Mary Herron Foster Care Home

Based on record review and interview, the manager failed to ensure a resident had a written service plan, reviewed and updated at least once every six months, for one of two residents sampled who received personal care services; and at least once every three months for one of one residents sampled who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care services dated September 11, 2023. A service plan completed no more than six months later was not available for review. 2. A review of R2's medical record revealed a written service plan for directed care services dated April 28, 2024. A service plan completed no more than three months later was not available for review. 3. In an interview, E1 acknowledged R1's and R2's services plans were not updated per R9-10-808.A.4.b.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received personal care, and medication administration services. The medical record contained a doctor's order, dated August 7, 2024, directing R1 take "Quetiapine Tab 25 mg: take 1 tablet by mouth daily." The order included a second dose of the same medication "as needed." 2. A review of R1's Medication Administration Record (MAR) for September 2024 revealed a section documenting the administration of "Quetiapine Tab 25MG Take 1 Tablet by mouth twice daily." Entries in the MAR reflected the medication was administered routinely to R1 at 8 a.m. and 5 p.m. 3. A review of R2's medical record revealed a service plan which indicated R2 received directed care, and medication administration services. The medical record contained a doctor's order, dated April 25, 2024, directing R2 take "Seroquel 25 mg tablet 1 tablet 2 times daily oral provider." 4. A review of R2's Medication Administration Record (MAR) for September 2024 revealed a section documenting the administration of "Quetiapine 1 Tablet by mouth every morning and 2 Tablets every night at bedtime." Entries in the MAR reflected the medication was administered to R2 at 8 a.m. and 8 p.m. 5. In an interview E1 advised R1 was being administered the second dose of Quetiapine daily, and not as needed. E1 acknowledged R1 and R2 were not being administered medication as ordered.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled, "AHCCCS Medical Policy Manual Exhibit 1620-15, Assisted Living Facility (ALF) Residency Agreement," which documented a contract between the facility, R2 and R2's insurer. However, evidence of a documented residency agreement was not available for review. Based on R2's date of acceptance, a residency agreement was required. 2. In an interview, E1 acknowledged R2's medical record did not contain a residency agreement which included the requirements in R9-10-807(D)(1-10).

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner which stated weighing the resident was contraindicated. Findings include: 1. A review of R1's medical record revealed service plan dated February 6, 2023, which indicated R1 was receiving directed care services. The service plan indicated R1's weight was to be documented monthly, however evidence of documentation of R1's weight was unavailable for review. Further, evidence of documentation from a medical practitioner which stated weighing R1 was contraindicated was not available for review. 2. In an interview, E1 acknowledged the service plan indicated R1's weight was to be documented monthly. E1 affirmed there was documentation from a medical practitioner which stated weighing R1 was contraindicated, however E1 failed to produce the documentation within two hours after a Department request or prior to the exit interview.

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. Findings include: 1. During a tour of the facility the Compliance Officer observed a dining table in the kitchen. On top of the table was a medication organizer which was filled with various types of medications. E1 was observed to leave the kitchen area and go into a back room of the residence, out of sight of the kitchen. 2. In an interview, E1 reported the medications in the medication organizer belonged to E1, and E1 acknowledged they had not been stored in a separate locked room, cabinet or self-contained unit the facility uses for medication storage. E1 removed the medication organizer, placed them in E1's bedroom and locked the door.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed two glass mason jars filled with a clear, brown liquid and a squeeze bottle containing a similar in color, clear liquid. The squeeze bottle was labeled, "Clairol natural instincts 2 Color Activator." 2. In an interview, E1 reported the brown liquid in the mason jars and the liquid in the squeeze bottle were chemicals for treating E1's hair color. 3. The Compliance Officer observed a bottle of Windex Multisurface Disinfectant Cleaner in an unlocked cabinet below the kitchen sink. The Compliance Officer also observed a spray bottle of "Home Store Glass Cleaner," located in another unlocked cabinet below the kitchen counter. 4. In an interview E1 acknowledged that the hair chemicals, disinfectant, and glass cleaners were not kept in a locked area, inaccessible to residents.