Highland Park Estate

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of the three employees reviewed. The deficient practice posed a safety risk to residents. Findings include: 1. ARS § 36-411(C)(3-4) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: (3) Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency may not hire the potential employee. (4) On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution, or home health agency shall take action to terminate the employment of that employee." 2. A review of E1's, E2's, and E3's personnel records revealed no documentation of good faith efforts to verify that each employee was not on the adult protective services registry pursuant to section 46-459. 3. A review of the adult protective services registry revealed that E1, E2, and E3 were not on the registry 4. In an interview, E1 acknowledged that good faith efforts to verify that each employee was not on the adult protective services registry were not conducted.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident, which covered orientation and in-service training 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 no policy and procedure covering orientation and in-service training for employees and volunteers. 2. In an interview, E1 acknowledged that the facility did not have a policy and procedure covering orientation and in-service training for employees and volunteers.

Based on 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, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed no documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant. 2. In an interview, E1 acknowledged documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant was not available for review. This is a repeat citation from the compliance inspection conducted on August 3, 2023.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following materials stored in the facility's unlocked cabinet under the sink: - All-purpose cleaner spray; - Regular bleach cleans and deodorizes; and - Multi-purpose vinegar. 2. In an interview, E1 acknowledged that poisonous or toxic materials stored by the facility were not maintained in a locked area and inaccessible to residents. This is a repeat citation from the compliance inspection conducted on January 26, 2022.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Staffing and Record Keeping" which stated, "A work schedule of all staff members who provides assisted living services to residents and volunteers is developed and maintained at the facility for at least 12 months from the date of the work schedule. The work schedule must contain facility name, dates, and a key of abbreviation (for names of working staff/volunteers, hours scheduled, hours worked, etc)." 2. The Compliance Officer requested to review documentation of the staff working each day, including the hours worked by each, for July 2023. However, documentation of caregivers and assistant caregivers working each day in July 2023, including the hours worked by each, was not available for review. 3. In an interview, E2 acknowledged documentation of the caregivers or assistant caregivers working each day, including the hours worked by each, was not maintained.

Based on 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, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed no documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant. 2. In an interview, E2 acknowledged documentation dated within 90 calendar days before R1 was accepted by the assisted living facility to include whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant was not available for review.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan when updated, for three of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated July 13, 2023. However, the service plan was not signed and dated by the resident or resident's representative, or the facility manager. 2. A review of R2's medical record revealed a service plan for personal care services dated March 14, 2023. However, the service plan was not signed and dated by the resident or resident's representative, or the facility manager. 3. A review of R3's medical record revealed a service plan for personal care services dated May 14, 2023. However, the service plan was not signed and dated by the resident or resident's representative, or the facility manager. 4. In an interview, E2 acknowledged R1's, R2's, and R3's written service plans were not signed and dated by the residents or residents' representatives, or the facility manager. This is a repeat citation from the previous on-site compliance inspection conducted on January 26, 2022.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of three residents sampled. Findings include: 1. A review of R3's medical records revealed a service plan for personal care services dated May 14, 2023. The service plan stated, "Complete Bath: Bed Bath, 2x/week, Dependent by CG...Partial Bath: On days when complete bath is not given, At Bedside, Dependent...Shampoo: 2x/week." 2. Further review of R3's medical record revealed an activities of daily living (ADL) document for July 2023. The aforementioned services were not documented in the July 2023 ADL document as provided for R3 on any day in July 2023. 3. In an interview, E2 and E3 reported all services in R3's service plan were provided to R3 at the frequency specified in R3's service plan. E2 and E3 acknowledged assistance provided to R3 with bathing and shampooing in July 2023 was not documented in R3's medical record.

Based on documentation review and interview, the administrator failed to ensure the disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of Department documentation revealed the license for AL11892 was active as of July 1, 2021. 2. A review of the facility's policies and procedures revealed an undated policy titled "Disaster Plan, Relocation, Records, Mediation (sic), Food & Water." The second page of the policy contained space to document when the disaster plan was last reviewed, the "employees participating in the review," a "critique of the disaster plan review," and "recommendations for improvement." However, the space beneath each section was blank. No additional documentation to indicate the disaster plan was reviewed was available. 3. In an interview, E2 acknowledged the facility's disaster plan was not reviewed at least once every 12 months. E2 reported being unaware an annual disaster plan review was required.