Kindred Homes Yuma LLC

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information required by Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9), for two of two sampled residents. Findings include: 1. A review of R1's and R2's medical records did not contain standardized emergency responder forms. 2. In an interview, E2 acknowledged medical records for R1 and R2 did not contain standardized emergency responder forms as required by the statute. E2 was provided with a copy of the statute for review.

Based on documentation review, record review, and interview, the manager failed to ensure that a manager or caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a negative one step TB skin tests; however, it was administered and read after E1 began providing services to residents. 4. In an interview, E2 acknowledged documentation of evidence of freedom from infectious TB was not dated within 12 months before the date E1 began providing services at or on behalf of the health care institution as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of two caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E1's personnel record revealed E1 worked as a caregiver with a hire date in July, 2021. The personnel record revealed a current first aid and CPR card. There was also a prior first aid and CPR card with a completion date of September 15, 2022; however, there was no documentation of required first aid and CPR before September 15, 2022. 2. In an interview, E2 acknowledged that E1's personnel record did not contain documentation of first aid and cardiopulmonary resuscitation training certification before E1 provided assisted living services to a resident.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(2)(a-b) states: "B. A health care institution's chief administrative officer shall: 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 2. A review of R1's medical record revealed no documentation of TB testing results. 3. In an interview, E2 acknowledged R1's medical record did not contain documentation of freedom from infectious tuberculosis.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not provided during the inspection. Findings include: 1. A review of R1's medical record revealed the most recent service plan available for review for personal care services dated December 19, 2023. 2. A review of R1's medical record did not contain service plan updates for March 2024 and September 2024. 3. In an interview, E2 reported that service plans were conducted for R1 for March 2024 and September 2024; however, the service plans were not in R1's medical record and were not available for review at the time of the inspection. 4. In an interview, E2 acknowledged that R1's medical record did not contain service plan updates that were conducted at least every six months as required.

Based on record review and interview, the manager failed to ensure the resident's medical record contained documentation of medication administered to the resident that included the dosage of administration for one of two residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed the most recent service plan dated December 19, 2023 for personal care services. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication order to include Tramadol 25 mg, one tab to be administered once daily. 3. A review of R1's medication administration record (MAR) for October 2024 and November 2024 recorded the dosage for Tramadol 25 mg to be administered as needed instead of once daily per the order. 4. In an interview, E2 acknowledged that documentation of medication administration did not include the proper dosage for R1.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services which reported that R1 received medication administration. 2. A review of R1's medical record revealed a medication order dated November 10, 2024, which included the following medications: -Potassium 10 meq, one tablet to be administered on Mondays only -Tramadol 25 mg to be administered once daily. 3. A review of R1's Medication Administration Record (MAR) for November 2024 revealed the following medications were not administered in compliance with the medication order: -Potassium 20 meq was administered to R1 on November 11, 14, 18-19, 21, and 25-26; not on Mondays and Potassium 10 meq as ordered -Tramadol 25 mg was not administered in October or November 2024; not once a day as ordered 4. In an interview, E2 acknowledged medication was not administered in compliance with the medication order.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the required information from a hospice agency, for one of one resident's medical record reviewed who had been receiving hospice services. Findings include: 1. In an interview at the beginning of the compliance inspection, E2 reported that R3 since accepted to the facility has been on hospice. The nurse comes once a week and as needed and the CNA comes twice a week. 2. Review of R3 medical record found no documentation, as required, each time hospice came to the facility to care for R3. 3. In an interview, E1 acknowledged there was no documentation available for review for each hospice visit. E1 reported, "they didn't leave anything".

Based on resident record review and interview, the manager failed to ensure that two of three sampled residents service plans that were available for review who were receiving personal care services found the service plans were not updated at least once every six months. Findings include: 1. Review of R1's medical record revealed that R1's most current written service plan was dated April 18, 2023. The service plan stated the resident required personal care and medication administration services. The service plan should have been updated at least by October of 2023. 2. Review of R8's medical record revealed that R8's most current written service plans was dated April 15, 2023. The service plan stated the resident required personal care and medication administration services. The service plan should have been updated at least by October of 2023. 3. In an interview, E1 acknowledged there were no other more current service plans available for review. E1 acknowledged there was no documented evidence the service plans were updated as required for these two residents receiving personal care services.

Based on record review and interview, the manager failed to ensure that a written service plan was completed and available for review, for the four of seven sampled residents' medical records reviewed. The deficient practice posed a risk as a service plan was not developed to reinforce or clarify services to be provided to meet the needs of residents. Findings include: 1. A review of R4's medical record revealed no documentation of a written service plan and updates. Based R4's date of acceptance, a service plan was required. 2. A review of R5's medical record revealed no documentation of a written service plan and updates. Based on R5's date of acceptance, a service plan was required. 3. A review of R6's medical record revealed no documentation of a written service plan and updates. Based on R6's date of acceptance, a service plan was required. 4. A review of R8's medical record revealed no documentation of a written service plan and updates. Based on R8's date of acceptance, a service plan was required. 5. Reviewed the current Medication Administration Record (MAR) and the current documentation of the activities of daily living (ADL) provided to the residents found these sampled residents were receiving medication administration services and hands-on care for services that each of these residents required. 6. In and interview, E1 acknowledged there were no service plans and updates available for review for these four sampled residents. E1 reported they were done, however, in a pile that needed filing.

Based on record review and interview, the manager failed to ensure that for four of five sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the residents' needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. During an interview, E2 revealed that R1, R2, and R7 were unable to ambulate even with assistance since accepted to the facility. E2 reported that R5 had a change in condition about a month ago, and since then has been unable to ambulate even with assistance. 2. Review of R1's medical record revealed a documented determination dated January 3, 2024. Based on the date of acceptance there was no prior determination completed in 2023 and updated at least every six months throughout the duration of the resident's condition. The determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R1 required personal care services. 3. Review of R2's medical record revealed a documented determination dated January 2, 2024. Based on the date of acceptance there was no prior determination completed in 2023 and updated at least every six months throughout the duration of the resident's condition. The determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R2 required personal care services. 4. Review of R7's medical record revealed a documented determination dated October 2, 2023. Based on the date of acceptance there was no prior determination completed in 2023 and updated at least every six months throughout the duration of the resident's condition. The determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R7 required personal care services. 5. Review of R5's medical record revealed no documented determination from the resident's PCP or other medical practitioner at the onset of the change in R5's condition about a month ago. The determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R5's service plan should have been updated at that time due to the change in condition of the resident. 6. In an interview, E1 acknowledged there was no other documentation of the required determinations available for review. This is a repeat deficiency from the compliance inspection on June 27, 2023

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to the residents, for one of four sampled staff records reviewed. Findings include: 1. Review of the facility's documentation revealed E5's personnel record did not contain any documented evidence the fall prevention and fall recovery training program had been implemented for this sampled staff. 2. In an interview, E1 acknowledged the facility had not provided the required fall prevention and fall recovery training for all staff. This is a repeat deficiency from the compliance inspection conducted on June 21, 2022.

Based on record review and interview, the manager failed to ensure that one of seven sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. During an interview, E1 and E2 revealed that R2 was unable to ambulate even with assistance since accepted to the facility. 2. Review of R2's medical record revealed no documented determination at the time of acceptance or onset and updated at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. Based on the date of acceptance this was required. 3. In an interview, E1 and E2 acknowledged there was no other documentation of the required determination completed for R2, who was unable to ambulate even with assistance, available for review.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below which posed a health and safety risk. Findings include: 1. During a facility tour, E1, E2, and the compliance officer observed the facility's black refrigerator in the attached garage contained food and had a thermometer that registered 50\'b0 F at the warmest area of the refrigerator. The compliance officer's thermometer registered at 49.9\'b0 F. The refrigerator was not in use during the observation. 2. During an interview, E1 and E2 acknowledged the facility's refrigerator was not maintained at 41\'b0 F or below.

Based on observation and interview, the manager failed to ensure a smoke detector was installed in the attached garage as required which posed a safety risk if there was no smoke detector in the attached garage. Findings include: 1. During a the testing of the required smoke detectors, E1, E2, and the compliance officer observed there was no smoke detector in the facility's attached garage. 2. In an interview, E1 reported a few months ago the garage ceiling was redone and "we forgot" to install a smoke detector.