Loving Mother Residency LLC

Based on documentation review, observation, and interview, the governing authority failed to designate a manager who had 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 as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. A review of Department documentation revealed O1 was no longer the facility's manager effective June 1, 2024. No additional information was received from the governing authority to indicate that a new manager had been appointed. 2. While on-site for the compliance inspection, the Compliance Officer did not observe a manager's certificate posted at the facility. However, E1 provided a manager certificate for E4 dated September 26, 2024 for review when requested. 3. In an interview, O2 reported O1 was the facility manager of record from January 3, 2021 to May 31, 2024. O2 also reported E4 was the facility manager of record from September 19, 2024 to current. 4. In an interview, E1 reported E4 was hired as the facility's manager sometime in September 2024. E1 acknowledged the governing authority failed to designate a manager who had 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.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for one of four personnel sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(C)(2) states, "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A review of the facility's personnel schedule for the month of October 2024 revealed E3 was scheduled to work. 3. A review of E3's personnel record revealed documentation of a fingerprint clearance card (FPCC). The FPCC was dated prior to E3's hire date of record; however, no documentation of FPCC verification was available for Compliance Officer review. 4. In an interview, E1 acknowledged that E3's FPCC card was not verified, and acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C)(2).

Based on documentation review and interview, the manager failed to ensure that 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 policy and procedure manual revealed a review date of January 16, 2021. However, no additional documentation of review was available for Compliance Officer review. 2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on documentation review, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services and the Department was provided false or misleading information. Findings include: 1. A review of the facility's personnel schedule revealed E2 was scheduled to work at the facility alone on the following dates: - September 1, 2024, from 7:00 PM - 7:00 AM; - September 3, 2024, from 7:00 PM - 7:00 AM; - September 4, 2024, from 7:00 PM - 7:00 AM; - September 5, 2024, from 7:00 PM - 7:00 AM; - September 7, 2024, from 7:00 AM - 7:00 PM; - September 9, 2024, from 7:00 PM - 7:00 AM; - September 10, 2024, from 7:00 PM - 7:00 AM; - September 11, 2024, from 7:00 PM - 7:00 AM; - September 12, 2024, from 7:00 PM - 7:00 AM; - September 13, 2024, from 7:00 PM - 7:00 AM; - September 16, 2024, from 7:00 PM - 7:00 AM; - September 17, 2024, from 7:00 PM - 7:00 AM; - September 18, 2024, from 7:00 PM - 7:00 AM; and - September 19, 2024, from 7:00 PM - 7:00 AM. 2. A review of E2's personnel record revealed a caregiver certificate issued on September 20, 2024. 3. In an interview, E1 reported E2 only interacted with residents under the supervision of E3. However, E3 reported E2 was on-site at the facility alone before E2 completed a caregiver training course. 4. In an interview, E1 acknowledged E2 interacted with residents without the supervision of a manager or caregiver.

Based on documentation review, record review, and interview, the manager failed to ensure that the assisted living facility had caregivers and assistant caregivers with the qualifications necessary to ensure the health and safety of a resident for one of four personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's personnel schedule revealed E2 was scheduled to work at the facility alone on the following dates: - September 1, 2024, from 7:00 PM - 7:00 AM; - September 3, 2024, from 7:00 PM - 7:00 AM; - September 4, 2024, from 7:00 PM - 7:00 AM; - September 5, 2024, from 7:00 PM - 7:00 AM; - September 7, 2024, from 7:00 AM - 7:00 PM; - September 9, 2024, from 7:00 PM - 7:00 AM; - September 10, 2024, from 7:00 PM - 7:00 AM; - September 11, 2024, from 7:00 PM - 7:00 AM; - September 12, 2024, from 7:00 PM - 7:00 AM; - September 13, 2024, from 7:00 PM - 7:00 AM; - September 16, 2024, from 7:00 PM - 7:00 AM; - September 17, 2024, from 7:00 PM - 7:00 AM; - September 18, 2024, from 7:00 PM - 7:00 AM; and - September 19, 2024, from 7:00 PM - 7:00 AM. 2. A review of R1's medical record revealed a progress note dated September 5, 2024. The note stated, "[R1] constipated and I give her Miralax." 3. A review of R1's medical record revealed a progress note dated September 13, 2024. The note stated, "[R1] is constipated and I give her Miralax. 2 Pm[sic]." 4. In an interview, E2 confirmed the aforementioned progress notes were written by E2. 5. A review of E2's personnel record revealed a caregiver certificate issued on September 20, 2024. No documentation of previous caregiver training was available for Compliance Officer review. 6. In an interview, E1 acknowledged E2 did not possess the qualifications necessary to ensure the health and safety of a resident.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E2 working at the facility independently at 12:30 PM. 2. A review of the facility's employee work schedule revealed a schedule for October 2024. The schedule indicated E2 and E3 were scheduled to work from 7:00 AM to 7:00 PM on October 4, 2024. No further documentation of the caregivers scheduled to work, and hours worked by each was available for Compliance Officer review. 3. In an interview, E1 acknowledged the employee work schedule did not include documentation of the caregivers who worked each day, and the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of four 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 E2's personnel record revealed a hire date of August 18, 2024. 4. A review of E2's personnel record revealed a negative TB skin test that was less than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. 5. In an interview, E1 reported E1 was unaware of the new TB policies as specified in R9-10-113. E1 acknowledged E2 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of the individual's completed orientation required by policies and procedures for one of four personnel sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Staffing, Hiring, and Discipline." The policy stated, "After the employee is hired by the facility, the employee shall ensure: That the new employee completed the New Employee Orientation ON or BEFORE the employee's first day of hire." 2. A review of E3's personnel record revealed no documentation of a completed employee orientation. 3. In an interview, E1 acknowledged E3's personnel record did not contain documentation of E3's completed orientation required by policies and procedures.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included the requisite components, for two of four personnel sampled. The deficient practice posed a risk as required information could not be verified for E1 and E4. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Staffing, Hiring, and Discipline." The policy stated, "That an employee file is maintained on the facility premises for each employee and that the file includes, but is not limited to: Application, with verified references. Employee name, Date of hire, Employee date of Birth, Employee Home Address, Employee Phone Number, Current TB test, Current CPR Certification, Current First Aid Certification, Caregiver/Manager Certificate, New Employee Orientation, Verification of Skills and Knowledge, Fingerprint Clearance Card and Manager Verification, if hired with existing card." 2. While on-site for the compliance inspection, the Compliance Officer requested all personnel records. However, personnel records for E1 and E4 were unavailable for Compliance Officer review. 3. In an interview, E1 reported E1 and E4 did not have a personnel record maintained on the facility premises. E1 acknowledged personnel files for E1 and E4 did not include the requisite components.

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated April 1, 2024) that indicated R1 would receive the following services: - Assistance with bathing, twice a week; - Peri care, daily and as needed (PRN); - Assistance with grooming, PRN; - Fluids, encourage 6 to 8 glasses per day; - Disposable undergarments change, PRN; and - Medication administration. 2. While on-site for the compliance inspection, the Compliance Officer requested R1's Activities of Daily Living (ADL) documentation for the month of October 2024. ADL documentation for the month of September 2024 was provided, however no documentation of current ADL services provided was available for Compliance Officer review. 3. A review of R2's medical record revealed a service plan (dated May 21, 2024) that indicated R2 would receive the following services: - Assistance with bathing, twice a week; - Peri care, daily and as needed (PRN); - Assistance with grooming, PRN; - Fluids, encourage 6 to 8 glasses per day; - Disposable undergarments change, PRN; and - Medication administration. 4. While on-site for the compliance inspection, the Compliance Officer requested R2's ADL documentation for the month of October 2024. ADL documentation for the month of September 2024 was provided, however no documentation of current ADL services provided was available for Compliance Officer review. 5. In an interview, E1 reported R1 and R2 received all aforementioned services in the month of October 2024. However, documentation of the services provided were not available for Compliance Officer review. E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical records.

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 one 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, "Flu/Pneumonia Vaccine Policy Procedure." The policy stated, "Make vaccination for influenza and/or pneumonia available to residents according to A.R.S. \'a7 36-406(1)(d)." 3. A review of R1's medical record did not include documentation of R1's notification of the availability of flu and pneumonia vaccinations. Based on R1's acceptance date, this documentation was required. 4. In an interview, E1 acknowledged R1's medical record did not contain documentation of R1's notification 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 failed to ensure medication administered to a resident was documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a signed medication list (dated April 17, 2024) for the following medications: - Losartan Potassium 50 milligrams (mg), by mouth (po) daily (qd); - Duloxetine 30 mg, 1 tablet po qd; - Cilostazol 50 mg, 1 tablet po twice a day (bid); - Prednisone 2.5 mg, 1 tablet po qd; - Pantoprazole 40 mg, 1 tablet po qd; - Aspirin 81 mg, 1 tablet po qd; - Acetaminophen 325 mg, 2 tablets po three times a day (tid); - Metoprolol ER 25 mg, 1 tablet po at bedtime (qhs); - Verapamil Tablet extended release 120 mg, po qhs; - Atorvastatin 40 mg, 1 tablet po qhs; and - Preparation H Rectal Ointment 0.25-14-74.9%, 1 application rectally qhs. 2. While on-site for the compliance inspection, the Compliance Officer requested R1's medication administration record (MAR) documentation for the month of October 2024. MAR documentation for the month of September 2024 was provided; however, R1's current MAR was unavailable for Compliance Officer review. 3. A review of R2's medical record revealed a signed medication list (dated June 11, 2024) for the following medications: - Aspirin 82 mg, 1 tablet po qd; - Bupropion HCl 300 mg, 1 tablet po qd; - Citalopram 20 mg, 1 tablet po qd; - Lorazepam 1 mg, 1 table po qhs; - Senna 8.6 mg, 2 tablets po bid; - Triple Antibiotic Ointment, 1 application qd; - Advair Diskus 250-50 micrograms (mcg), 1 inhalation bid; - Albuterol Sulfate 3 mg, bid; and - Incruse Ellipta 62.5mcg, 1 inhalation qd. 4. While on-site for the compliance inspection, the Compliance Officer requested R2's MAR documentation for the month of October 2024. MAR documentation for the month of September 2024 was provided; however, R2's current MAR was unavailable for Compliance Officer review. 5. In an interview, E2 reported all medications had been administered to R1 and R2 in the month of October 2024. E1 acknowledged medication administered to R1 and R2 was not documented in R1's and R2's medical records.

Based on observation and interview, the manager failed to ensure that a life preserver or shepherd's crook was available and accessible in the swimming pool area. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer did not observe a life preserver or shepherd's crook available in the facility's swimming pool area. 2. In an interview, E1 acknowledged a life preserver or shepherd's crook was not available and accessible in the facility's swimming pool area.

Based on observation and interview, the manager failed to ensure that pool safety requirements were conspicuously posted in the swimming pool area. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer did not observe pool safety requirements conspicuously posted in the facility's swimming pool area. 2. In an interview, E1 acknowledged that pool safety requirements were not conspicuously posted in the facility's swimming pool area.