Hummingbird Grove Peoria

Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E1, E2 and E3 were the only personnel members working at the facility. 2. During the environmental tour, the Compliance Officer observed there was no personnel schedule posted. The Compliance Officer requested the personnel schedule, however, E1 was not able to provide the work schedules for the month of September and October 2024. 3. In an interview, E1 reported that E1 was the only employee for the months of September and October. E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.

Based on observation, record review, and interview, the manager failed to ensure a complete personnel record was available for two of four personnel sampled. The deficient practice posed a risk as required information could not be verified for E2 and E3 and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. Upon arrival, the Compliance Officer was greeted by E1 at the door and observed E2 exiting a resident's room and E3 in the kitchen. 2. During a review of personal records, the Compliance Officer requested to review E2's and E3's personnel record, however, no personnel record for E2 and E3 was available for review at the time of the inspection. 3. In an interview, E1 reported E2 and E3 were assistant caregivers, and their personnel records were not available for review at the time of the inspection. E1 acknowledged a personnel record was not maintained for E2 and E3.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of four residents sampled. The deficient practice posed a risk as required information could not be verified for R4 and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. During the inspection, the Compliance Officer requested to review the medical records of R1, R2, R3, and R4 from E1, however, the medical record for R4 was not available for review at the time of the inspection. 3. In an interview, E1 reported that R4's medical record was unavailable for review. E1 reported that R4 was at the facility for less than 24 hours; however, E1 had failed to collect the required documentation before or at the time of R4's admission. E1 acknowledged that the medical record for R4 was not available for review during the inspection.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Disaster plan, Relocation, Records, Medication, Food and Water". However, the disaster plan was reviewed last on February 22, 2023. 2. A review of facility policies and procedures revealed a policy "Disaster plan, Relocation, Records, Medication, Food and Water," the policy stated "8. The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement." 3. In an interview, E1 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months.

Based on observation, documentation review and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental tour, the Compliance Officer observed four ambulatory residents. 2. During the environmental tour, the Compliance Officer observed the following poisonous and toxic materials in an unlocked cabinet in a common bathroom: - one spray bottle of "WinCO Foods All Purpose Cleaner with Bleach" - one canister of "Pledge Lemon Enhancing Polish" - one jug of "LA's Totally Awesome Liquid Bleach Fresh Scent" 3. During the environmental tour, the Compliance Officer observed an unlocked laundry room. The following poisonous and toxic materials were observed: - one canister of "Pledge Lemon Enhancing Polish" - four spray bottle of "Febreze Air Freshener Spray" - two spray bottle of "PINALEN Multipurpose Cleaner Spray" - three spray bottle of "Clorox Original Clean-Up All Purpose Cleaner with Bleach Spray Bottle" - two jug of "LA's Totally Awesome Liquid Bleach Fresh Scent" 4. A review of facility documentation revealed a policy titled "Environmental and Physical Plant Safety," the policy stated "15. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dinning areas, and medications and are inaccessible to residents." 5. In an interview, E1 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted June 23, 2023.

Based on observation and interview, the manager failed to ensure a resident bathroom used by more than one resident contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available for two of the common area bathrooms in the facility used by residents and visitors. 2. In an interview, E1 acknowledged the bathrooms used by more than one resident did not contained paper towels in a dispenser or a mechanical air hand dryer.

Based on observation and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility was enclosed by a wall or fence with a self-closing, self-latching gate that was locked when the swimming pool was not in use. The deficient practice posed a risk to the physical health and safety of residents with access to the swimming pool. Findings include: 1. The Compliance Officer observed four ambulatory residents in the facility. 2. During the inspection, the Compliance Officer observed R5 attempting to exit the facility multiple times without authorization and required staff redirection. 3. During the environmental tour, the Compliance Officer observed a swimming pool on the premises, however, the pool gate towards the casita was unlocked. The pool was found uncovered and filled with water. 4. In an interview, E1 acknowledged the swimming pool gate was unlocked.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. Findings include: 1. Review of R2's medical record revealed a service plan for directed care services dated May 23, 2023. The service plan documented R2 required the following assisted living service: "Non Ambulatory, requires positioning every 2-3 hours." 2. Documentation review of R2's medical record revealed R2 was repositioned in the evenings at approximately 10 pm, 1 am, 4 am, and 7 am. No additional documention was available for review to demonstrate R2 was repositioned outside of those identified hours. 3. In an interview, E1 reported R2 is placed in R2's wheelchair at 7 a.m. until approximately 12 pm daily. E1 reported R2 returns to bed at approximately 12 pm. E1 reported R2 does not like to be repositioned when in the wheelchair. E1 acknowledged R2 is not repositioned every "2-3 hours" when R2 is in R2's wheelchair. E1 reported when R2 is placed back in bed R2 is repositioned from 12 pm to 10 pm however this repositioning is not documented in R2's medical record. E1 acknowledged R2 was not provided the assisted living services according to R2's service plan.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider. Findings include: 1. Review of R3's medical record revealed a document titled "Report of Unusual Occurrence" dated August 5, 2022. This document indicated R3 was found laying down on the floor and emergency medical services were called to assess R3. This document indicated no documentation R3's primary care provider was notified. 2. Review of R4's medical record revealed a document titled "Report of Unusual Occurrence" dated June 21, 2022. This document indicated emergency medical services were called for R4 and R4 was taken to the hospital. This document indicated no documentation R4's primary care provider was notified. 3. During an interview, E1 reviewed R3 and R4's medical records. E1 acknowledged the medical records revealed no documention showing R3 and R4's primary care providers were immediately notified when R3 and R4 had an incident resulting in needing medical services.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. Findings include: 1. During the facility tour with E1, the surveyor observed the water temperature at 127\'b0 F in a resident shared bathroom. 2. In an interview, E1 reviewed the hot water temperature reading. E1 acknowledged the resident shared bathroom temperature was not maintained between 95\'b0 F and 120\'b0 F in the area of a facility used by residents.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored 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 the facility tour, the Compliance Officer observed one bottle of Disinfecting Wipes unlocked on a resident bedside table. 2. During an observation, the caregivers were not accessing the toxic materials at the time of the inspection. 3. During an interview, E1 reported the disinfecting wipes belonged to the facility and were used to clean the resident room and was not returned to the facility's locked storage area when finished. E1 acknowledged the toxic material was stored unlocked and accessible to residents.