Inspirations of Tempe

Based on observation, record review, and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R1's medical record revealed a service plan for directed care dated March 2025.The service plan stated the following services were required: - "Provide personal laundry service Laundry 1/week. Laundry is being provided as needed more than 1x per week as resident is soiling clothes with urine and feces throughout the day." -"Housekeeping is cleaning room more frequently than once a week and at a PRN basis as the resident is relieving [self] on the floor." 2. During the environmental inspection of the facility, the Compliance Officer observed R1 walking barefoot through urine which was on the bathroom, living room, and bedroom floors of R1's unit. The Compliance Officer observed a strong smell of urine on R1's clothing. 3. In an interview, E6 reported that the unit was last cleaned a week before the inspection. 4. In an interview, E2 and E4 acknowledged that a caregiver or assistant caregiver did not provide R1 with the assisted living services in the resident's service plan.

Based on observation and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. Findings include: 1. During the environmental inspection of the facility with E1 and E4 around 10 a.m. the Compliance Officer observed R1's unit had a very strong urine smell and had urine leading from R1's bathroom to the living room and bedroom area. The bedroom area had carpet, the carpet had tracks of urine from where the resident was walking to and from the bathroom and living room area. The Compliance Officer also observed R1 walking through the urine. The Compliance Officer's shoes were sticking to the floor due to the dry, sticky urine on the floor. The Compliance Officer also observed the toilet had dry urine on the seat of the toilet. 2. A review of R1's service plan for directed care services. The services plan revealed R1 was to receive Housekeeping, “housekeeping is cleaning the room more frequently than once a week and at a PRN bases as resident is relieving themselves on the floor’. 3. In an interview, E1 acknowledged the urine on the bathroom floor, living room floor, and in bedroom carpeted flooring had been there for at least a week. 4. In an interview, E1 acknowledged that R1 was not treated with dignity, respect, and consideration.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected to prevent, minimize, and control illness or infection. Findings include: 1. During the environmental inspection of the facility with E1 and E4 around 10 a.m. the Compliance Officer observed R1's unit had a very strong urine smell and had urine leading from R1's bathroom to the living room and bedroom area. The bedroom area had carpet, the carpet had tracks of urine from where the resident was walking to and from the bathroom and living room area. The Compliance Officer also observed R1 walking through the urine. The Compliance Officer's shoes were sticking to the floor due to the dry, sticky urine on the floor. The Compliance Officer also observed the toilet had dry urine on the seat of the toilet. 2. In an interview, E6 reported R1's unit was last cleaned a week before the date of the inspection. 3. In an interview, E1 and E6 acknowledged R1's bedroom had urine leading from the bathroom to the living room and the bedroom area. E1 acknowledged the facility staff was aware of the issue of R1 dragging urine-soaked briefs across the unit. E1 acknowledged R1 had been walking through the urine for about at least a week. 4. In an interview, E1 and E2 acknowledged the premises used at the assisted living facility was not cleaned and disinfected to prevent, minimize, and control illness or infection.

Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. Findings include: 1. A review of facility documentation revealed a staff schedule. The staff schedule revealed only one staff member was schedule for December 4, 2024. 2. A review of facility documentation revealed an incident report dated December 4, 2024. The incident report revealed R1 had fallen and staff was unble to assist R1 up off the ground. 3. A review of R1's medical revealed a service plan for supervisory care services. The service plan revealed R1 needed a two person assist when toileting and one person assist with mobility and transfers, however R1 needed 4 person assisted when being lifted off the ground. 4. During an interview, E1 acknowledged R1 required a four person assist. E1 also acknowledged the facility only had one caregiver on staff December 4, 2024 when R1 needed assistance with being lifted of the ground. 5. In an interview, E1 acknowledge the facility did not provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently.

Based on documentation review, record review, and interview, the manager failed to ensure the assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services and ancillary services in the assisted living facility's scope of services. Findings include: 1. A review of facility documentation revealed a staff schedule. The staff schedule revealed only one staff member was schedule for night shift December 4, 2024. 2. A review of facility documentation revealed an incident report dated December 4, 2024. The incident report revealed R1 had fallen and staff was unable to assist R1 up off the ground. 2. A review of R1's medical revealed a service plan for supervisory care services. The service plan revealed R1 needed a two person assist when toileting and one person assist with mobility and transfers, however R1 needed 4 person assisted when being lifted off the ground. 3. During an interview, E1 acknowledged R1 required a four person assist. E1 also acknowledged the facility only had one caregiver on night shift December 4, 2024 when R1 needed assistance with being lifted of the ground.

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 if a review was required, by the nurse or medical practitioner (MP) who reviewed the service plan, for four of ten residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan for supervisory care services dated June 10, 2024, and an updated services plan dated July 5, 2024. However, neither service plan was not signed and dated by the resident or resident's representative, the manager. 2. A review of R2's medical record revealed a service plan dated September 25, 2023. R2 was receiving supervisory services and medication administration services. However, the initial service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 3. A review of R3's medical record revealed a service plan dated November 11, 2022. R3 was receiving personal services and medication administration services. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 4. A review of R5's medical record revealed a service plan dated June 1, 2023. R5 was receiving supervisory services and medication administration services. However, the service plan was not signed and dated by the resident or resident's representative, the manager, and a nurse or medical practitioner. 5. In an interview, E1 acknowledged the residents' service plans were not signed and dated by the resident or resident's representative, the manager, or by the nurse or medical practitioner who reviewed the service plans.

Based on observation and interview, the manager failed to ensure medication 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 the physical health and safety of residents with access to the unsecured medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bottle of "Escitalopram 20 milligrams", "Propranolol 10 milligrams", "Prazosin 1 milligram", and "Bupropion HCL SR 150 milligrams" in a purse on a counter in the activities area. The activities area was a common area where residents were present to interact with other residents and have access to the area. 2. In an interview, E1 acknowledged the "Escitalopram", "Propranolol", "Prazosin", and "Bupropion HCL SR" were not stored in a secured area used only for medication storage. 3. In an interview, E1 reported the facility provides employees with lockers to secure items during work hours, but E7 did not use them. E1 and E7 acknowledged the "Escitalopram", "Propranolol", "Prazosin", and "Bupropion HCL SR" were not stored in a secured area used only for medication storage.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a staff schedule. The schedule indicated the facility operated on three shifts: -"1st shift" from 6:00 AM to 2:00 PM; -"2nd shift" from 2:00 PM to 10:00 PM; and -"3rd shift" from 10:00 PM to 6:00 AM. 2. A review of facility documentation revealed the most recent documented disaster drill was conducted on November 28, 2023, on the second shift. No other documentation of disaster drills conducted at the facility was provided for review. 3. In an interview, E1 acknowledged the disaster drills were not up to date at the time of the inspection.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency situation. Findings include: 1. A review of facility documentation revealed an evacuation drills sheet dated September 19, 2022. No other documentation was available for review to show evacuation drills were conducted after September 19, 2022. 2. In an interview, E1 acknowledged there was no other documentation available for review at the time of the inspection to indicate evacuation drills for employees and residents were conducted at least once every six months after September 19, 2022.