Immaculate Heart of Mary Assisted Living Home LLC

Based on observation, documentation review, and interview, the governing authority failed to designate, in writing, a manager who had either a certificate as an assisted living facility manager issued under 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 if the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. The Compliance Officer observed E2's manager's license posted conspicuously near the front door of the facility. 2. A review of the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers website revealed E2's manager's license was revoked on July 5, 2024. 3. In an interview, O1 reported E2's license was revoked on July 5, 2024. 4. In an interview, E1 acknowledged E2 did not have an active manager's license.

Based on documentation review, 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. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed three separate alarms located on the front door of the facility leading to the front yard and a deadbolt requiring a key. The Compliance Officer also observed four separate alarms located on the back door leading to the back yard and a deadbolt requiring a key. At the time of the observation, none of the alarms were working, and the deadbolts were unlocked. 3. In an interview, E2 reported there was a system that should state which door was opened, and was unsure why the system was not working. E2 acknowledged 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 record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. In an interview, E2 reported residents received medication administration. 2. A review of R1's medical record revealed a signed medication order for the following medications: -"Fluoxetine HCI 20 MG (milligrams) 3 capsules 1 time a day in the morning"; -"Quetiapine 50 MG 1 tablet at bedtime"; -"Lorazepam 2 MG 1 tablet at bedtime"; and -"Risperidone .25 MG 1 tablet in the evening." 3. Further review of R1's medical record revealed a medication administration record (MAR) dated June 2024. The MAR revealed the following medications were not marked as administered on the following dates: -"Fluoxetine" at 8:00 AM on June 25 and 26, 2024; -"Quetiapine" at 8:00 PM on June 24 and 25, 2024; -"Lorazepam" at 8:00 PM on June 24 and 25, 2024; and -"Risperidone" at 8:00 PM on June 24 and 25, 2024. 4. A review of R2's medical record revealed a signed medication order for "Gabapentin 100 MG capsules for 1 tablet at night daily." Further review of R2's medical record revealed a MAR dated June 2024. The MAR revealed "Gabapentin" was not marked as administered on June 1-14, 2024. 5. In an interview, E2 reported both residents were administered all required medications, and acknowledged the administration was not documented on the aforementioned dates.

Based on observation and interview, the manager failed to ensure poisonous or 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 residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a can of "Great Value Disinfectant Spray", a can of "Scrub Free Oven Cleaner" and a bottle of "Great Value Glass Cleaner" in an unlocked cabinet under the kitchen sink. The Compliance Officer also observed a bottle of "Clorox Bleach Foamer" and a container of "Comet Bleach" in an unlocked cabinet under a hallway bathroom sink. 2. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a cabinet in the kitchen labeled "Medication." The Compliance Officer was able to open the cabinet and observed the locking mechanism was not engaged. The cabinet held all of the current resident's medications. The Compliance Officer also observed a metal lockbox in the fridge in the kitchen. The Compliance Officer was able to open the lockbox without using a key. The lockbox contained a box of "Lantus INJ 100IJ/ML (milliliters)". 2. In an interview, E2 acknowledged medication stored by the facility was not stored in a locked area.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employees to have a valid fingerprint clearance card or fingerprint clearance card application within 20 working days of hire and for owners to make documented, good faith efforts to verify the current status of a person's fingerprint clearance card; for one of five sampled personnel records which posted a safety risk. Findings include: 1. Review of E4's personnel record revealed E4 was hired on August 1, 2023 as a caregiver. There was a photocopy of E4's fingerprint clearance card that was issued on October 26, 2022 which was prior to the date of hire. There was no documentation from the DPS website at the time of hire nor any time since that E4 had a valid fingerprint clearance card. 2. In an interview, E6 acknowledged E4's fingerprint card was never verified with DPS. The compliance officer verified on the DPS website that E4 had a valid fingerprint clearance card.

Based on observation, record review, and interview, the manager failed to ensure if the manager or caregiver was not awake during nighttime hours, the manager or caregiver could hear and respond to a resident needing assistance. The deficient practice posed a health and safety risk to the resident. Findings include: 1. During the onsite investigation, E6 revealed the night of the incident two caregivers were on duty, however, allowed to sleep during the nighttime hours. R2 fell during the night and was unable to arouse either caregiver who were sleeping not far from R2's bedroom. 2. In an interview, E6 reported that E2 and E3 were working the night of the incident. Both caregivers were sound asleep. E6 was notified by R2 by calling E6 on R2's cell phone twice when the caregivers would not respond. E6 was not at the facility at the time of the incident. 3. Review of E2's personnel record who was hired June 19, 2023 was a live-in caregiver. E3 had no personnel record available for review. E6 reported that E3 "took it." E6 agreed both caregivers were documented on the personnel work schedule 4. During the interview, E6 acknowledged the two caregivers were not able to be alerted to R2's needs.

Based on observation, documentation review, record review, and interview, the manager failed to ensure one of six sampled employees or volunteers had a record maintained at the facility. Findings include: 1. In an interview for the complaint investigation, the compliance officer requested and was not provided with E3's personnel record. Review of the incident report and the work schedule shows E2 and E3 were on the work schedule for the incident that happened during the night. 2. During the interview, E6 reported, there was no personnel record for (E3); the caregiver "took it" when (E3) quit working at the facility. E6 acknowledged that E3 was working the night of the incident, however, both caregivers were sound asleep and E6 was notified by R2 by calling E6 on R2's cell phone when the caregivers would not respond.

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. Findings include: 1. During a tour of the facility at the time of the complaint investigation, E6 and the compliance officer observed R3 was laying in bed with half length bedrails in the up position on the upper half of the bed; one on each side of the bed. The bedrail on the side of the bed that R3 could exit the bed may cause physical injury if R3 would go over the top of the bedrail and fall on the floor. 2. R3 was sleeping and not interviewable. Review of R3's medical record revealed that R3 was receiving directed care services. 3. In an interview, E6 and E2 acknowledged the bedrails were a hazard and could cause R3 health and safety issues. E2 reported that R3 could not lower the bedrails. .