Liberty Care Home II

Based on documentation review, record 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 that included initial training and continued competency training, for two of two personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Fall Prevention and Recovery Training Programs." 3. After the initial training, all employees will be required to attend continuing competency training on fall prevention and fall recovery at least every 12 months." 2. A review of E1's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated August 3, 2022. However, no documentation of additional fall prevention and fall recovery training was available for Compliance Officer review. 3. A review of E2's personnel record revealed documentation of Fall Prevention and Fall Recovery Training dated August 5, 2022. However, no documentation of additional fall prevention and fall recovery training was available for Compliance Officer review. 4. In an interview, E1 acknowledged the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included continued competency training.

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in in A.R.S. 36-420.04.A. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of facility documentation did not include a standardized form that included the aforementioned information for each resident of the facility. 3. A review of R1's and R2's medical records revealed all required information, however, a standardized form with all aforementioned information was not available for review. 4. In an interview, E1 acknowledged the facility did not maintain a standardized form for each resident that included the information prescribed in in A.R.S. 36-420.04.A.

Based on documentation review and interview, the manager failed to ensure that the facility's policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review was conducted on July 18, 2019. However, no additional documentation of review was available. 2. In an interview, E1 acknowledged that the facility's polices and procedures were not reviewed at least once every three years and updated as needed.

Based on documentation review, observation, and interview, the manager failed to ensure that the current phone numbers required in R9-10-803.D.3.a-d were conspicuously posted. Findings include: 1. R9-101.54 states, "Conspicuously posted" means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. R9-10-803.D.3.a-d states, "Current phone numbers of: a. The unit in the Department responsible for licensing and monitoring the assisted living facility, b. Adult Protective Services in the Department of Economic Security, c. The State Long-Term Care Ombudsman, and d. The Arizona Center for Disability Law." 3. During the environmental tour of the facility, the Compliance Officers observed the facility's required postings stored on a shelf in the facility's office. However, the required phone numbers were not conspicuously posted. 4. In an interview, E1 reported the facility was undergoing renovations, and the postings were removed from the wall in the process. E1 acknowledged that the phone numbers required by R9-10-803.D.3.a-d were not conspicuously posted.

Based on documentation review, observation, and interview, the manager failed to ensure that a list of resident rights was conspicuously posted. Findings include: 1. R9-101.54 states, "Conspicuously posted" means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. During the environmental tour of the facility, the Compliance Officers observed the facility's required postings stored on a shelf in the facility's office. However, a list of residents rights was not conspicuously posted. 3. In an interview, E1 reported the facility was undergoing renovations, and the postings were removed from the wall in the process. E1 acknowledged that a list of resident rights was not conspicuously posted.

Based on documentation review, observation, and interview, the manager failed to ensure that the assisted living facility's license was conspicuously posted. Findings include: 1. R9-101.54 states, "Conspicuously posted" means placed: a. At a location that is visible and accessible; and b. Unless otherwise specified in the rules, within the area where the public enters the premises of a health care institution." 2. During the environmental tour of the facility, the Compliance Officers observed the facility's required postings stored on a shelf in the facility's office. However, the facility's license was not conspicuously posted. 3. In an interview, E1 reported the facility was undergoing renovations, and the postings were removed from the wall in the process. E1 acknowledged that the assisted living facility's license was not conspicuously posted.

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officers requested R1's medical record with all required documents at 10:45 AM. However, the medical record provided did not include documentation signed by a medical practitioner that included if R1 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E1 acknowledged R1's medical record did not contain documentation signed by a medical practitioner that included if R1 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R1 was accepted into the facility.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 8, 2023, that indicated R1 received personal care services. However, R1's medical record did not contain documentation of additional, updated, service plans. 2. A review of R2's medical record revealed a service plan, dated August 11, 2022, that indicated R2 received personal care services. However, R2's medical record did not contain documentation of additional, updated, service plans. 3. In an interview, E1 acknowledged that R1's and R2's medical records did not contain a service plan that was reviewed and updated at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R2's medical record did not include documentation of medication orders for the following medications: - Amlodipine Besylate 10 milligrams (mg), 1 tablet by mouth (po) daily (qd); and - Omeprazole 10 mg, 1 capsule po qd, 30 minutes before breakfast. 2. A review of R2's medication administration record (MAR) for January 2025 revealed R2 received the following medications January 1, 2025 - Present: - Amlodipine Besylate 10 mg, 1 tablet po qd; and - Omeprazole 10 mg, 1 capsule po qd, 30 minutes before breakfast. 3. While on-site for the compliance and complaint inspection, the Compliance Officers observed the following medications stored at the facility for administration to R2: - Amlodipine Besylate 10 mg; and - Omeprazole 10 mg. 4. During an interview, E1 acknowledged R2's medical record did not contain a medication order from a medical practitioner for each medication that was administered to R2.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), for two of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of the facility's policies and procedures revealed a policy titled, "POLICY ON MAKING VACCINATIONS FOR INFLUENZA AVAILABLE TO RESIDENTS." The policy stated, "The manager shall ensure that vaccinations for influenza and pneumonia be made available to the residents on a yearly basis." 3. A review of R1's medical record revealed R1 was offered the flu and pneumonia vaccines on February 2, 2021. However, there was no documentation of additional offerings available for review. Based on R1's acceptance date, this documentation was required. 4. A review of R2's medical record revealed R2 was offered the flu and pneumonia vaccines on August 11, 2021. However, there was no documentation of additional offerings available for review. Based on R2's acceptance date, this documentation was required. 5. In an interview, E1 acknowledged R1's and R2's medical records did not contain documentation of R1's and R2's notifications of the availability of vaccinations according to A.R.S. \'a7 36-406(1)(d).

Based on documentation review, record review, and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2's service plan (dated August 11, 2022) revealed R2 received personal care services, and was confined to a bed or chair. 3. A review of R2's medical record revealed a determination for continued residency dated February 18, 2024. However, no further documentation was available for Compliance Officer review. 4. In an interview, E1 acknowledged R2's medical record did not include the required determination per R9-10-814(B)(2) updated at least once every six months.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed that the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officers observed the facility's front and back doors did not contain a way to alert employees of egress from the facility. 3. In an interview, E1 reported the facility had been making renovations and removed the alarms during the process. E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on observation and interview, the manager failed to ensure that 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 residents who were not prescribed the accessible medication. Findings include: 1. During the environmental tour of the facility, the Compliance Officers observed Lantus Solos Injector 100/ML stored in the door of the facility's unlocked kitchen refrigerator. However, the medication was not stored in a self-contained unit used only for medication storage. 2. In an interview, E1 acknowledged medication stored by the assisted living facility was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver documented the requirements in R9-10-818.D.2.a-f. Findings include: 1. R9-10-818.D.2.a-f states, "2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; f. Any action taken to prevent the accident, emergency, or injury from occurring in the future." 2. A review of the facility's policies and procedures revealed a policy titled, "Medical Emergencies." The policy stated, "In the event of a medical emergency involving a resident, the following procedure should be followed: 1. If the resident is showing signs of any life threatening condition... 4. Complete an incident report." 3. A review of the facility's incident report documentation did not include any incident reports filed within the last 12 months. 4. In an interview, E1 reported R3 was transferred to the hospital following a breathing medical emergency in November 2024. 5. In an interview, E1 reported the facility did not document the aforementioned incident. E1 acknowledged that a caregiver did not document the requirements in R9-10-818.D.2.a-f, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.

Based on observation and interview, the manager failed to ensure that the premises of the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officers observed the facility's back patio area to be filled with a large pile made up of the following materials: - Patio furniture; - Broken pieces of wood; - A broom; - Pillows; - A motorized wheelchair; - An unlabeled bottle of yellow liquid; - A folding table; - Linens; and - A bucket of paint materials. However, the pile of materials appeared to be stacked precariously. 2. The Compliance Officers observed R3 to be ambulatory and able to move around the facility with a walker. 3. In an interview, E2 reported the facility recently repainted the patio area, and explained the pile was placed there during the painting process. E1 acknowledged the facility was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on documentation review, record review, and interview, the chief administrative officer failed to ensure that the health care institution implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for two of two personnel sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "ANNUAL TB TRAINING AND EDUCATION." The policy included a form to indicate each employee had completed the TB education course. 2. A review of E1's personnel record did not include documentation of annual training and education related to recognizing the signs and symptoms of TB. 3. A review of E2's personnel record did not include documentation of annual training and education related to recognizing the signs and symptoms of TB. 4. In an interview, E1 reported E1 was unaware of the new TB requirements per R9-10-113. E1 acknowledged E1's and E2's personnel records did not include documentation of completed annual training and education related to recognizing the signs and symptoms of TB.

Based on documentation review and interview, the healthcare institution failed to implement tuberculosis (TB) infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Tuberculosis Screening 28 A.A.R. 1113." The policy stated, "d) Annually assessing the health care institution's risk of exposure to infectious tuberculosis." 2. A review of facility documentation did not include documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 reported E1 was unaware of the new TB requirements per R9-10-113. E1 acknowledged the health care institution did not implement TB infection control activities that included annually assessing the health care institution's risk of exposure to infectious TB.