Heritage Manor Assisted Living LLC

Based on 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. During the environmental inspection of the facility, the Compliance Officer observed a bell system placed on the back door of the facility. However, the Compliance Officer was able to open the back door without causing the alert to make noise to alert employees of egress. 2. In an interview, E1 and E4 acknowledged the means of exiting the facility did not control or alert employees of the egress of a resident from the facility at the time of the inspection.

Based on interview and record review, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of three 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, E2 reported all residents received medication administration services. 2. A review of R2's medical record revealed a signed medication order dated September 20, 2024. The order included "Cyanocobalamin 1000 MCG/ML INJ... Inject 1ML intramuscularly every month...Bring labeled vial to clinic to have nurse administer injection." 3. A review of R2's medical record revealed R2's Medical Administration Record (MAR) sheet. The MARs sheet revealed Cyanocobalamin had not been administered this month. However, in an interview, E2 reported E2 had administered the medication to R2 on December 7, 2024 and forgot to document it. 4. A review of E2's personnel record revealed no documentation of a nursing license. 5. In an interview, E2 and E4 acknowledged medication was not administered in compliance with an order and documented.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the front door of the facility had an alternative locking mechanism screwed in towards the top of the door. The Compliance Officer tried to lock the door using the deadbolt on the door, but the deadbolt would not fully turn. 2. During an environmental inspection of the facility, the Compliance Officer observed the back yard gate allowing access to the front of the house. The latch for the gate was broken off and the gate would open without any resistance. 3. In an interview, E2 and E4 acknowledged the front door and the backyard gate posed a risk to health and safety of the residents.

Based on observation and interview, the manager failed to ensure a toxic material stored by the facility was 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 the environmental inspection of the facility, the Compliance Officer observed the following in unlocked cabinets in the kitchen, accessible to residents: -"Great Value" dishwasher gel; -"Great Value" disinfectant spray; -"RMR-86" mold and mildew stain remover; -"Great Value" glass cleaner; -"Great Value" multi-purpose cleaner; -"Greased Lightning" cleaner and degreaser; and -"Easy-Off" grill cleaner. 2. In an interview, E1 and E4 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

Based on documentation review, observation, and interview, the manager failed to ensure a list of resident rights was conspicuously posted. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(54) states "conspicuously posted" means, "a. A location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution". 2. During the environmental inspection of the facility, the Compliance Officer did not observe a posted list of the resident rights in A.A.C. R9-10-810(C). 3. In an interview, E1 acknowledged a list of resident rights was not conspicuously posted.

Based on observation, documentation review, and interview, the manager accepted and retained an individual who required restraints, including the use of bedrails. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1 in a bed with half bedrails. 2. In an interview, E1 reported R1 used the bedrails as a means of support and help moving around. E1 reported to have documentation from a medical practitioner stating R1 needed bedrails. 3. A review of R1's medical record revealed a document titled, "Resident Service Plan," dated February 1, 2021, which stated, "...Level of Care: Directed (Cannot Call For Help, Unable To Make Sound Judgement, Or Direct Care)...Bedbound; History Of Falls..." The document was signed and dated by R1, the manager, and a registered nurse. 4. A review of R1's medical record revealed a document titled, "Determination and Assessment For Admission," signed and dated by a medical practitioner on April 30, 2021, which stated, "...Is the resident bedbound or similarly immobilized? NO...Does resident require a physical restraint: NO..." 5. In an interview, E1 confirmed R1 was bedbound, and acknowledged the facility did not have a medical order stating R1 requires restraints or the use of bedrails. E1 reported the facility will remove the bedrails on R1's bed.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the facility's bathroom between bedroom 4 and bedroom 5 contained a shower. However, the shower did not contain a slip-resistant surface. 2. In an interview, E1 acknowledged the shower in the bathroom did not contain a slip-resistant surface.

Based on observation and interview, the manager failed to ensure a resident's sleeping area had a window or door that could be used for direct egress to outside the building. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the bedroom for R1 contained a window. However, R1's bed was in front of the window, preventing direct egress. 2. During the environmental inspection of the facility, the Compliance Officer observed the bedroom for R4 and R6 contained a window. However, two nightstand tables were blocking the window, preventing direct egress. 3. During the environmental inspection of the facility, the Compliance Officer observed the bedroom for R3 and R5 contained a window. However, R3's bed was blocking the window, preventing direct egress. 4. In an interview, E1 acknowledged the manager failed to ensure the aforementioned sleeping areas had a window or door that could be used for direct egress to outside the building.