lock, however, the lock was not in use at the time of inspection. 2. The Compliance Officer observed an unlocked maintenance room accessible from the facility's outside patio area which contained the following poisonous materials: - Mapei Novoplan 2 Plus Professional Self-Leveling Underlayment; - Roundup Concentrate; - Polyblend Plus Non-Sanded Grout; - Rustoleum Protective Enamel Paint; - Western Stucco-patch; - USG All Purpose Joint Compound; - Tomcat Bait Chunx; and - Glidden Premium Interior Paint and Primer. 3. In an interview, E1 acknowledged poisonous or toxic materials stored by the facility were not maintained in a locked area inaccessible to residents.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of eight residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated July 1, 2024) that indicated R1 received the following services: - Assistance with dressing each morning; - Minimal assistance with personal hygiene/grooming; - Assistance with bathing, twice a week; - Requests staff to make bed once daily; - Assistance with dining; - Weekly personal laundry service; - Pericare provided with each incontinence episode; - Moisturizer applied as needed (PRN) and/or after showers; - Daily/PRN skin checks; - Daily minor housekeeping; - Assure resident is in bed with pajamas on at night; and - Assistance for nighttime preparation. 2. A review of R1's activities of daily living (ADL) documentation for October 15, 2024, revealed documentation of the following services: - Peri Care/Skin Check; and - Oral Care. However, there was no additional documentation of these services provided in the month of October 2024. 3. A review of R1's ADL documentation for October 2024, revealed no documentation of the following services: - Nail Care; and - Assistance with meals. 4. In an interview, E1 reported R1 received all aforementioned services in the month of October 2024. In an interview, E1 acknowledged a caregiver failed to document the services provided in R1's medical record.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the water temperature in R1's bathroom to be 122.5\'ba F. 2. In an interview, E1 acknowledged hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for three of six personnel members sampled. The deficient practice posed a risk if the personnel members were a danger to a vulnerable population. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "STAFFING AND RECORD KEEPING" dated July 1, 2023. The policy and procedure stated: "The facility manager shall ensure that the personnel record for each employee and volunteer Includes: Documentation of: documentation of compliance with the requirements in A.R.S. \'a736-411(A) and (C) (DPS fingerprinting clearance requirements)." 2. A review of the personnel records of E5, E6, and E8 revealed documents titled "Application for Employment." E5's and E6's applications included contact information for E5's and E6's previous employers. E8's application had the name of a country written in under the section for "Work History." However, the review revealed the following: -No documentation indicating the governing authority made documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E5's fitness to work in a residential care institution; -Documentation indicating the governing authority contacted "co-worker[s]" and not previous employers to obtain information or recommendations that may have been relevant to E6's fitness to work in a residential care institution; and -Documentation indicating the governing authority contacted "friend[s]" and not previous employers to obtain information or recommendations that may have been relevant to E8's fitness to work in a residential care institution. 3. A review of the Department of Public Safety website revealed the fingerprint clearance cards of E5, E6, and E8 were valid. 4. In an interview, E1 reported E5 and E6 were hired as caregivers and E8 was hired as a housekeeper. E1 reported housekeepers provided housekeeping services in resident rooms.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for four of five residents sampled, which posed a health and safety risk. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed current service plans indicating R1, R2, R3, and R4 received directed care services. 2. A review of R1's, R2's, R3's, and R4's service plans revealed R1, R2, R3, and R4 required "assistance with dressing each morning." However, further review of R1's, R2's, R3's, and R4's medical records revealed no documentation of the services having been provided. 3. In an interview, E1 reported the services were provided but not documented. E1 acknowledged a caregiver or an assistant caregiver failed to document the services provided to R1, R2, R3, and R4 in R1's, R2's, R3's, and R4's medical records.

Based on documentation review, interview, and record review, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "EMPLOYEE JOB DESCRIPTIONS, DUTIES AND QUALIFICATIONS (INCL. REQUIRED SKILLS AND KNOWLEDGE, EDUCATION AND EXPERIENCE)" dated July 1, 2023. The policy and procedure included sections for the job descriptions, duties, and required education and experience for caregivers and assistant caregivers. However, the policy and procedure did not include the required skills and knowledge for caregivers and assistant caregivers nor did it include the job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience, for housekeepers or volunteers. 2. In an interview, E1 stated E7 and E8 were "housekeeper[s]." When asked if the facility provided the Compliance Officers with all facility policies and procedures, E1 stated. "Yes." 3. A review of the personnel records of E7 and E8 revealed E7 and E8 were hired as housekeepers. 4. In an interview, the Compliance Officers informed E1 and E2 the policy and procedure was missing the aforementioned items required by rule, and E1 and E2 offered no comment.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered orientation for employees and volunteers, for five of six employees sampled. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "ORIENTATION AND IN-SERVICE EDUCATION" dated July 1, 2023. The policy and procedure stated: "New employee orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the residents. The orientation is complete within 48 hours from the employment." The policy and procedure then listed 39 items to be covered during orientation. 2. A review of the personnel records of E1, E4, E5, E6, E7, and E8 revealed a series of documents titled "EMPLOYEE ORIENTATION ACKNOWLEDGMENT" dated between June 9, 2015, and September 5, 2023. The documents revealed the following: -E1 received orientation on April 1, 2016, then again on April 5, 2017; April 2, 2018; April 1, 2019; April 1, 2020; April 1, 2021; and April 1, 2022; -E4 received orientation on July 5, 2015, then again on July 5, 2016; July 5, 2017; July 2, 2020; July 5, 2021; July 1, 2022; and July 1, 2023; -E6 received orientation on September 5, 2020, then again on September 5, 2022, and September 5, 2023. -E7 received orientation on June 9, 2015, then again on June 14, 2016; June 14, 2017; May 29, 2018; May 24, 2019; May 4, 2020; May 3, 2021; May 3, 2022; and May 1, 2023; and -E8 received orientation on May 25, 2016, then again on May 25, 2017; June 8, 2018; May 25, 2019; May 4, 2020; May 4, 2021; and May 1, 2022. However, none of the aforementioned "EMPLOYEE ORIENTATION ACKNOWLEDGMENT" documents matched the items listed in the facility's policies and procedures. 3. In an interview, when asked if the facility provided the Compliance Officers with all facility policies and procedures, E1 stated. "Yes." When the Compliance Officers informed E1 and E2 the employee orientation acknowledgment documents did not match the facility's policies and procedures, E1 and E2 offered no comment.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training, for four of four applicable employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "FIRST AID AND CPR TRAINING" dated July 1, 2023. The policy and procedure stated: "All applicable employees, defined as employees who provide direct hands on care to Heritage residents, such as caregivers, and volunteers who direct work directly with seniors in our community, shall keep First Aid and CPR training and skills up to date, and provide the following: Documentation that verifies that the employee or volunteer has received CPR and First Aid training specific to adults, which includes a demonstration of caregiver's ability to perform CPR from American Red Cross, American Heart Association, National Safety [Council] or their authorized agents...The individual who provides CPR and First Aid Training has to be certified by American Red Cross, American Heart Association or National Safety Council and have the instructor ID number on the card." 2. A review of the personnel records of E1, E4, E5, and E6 revealed the following: -A printout of E1's "ADULT FIRST AID / CPR AED" training certificate from Health and Safety Institute (HSI) dated as issued on January 30, 2023; -A printout of E4's "CPR FIRST AID" training certificate from EMS Safety (An HSI Company) dated as issued on January 20, 2022; -A printout of E5's "ADULT FIRST AID / CPR AED" training certificate from HSI dated as issued on September 7, 2023; and -A printout of E6's "ADULT FIRST AID / CPR AED" training certificate from HSI dated as issued on August 1, 2023. 3. A series of telephonic interviews with representatives from American Red Cross and American Heart Association revealed HSI was not an "authorized agent" of American Red Cross or American Heart Association as stated in the facility's policies and procedures. 4. A review of the National Safety Council website revealed the instructors for E1's, E4's, E5's, and E6's CPR courses were not certified National Safety Council instructors as required by the facility's policies and procedures. 5. A review of facility documentation revealed a series of personnel schedules dated between February 1, 2023, and September 6, 2023. The schedules revealed E5 worked as a caregiver on at least one shift each week between February 1, 2023, and September 6, 2023. 6. A review of the personnel records of E1, E4, E5, and E6 revealed the individuals who provided CPR training to E1, E4, E5, and E6 were not certified by American Red Cross, American Heart Association, or National Safety Council as required by the facility's policies and procedures. The review revealed E5 wo

Based on observation, interview, and documentation review, the manager failed to ensure the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could have been viewed was conspicuously posted. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed a series of postings on a wall in a hallway near the entryway. One of the postings, in small print, stated, "If you'd like to see a copy of our latest inspection report. Please ask one of our office team members. Thank you." However, the posting did not include the location at which a copy of the most recent Department inspection report could have been viewed and did not mention any plan of correction resulting from a Department inspection. 2. In an interview, when the Compliance Officers asked if the facility had required postings in a different area of the facility, E3 stated, "On the wall it's the only ones." 3. In a separate interview, when the Compliance Officers brought up the missing information on the aforementioned posting, E1 stated, "No one ever told us that." 4. A review of Department documentation revealed technical assistance was provided on this rule during the compliance inspection conducted on June 9, 2015, the complaint/compliance inspection conducted on March 8, 2016, the complaint inspection conducted on July 27, 2016, and the complaint/compliance inspection conducted on January 5, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures, for two of four applicable personnel members sampled. The deficient practice posed a risk if the personnel members did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of facility documentation revealed no policy and procedure covering how to verify and document a caregiver's or assistant caregiver's skills and knowledge. However, the review did reveal a list of required skills and knowledge for a manager as well as a similar list for caregivers. 2. A review of the personnel records of E1 and E5 revealed E1 was hired as the manager and E5 was hired as a caregiver. However, the review revealed no documentation to indicate E1's and E5's skills and knowledge were verified. 3. A review of facility documentation revealed a series of personnel schedules dated between February 1, 2023, and November 15, 2023. The schedules revealed E5 worked as a caregiver on at least one shift each week between February 1, 2023, and November 15, 2023, minus one week in October 2023. 4. In an interview, when the Compliance Officers asked if the facility had items yet to be filed in personnel records, E1 stated, "Not to my knowledge."

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of five residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states: "1. The department shall: d. Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R5's medical record revealed two documents titled, "Resident TB Test, Influenza Vaccination, and Pneumoccocal [sic] Vaccination." Both documents included R5's tuberculosis (TB) tests, however, the documents revealed no documentation of R5 having been offered the flu and pneumonia vaccinations for 2021 and 2022. Additionally, neither document indicated R5 refused the flu and pneumonia vaccinations. 3. A review of facility documentation revealed a policy and procedure titled, "8.8 RESIDENT IMMUNIZATION." The policy and procedure stated: "Residents shall have vaccination of influenza and pneumonia available for inoculation...Vaccinations for Influenza/Pneumonia are offered on site...This requirement shall be properly documented...duly signed by the Resident or representative." 4. In an interview, E1 and E2 acknowledged R5's medical record did not contain documentation of notification of R5 of the availability of vaccination for influenza and pneumonia.

Based on documentation review, interview, and observation, the manager failed to ensure 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 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 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. In an interview, E1 reported the facility had multiple sections, including a memory care unit used only for those at the directed level of care and another section directly next to the memory care unit used for personnel and directed care residents. 3. During the environmental inspection of the facility, the Compliance Officers observed a double door leading from the area used for personnel and directed care residents into an outside courtyard. The Compliance Officers observed a keypad next to the door. However, the Compliance Officers were able to open the door without a key, special knowledge, or the need to expend increased physical effort. Upon opening the doors, the Compliance Officers heard no alert. The Compliance Officers and E1 exited the facility through the doors. The Compliance Officers observed a button next to the rightmost door as seen from the outside which stated "PUSH TO ENTER." Before reentering the facility through the doors, the Compliance Officers observed E1 push the button and enter with one of the Compliance Officers. The other Compliance Officer waited for the door to close, opened the door without pushing the button, entered, and again heard no alert. 4. In an interview, E1 stated, "I don't know why this one is not locked." E1 reported the door had been operating the day before when the Fire Department came to the facility for an inspection. E1 then reported the Fire Department did not come for an inspection, but instead a third party came to perform maintenance on the facility's emergency systems. E1 reported the facility had created a work order for the door already. 5. A review of facility documentation revealed a photo of an internal work order dated November 16, 2023, the day of the inspection. The work order did not contain a time or information for the company contacted to perform the work. The work order stated: "SERVICE WANTED: Courtyard door repair schedule ASAP (anytime)." This is a repeat citation from the complaint inspection conducted on January 5, 2023.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed a common area in the memory care unit. In the common area, the Compliance Officers observed a cabinet above the counter. The cabinet had a magnetic locking mechanism installed. However, the magnet used to unlock the cabinet was attached to a refrigerator to the left of the cabinet. Upon using the magnet to unlock and open the cabinet, the Compliance Officers observed a bottle of "Polyethylene Glycol 3350." The Compliance Officers further observed four cabinets approximately five feet to the left and in front of the refrigerator. The cabinets had magnetic locking mechanisms installed. However, the magnet used to unlock the cabinets was attached to a refrigerator to the right of the cabinets. Upon using the magnet to unlock and open each of the four cabinets, the Compliance Officers observed a variety of resident medications. In the bottom-right cabinet, the Compliance Officers observed air freshener, disinfectant spray, and "Raid" fly traps stored with the medications. 2. In an interview, E1 stated the magnet on the fridge near the cabinet was there "for ease of use." E1 reported caregivers normally kept the magnet on the caregiver's person. The Compliance Officers then observed E4 place the magnet on one of two plastic disks on the cabinetry above the refrigerator.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day, was conspicuously posted at least one calendar day before the first meal on the food menu was served, included any food substitution no later than the morning of the day of meal service with a food substitution, as applicable, and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed two food menus on a table near the dining room as well as posted in the common room in the memory care unit. However, the menus did not include breakfast. 2. A review of facility documentation revealed no food menu for breakfast meeting the following requirements: -Was prepared at least one week in advance; -Included the foods to be served each day; -Was conspicuously posted at least one calendar day before the first meal on the food menu was served; -Included any food substitution no later than the morning of the day of meal service with a food substitution, as applicable; and -Was maintained for at least 60 calendar days after the last day included in the food menu. 3. In an interview, E3 stated, "Breakfast is continental." When the Compliance Officers asked if the facility had a menu for breakfast, E3 stated, "No." Technical assistance was provided on this rule during the complaint/compliance inspection conducted on January 5, 2023.

Based on documentation 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 an assistant caregiver documented the action taken to prevent the incident from occurring in the future. The deficient practice posed a potential risk of re-injury. Findings include: 1. A review of facility documentation revealed a series of incident reports involving residents who were sent to the hospital. The first incident report revealed R6 fell and was sent to the hospital. The incident report included a section titled, "Action Taken To Prevent Incident" and the following checkboxes were selected: "Facility Staff," "Family," and "Physician." However, the aforementioned section did not include specific information or a description regarding the actions taken to prevent the incident from reoccurring. The second incident report revealed R4 was very aggressive, and physically and verbally violent. The incident report indicated R4 was sent to the hospital. Additionally, the incident report had a section titled, "Action Taken To Prevent Incident" and the following checkboxes were selected: "Facility Staff," "Family," and "Physician." However, the aforementioned section did not include specific information or a description regarding the actions taken to prevent the incident from reoccurring. 2. A review of facility documentation revealed a policy and procedure (P&P) titled, "18.4 INCIDENT REPORT." The P&P stated: "In the event of a resident accident, incident or injury that results in resident requiring medical services, the Incident Report will be filled out completely to document the incident and address corrective actions to prevent future reoccurrence...Staff shall...Document on the Incident Report Form...Action taken to prevent the incident." 3. In an interview, E1 reported the facility used checkboxes to make it easier for the staff to complete the incident reports. E1 and E2 acknowledged the facility's incident reports did not include the actions taken to prevent the incident from occurring in the future.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area separate from medications, 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 Officers observed a janitorial cart near a bathroom in a hallway near the dining room. On the cart, the Compliance Officers observed a variety of poisonous or toxic materials, including air freshener, bleach, "Comet" cleaner, disinfectant spray, glass cleaner, toilet bowl cleaner, and wood polish. The Compliance Officers observed no personnel member within sight of the cart. In a common area in the memory care unit, the Compliance Officers observed a cabinet. The cabinet had a magnetic locking mechanism installed. However, the magnet used to unlock the cabinet was attached to a refrigerator approximately five feet away from the cabinet. Upon using the magnet to unlock and open the cabinet, the Compliance Officers observed resident medication as well as air freshener, disinfectant spray, and Raid fly traps. 2. In an interview, E1 stated the magnet on the fridge near the cabinet was there "for ease of use." E1 reported caregivers normally kept the magnet on the caregiver's person. The Compliance Officers then observed E4 place the magnet on one of two plastic disks on the cabinetry above the refrigerator. 3. In another area of the facility, one of the Compliance Officers observed the first-floor laundry room. The Compliance Officer observed the door knob was in the lock position, however, the door was not fully closed and the locking mechanism was not latched shut. The Compliance Officer was able to gain access to the laundry room and observed accessible poisonous or toxic materials, including two bottles of bleach, "Comet" cleaner, "Lime-A-Way", "Lysol" disinfectant spray, "Lysol" toilet bowl cleaner, "Pledge", "Sprayway" glass cleaner, "Sprayway" stainless steel cleaner, "Windex", and "Zep." 4. In an interview regarding the unlocked laundry room door, E1 acknowledged the poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area. E1 reported E1 would fix the issue.