Marcos and Secilia Ramon Home Care

Based on documentation review and interview, the manager failed to ensure there was an established and documented policy and procedure that covered how a caregiver would respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The deficient practice posed a risk as there was no policy and procedure to reinforce and clarify the assisted living home’s standards on how to handle such an incident, if necessary. Findings include: 1. A review of the facility's policies and procedures revealed there was no documentation of a policy that covered how a caregiver would respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 2. In an interview, E3 clearly explained the appropriate steps that the caregiver would follow in such an event, if necessary, and also confirmed that the caregiver had completed recent training on the topic during the memory care training. However, E3 acknowledged that the facility did not have a documented policy on the topic as required.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of facility documentation revealed a policy and procedure manual labeled "Maros and Secilia Policy and Procedure Manual." The documentation indicated the most recent review date was March 16, 2020. 2. In a interview, E1 acknowledged the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted, 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 two sampled residents. Findings include: 1. A review of R2's medical record revealed no documentation dated within 90 calendar days before R2 was accepted by the assisted living facility to include whether R2 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. 2. In an interview, E1 acknowledged the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted, 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.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, there was a documented residency agreement with the assisted living facility, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed documentation of a residency agreement was not available for review. 2. In an interview, E1 acknowledged there was no documentation of a residency agreement for R2 available for review.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to the resident. Findings include: 1. A review of R2's medical record revealed no documentation of a written service plan. Based on R2's date of acceptance, a service plan was required. 2. In an interview, E1 acknowledged R2's medical record did not include a written service plan.

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 and the manager, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services updated on August 12, 2023. However, the service plan was not signed and dated by R1 or R1's representative, or the facility manager. 2. In an interview, E1 acknowledged R1's written service plan was not signed and dated by R1 or R1's representative, or the facility manager.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (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: "1. The department shall: d. 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 licensee 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 R1's medical record revealed documentation of the notification of R1 of the availability of vaccination for influenza and pneumonia, dated September 16, 2022. However, there was no current documentation of the notification of R1 of the availability of vaccination for influenza and pneumonia. 3. In an interview, E1 acknowledged R1's medical record did not include current documentation showing the influenza and pneumonia vaccination was offered or received.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of two residents sampled. The deficient practice posed a risk if the resident was unable to safely evacuate the facility in the event of an emergency. Findings include: 1. A review of R2's medical record revealed documentation of R2's orientation to exits from the assisted living facility was not available for review. 2. In an interview, E1 reported R2 received orientation to exits from the facility. However, E1 acknowledged R2's medical record did not contain documentation of the R2's orientation to exits from the facility.