Mary's Group Home

Based on documentation review, the manager failed to ensure as a part of the policies and procedures, a plan was established, documented, and implemented to ensure the manager or a caregiver is available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work is not available or not able to provide the required assisted living services. Findings include:  1. A review of the facility’s documentation revealed there was no established and documented back-up plan to ensure a manager or caregiver was available to provide assisted living services to residents. 2. When the compliance officer arrived at 1 pm, E3 was the only employee at the facility with three residents on the premises. 3. In a request to review E3’s personnel record revealed that E3 did not have a personnel record available for review. Therefore, E3 did not have documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 4. In an interview, E1 acknowledged that E3 was a housekeeper, the residents were in the facility without a manager or caregiver present to provide assisted living services, and there was no back-up plan established, documented, or implemented.

Based on observation review, personnel record review, and interview, the manager failed to ensure a manager or caregiver was present at an assisted living home when a resident was present at the assisted living home. Findings include: 1. When the compliance officer arrived at 1 pm, E3 was the only employee at the facility with three residents on the premises. 2. A request to review E3’s personnel record revealed that E3 did not have a personnel record available for review. Therefore, E3 did not have documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 3. In an interview, E1 acknowledged E3 did not have a caregiver certification, and that E3 was a housekeeper. E1 acknowledged the residents were present, but a caregiver or manager was not.

Based on record review and interview, the manager failed to ensure a personnel record included the individual's name, date of birth, and contact telephone number; the individual's starting date of employment or volunteer service; and documentation of: i. the individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. the individuals’ education and experience were to their job duties; iii. individuals’ completed orientation; iv. the individuals’ license or certification vii. cardiopulmonary resuscitation training; viii first aid training ix; documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C). Findings include: 1. When the compliance officer arrived, the compliance officer observed that E3 was the only personnel member present with three residents. 2. A request to review E3's personnel record revealed that E3 did not have a personnel record available for review. 3. In an interview, E1 reported having documentation of E3’s two-step tuberculosis skin test and baseline questionnaire. However, E1 acknowledged E3’s personnel record was not available for review at the time of the survey.

Based on record review and interview, the manager failed to ensure that an individual who required continuous medical services, continuous or intermittent nursing services, or restraints was not accepted or retained. Findings include: 1. A review of R1's medical record revealed documentation indicating R1 required continuous medical services, continuous nursing services, restraints, and behavioral care dated January 2025 and signed by a physician. 2. In an interview, E1 acknowledged R1's documentation reflected R1 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation, documentation review, and interview during a complaint investigation, the manager failed to ensure the facility's policy and procedure was established and documented to ensure the safety of a resident who may wander to protect the health and safety of a resident. The facility was licensed to provide directed care services. Findings include: 1. A review of Department documentation revealed AL7702H was licensed to provide directed care services. 2. There was no documentation available for review that the facility had an established and documented policy and procedure to ensure the safety of a resident who may wander. 3. In an interview, E1 reported that E1 was unable to locate the facility's wandering policy and procedure at the time of the survey.

Based on record review and interview, the manager failed to ensure that medications were administered in compliance with a medication order and failed to accurately document the administration of medications in the medical records for one of two sampled residents who received medication administration services. The deficient practice posed a risk to residents if medications were not administered according to the medication orders. Findings include: 1. A review of R1's medical records revealed service plans reflecting that R1 received medication administration services. 2. A review of R1’s medical record medication order dated January 21, 2025, for Humalog 100 unit/ml (Lispro) per sliding scale subcutaneously four times a day as follows: blood sugar 200 through 250 administer two units; 251 through 300 administer four units; 301 through 350 administer six units; 351 through 400 administer eight units; above 400 call R1’s physician. 3. A review of R1’s medication administration record (MAR) dated June 2025 reflected that R1 was not administered Humalog from June 1, 2025 through June 4, 2025. 4. In an interview, E1 reported that R1’s Humalog medication was administered; however, acknowledged R1’s administration was not documented in R1’s medical record.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. 1. A review of the facility's documentation revealed that there was no disaster plan review available. 2. In an interview, E1 reported that E1 was unable to find documentation indicating a disaster plan review was conducted every 12 months.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95 °F and 120 °F in areas of the assisted living facility used by residents. The deficient practice posed a potential burn risk to residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a shared resident bathroom. Using a Department-issued thermometer, the Compliance Officer measured the hot water temperature and observed it to be 133.3 °F in the sink of the shared resident bathroom. 2. In an interview, E1 acknowledged the hot water temperature was not maintained between 95 °F and 120 °F.

Based on interview and record review, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of two residents sampled who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet the resident's needs. Findings include: 1. In an interview, E1 reported that R1 received personal care services and was non-ambulatory upon admission. 2. A review of R1's medical record revealed a service plan dated January 3rd, 2024 and May 1st, 2024. These service plans stated R1 was "confined to a chair". 3. Further review of R1's medical record revealed documentation dated May 5th, 2023 indicating R1 had been examined and was appropriate for the facility and R1's needs were within the facility's scope of services. However, evidence R1's primary care provider or other medical practitioner examined R1 at least once every six months from R1's date of admission was not provided for review. 4. In an interview, E1 acknowledged evidence R1's medical practitioner examined R1 at least once every six months was not available for review.

Based on record review, observation, 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. The deficient practice posed a risk if the resident had a change of condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan dated May 1, 2024 for personal care services that included medication administration. 2. A review of R2's medical record revealed a signed medication order dated March 27, 2024 for the following medications: -DuoNeb Nebulizer every 4 hours schedule for shortness of breath; -DuoNeb Nebulizer every 2 hours PRN for shortness of breath. 3. A review of R2's medical record revealed a document dated April 3, 2024 for the following medication: -DuoNeb 3 ML vial every 4 hours for shortness of breath However, the document was not signed by a medical practitioner. 4. A review of R2's May 2024 medication administration record (MAR) stated "Ipratropium SOL ALB Use 1 Nebulizer Every 4 HRS PRN." However, the MAR revealed R2 did not received Ipratropium (DuoNeb) as scheduled. 5. The Compliance Officers observed a medication bottle for "DuoNeb." The label stated, "Use 1 Vial Via Nebulizer Every 4 Hours Scheduled." 6. In an interview, E1 reported R2 only needed to use DuoNeb as needed. E1 acknowledge R2's medication was not administered in compliance with the available medication order.

Based on observation, documentation review, and interview, the manager failed to ensure a pest control program that complied with A.A.C. R3-8-20l(C)(4) was implemented and documented. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed the backyard. the backyard had a large tree where large quantities of bees and flies were enveloped. 2. Pest control documentation was not available. 3. During an interview, E1 reported that the bees and flies developed as the tree grew and during the winter months they went away. 4. During an interview, E1 reported they have "some guy" that comes out to spray the facility. However, when asked E1 for an invoice or documentation of pest control, E1 stated E1 never gets an invoice from the pest control company.