Joyville Assisted Living Home

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 employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed an evacuation drill for employees and residents was conducted on November 1, 2021 at 9:00 AM. However, additional documentation of evacuation drills for employees and residents conducted at least once every six months was not available for review. 2. In an interview, E1 acknowledged evacuation drills for employees and residents were not conducted at least once every six months.

Based on documentation review and interview, the manager failed to implement the facility's ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of facility documentation revealed a policy titled "QUALITY MANAGEMENT POLICY" (dated June 4, 2023). The policy stated "...Conduct a Self-audit on the Facility Grounds at least once a year...Conduct a self-audit on the Resident's File every six (6) months...Conduct a self-audit on Personnel Files and Review the Skills and Knowledge of the Caregivers every six (6) months...Conduct a self-audit on Miscellaneous Files every six (6) months...Match Residents' medications with the Resident's Doctor's Orders and the Medication Administration Record every end of the month...Identify, document and evaluate incidents and accidents...every six (6) months...A tally of these reports shall be made by the Manager for easy identification of areas of concern...A report of the results of these meetings shall be submitted by the Manager to the Governing Authority and a copy of which shall be kept in the Facility and filed for at least 12 months." 2. The Compliance Officer requested to review documentation of the facility's quality management summary reports. However, the documentation was not provided for review. 3. In an interview, E1 acknowledged a quality management summary report was not available for review. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on May 17, 2022.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures, for two of two assistant caregivers sampled. The deficient practice posed a risk if E2 and E3 were unable to meet a resident's needs. Findings include: 1. The Compliance Officer observed E2 and E3 on the premises and working upon arrival. 2. A review of the facility's policies and procedures revealed a policy titled "Employees and Volunteers Qualifications" (dated June 4, 2023). The policy stated "...The hiring individual will check and document qualification, skills and knowledge for each employee..." 3. In an interview, E1 reported E2 and E3 were hired as assistant caregivers and E2's and E3's personnel records were not complete. 4. A review of documentation provided by E1, for E2, revealed documentation of the verification of E2's skills and knowledge was not available for review. 5. A review of documentation provided by E1, for E3, revealed documentation of the verification of E3's skills and knowledge was not available for review. 6. In an interview, E1 acknowledged E2's and E3's skills and knowledge were not verified and documented prior to E2 and E3 providing physical health services and according to the facility's policies and procedures.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregiver working each day, including the hours worked. Findings include: 1. The Compliance Officer observed E2 and E3 on the premises and working upon arrival. 2. A review of facility posted documentation, per R9-10-807.A.7., revealed a staffing schedule dated August 29 - 31, 2023. However, a current staffing schedule was not available for review. 3. In an interview, E1 reported the facility did not maintain a current staff schedule. 4. The Compliance Officer requested to review staff schedules maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. However, the last documented staff schedule was dated March 5, 2022. 5. In an interview, E1 acknowledged documentation was not maintained for at least 12 months of the caregivers and assistant caregiver working each day, including the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of two assistant caregivers sampled. The deficient practice posed a risk to the health and safety of residents if E3 was not orientated to the specific duties to be performed. Findings include: R9-10-101.155."Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of the facility's policies and procedures revealed a policy titled "Orientation and In-Service Training" (dated June 4, 2023). The policy stated "...New employee orientation is required to be completed by all new employees and volunteers before providing assisted living services to the residents..." 2. A review of documentation provided by E1, for E3, revealed documentation E3 received orientation specific to the duties to be performed was not available for review. 3. In an interview, E1 reported E3 was hired as an assistant caregiver and E3's personnel record was not complete. 4. In an interview, E1 acknowledged E3 did not receive orientation specific to the duties to be performed before providing assisted living services to the residents.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(vi)(ix), for one of two assistant caregivers, R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii)(vi)(ix) for one of two assistant caregivers sampled, and R9-10-806(C)(1)(c)(vi) for one of one manager sampled. The deficient practice posed a risk as the required information could not be verified for E2, E3, and E4. Findings include: 1. A review of documentation provided by E1, for E2, revealed the following documentation for E2: -E2's completed orientation; -Tuberculosis (TB) baseline screening and risk assessment; -Cardiopulmonary resuscitation training (CPR); and -First aid. However, documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(vi)(ix) was not available for review. 2. A review of documentation provided by E2, for E2, revealed a valid fingerprint clearance card. 3. A review of documentation provided by E1, for E3, revealed the following documentation for E3: -CPR; -First aid; and -Copy of E3's valid fingerprint clearance card. However, documentation of the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii)(vi)(ix). 4. A review of E4's personnel record revealed documentation of the requirement in R9-10-806(C)(1)(c)(vi) was not available for review. 5. In an interview, E1 acknowledged E2's personnel record to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(vi)(ix) was not available for review, E3's personnel record to include the requirements in R9-10-806(C)(1)(a)(b)(c)(i)(ii)(iii)(vi)(ix) was not available for review, and E4's personnel record to include the requirement in R9-10-806(C)(1)(c)(vi) was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, 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 five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's (accepted in 2022) medical record revealed documentation 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 was not available for review. 2. In an interview, E1 acknowledged documentation 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 submitted by R1.

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility to include the manager's signature and date signed, for one of five residents sampled. Findings include: 1. A review of R4's (admitted in 2022) medical record revealed a documented residency agreement. However, the residency agreement did not include the manager's signature and date signed. 2. In an interview, E1 acknowledged R4's residency agreement did not include the manager's signature or the date signed.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after a resident's date of acceptance, for one of five residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R5's (accepted in 2023) medical record revealed a written service plan was not available for review. Based on R5's date of acceptance, a service plan was required. 2. In an interview, E1 acknowledged a written service plan was not completed within 14 calendar days after R5's acceptance.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for one of five residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: A.R.S. \'a7 36-401.38 defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.38 defines "Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.16 defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. A review of R2's medical record revealed a service plan (dated in April 2023). However, the service plan did not include the level of service R2 was expected to receive. 2. In an interview, E1 reported R2 received directed care services. 3. In an interview, E1 acknowledged R2's service plan did not include the level of service R2 was expected to receive.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for two of four residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services dated in April 2023. However, a reviewed and updated service plan was not available for review. 2. A review of R4's medical record revealed a written service plan for directed care services dated in May 2023. However, a reviewed and updated service plan was not available for review. 3. In an interview, E1 acknowledged a reviewed and updated service plan for R2 and R4 was not available for review.

Based on record review and interview, the manager failed to ensure a written service plan was signed and dated by the resident or resident's representative, for one of five 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 R3's medical record revealed a current service plan (dated in April 2023) for personal care services. However, the service plan was not signed and dated by the resident or resident's representative. 2. In an interview, E1 acknowledged R3's written service plan did not include a signature and date from the resident or resident's representative.

Based on record review, observation, and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and false or misleading information was provided to the Department. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed current service plans describing the services to be provided by the facility. 2. A review of R5's medical record revealed a written service plan was not available for review. 3. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed an activities of daily living (ADL) log for September 2023 and October 2023. However, R1's, R2's, R3's, R4's, and R5's ADL logs did not indicate services were provided on September 25 - 30, 2023 and October 1 - 2, 2023. 4. The Compliance Officer observed E1 physically documenting on activities of daily living (ADL) logs during the inspection. 5. In an interview, E1 reported services provided to R1, R2, R3, R4, and R5 from September 25, 2023 to October 2, 2023 were not documented. 6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's medical records did not include documentation of services provided and reported the services were provided. E1 acknowledged documenting the services provided, during the inspection, was false or misleading.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. Findings include: 1. The Compliance Officer observed R3's bedroom did not have a bell, intercom, or other mechanical means to alert the employees to a resident's needs or emergencies. 2. A review of R3's medical record revealed a service plan for personal care services. 3. In an interview, E1 acknowledged R3 did not have a bell, intercom, or other mechanical means to alert the employees to a resident's needs or emergencies. Technical assistance was provided on this Rule during the on-site compliance inspection conducted on May 17, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order, and false or misleading information was provided to the Department. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed current service plans indicating R1, R2, R3, and R4 received medication administration. 2. In an interview, E1 reported E5 received medication administration. 3. A review of R1's, R2's, R3's, R4's, and R5's medical records revealed medication administration records (MAR'\) for September 2023 and October 2023. However, R1's, R2's, R3's, R4's, and R5's MAR'\ did not indicate medications were administered on September 25 - 30, 2023 and October 1 - 2, 2023. 4. The Compliance Officer observed E1 physically documenting on MARs. 5. In an interview, E1 reported medications administered to R1, R2, R3, R4, and R5 were not documented as administered from September 25, 2023 to October 2, 2023. 6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's medical records did not include documentation medication administered to R1, R2, R3, R4, and R5 and reported the medications were administered. E1 acknowledged documenting on the MARs, during the inspection, was false or misleading.

Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance, was conspicuously posted at least one calendar day before the first meal on the food menu was served, and included any food substitution no later than the morning of the day of meal service with the food substitution. Findings include: 1. The Compliance Officer observed a "weekly menu" posted on a bulletin board near the kitchen. The menu was dated September 1, 2023 - September 7, 2023. The menu revealed on Monday the lunch was going to be "All American Hamburger; French Fries; Mixed Vegetables; Fresh Fruits; Cookies; Coffee/Tea; Water." 2. The Compliance Officer observed the facility received Taco Bell from Door Dash for lunch. 3. In an interview, E1 reported the posted menu does not change and acknowledged the posted menu included dates from September 2023. E1 acknowledged the posted menu was not prepared at least one week in advance, was not conspicuously posted at least one calendar day before the first meal on the food menu was served and did not include any food substitution no later than the morning of the day of meal service.

Based on observation and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. Findings include: 1. The Compliance Officer observed a "weekly menu" posted on a bulletin board near the kitchen. The menu was dated September 1, 2023 - September 7, 2023. The menu revealed on Monday the lunch was going to be "All American Hamburger; French Fries; Mixed Vegetables; Fresh Fruits; Cookies; Coffee/Tea; Water." 2. The Compliance Officer observed the facility received Taco Bell from Door Dash for lunch. 3. In an interview, E1 reported the posted menu does not change, and acknowledged the posted menu included dates from September 2023. E1 acknowledged lunch was not served according to the posted menu.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation, per R9-10-807.A.7., revealed a staffing schedule dated August 29 - 31, 2023. The schedule revealed the facility maintained the following shifts: - 7:00 AM - 7:00 PM; and - 7:00 PM - 7:00 AM. 2. A review of facility documentation revealed a disaster drill conducted on: November 1, 2021 at 6:30PM. However, additional documentation of disaster drills for employees conducted on each shift at least once every three months and documented was not available for review. 3. In an interview, E1 acknowledged the facility had not conducted a disaster drill on each shift at least once every three months.