Mayfair Eden Homes INC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.C , for one of four personnel records sampled. The deficient practice posed a risk if the personnel were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411.C states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E1's personnel record revealed documentation showing that the owner had made a good faith effort to contact previous employers to obtain information or recommendations was available. 3. A review of E2's personnel record revealed documentation showing that the owner had made a good faith effort to contact previous employers to obtain information or recommendations was available. 4. A review of E1's personnel record revealed no documentation showing that the status of E1's fingerprint clearance card had been verified. 5. A review of E2's personnel record revealed no documentation showing that the status of E2's fingerprint clearance card had been verified. 6. A review of E3's personnel record revealed no documentation showing that the status of E3's fingerprint clearance card had been verified. 7. In an interview, E1, E2, and E3 acknowledged documentation of compliance with A.R.S. \'a7 36-411.C.1 for E1, E2, and E3 was not available for review.

Based on interview and documentation review, the manager failed to document the suspected abuse, neglect or exploitation and any action taken to immediately stop the suspected abuse, neglect or exploitation when the manager had a reasonable basis to believe abuse, neglect or exploitation had occurred on the premises or while a resident was receiving services from an assisted living facility. The deficient practice posed a risk as the facility failed to properly document the report of suspected neglect. Findings include: 1. In an interview, E2 reported that Adult Protective Services had been to the facility to investigate an allegation of neglect for R3 two days before the Department complaint investigation. 2. A review of facility incident report documentation revealed no documentation of the suspected neglect or actions taken to immediately stop the suspected neglect. 3. In an interview, E1, E2, and E3 acknowledged that the suspected neglect or actions taken to immediately stop the suspected neglect had not been documented.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of three caregivers reviewed. The deficient practice posed a risk if the caregiver was unable to meet a resident's needs. Findings include: 1. Review of E2's personnel record revealed E2 was hired as a caregiver. 2. Review of the October 2024 staff schedule revealed E2 worked the following dates 7am-7pm: -October 1-4; -October 14-18; -October 21-24. 3. Review of E2's personnel record revealed no documentation that E2's skills and knowledge were verified. 4. In an interview, E1, E2, and E3 acknowledged that the manager failed to ensure that caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of three caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E2's personnel record revealed E2 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of September ,2024. There was no other current documentation of first aid and CPR training in E2's record. 2. In an interview, E2 reported that E2 had taken a course to renew E2's CPR and first aid training, however, E2 was unable to provide documentation demonstrating this. E1, E2, and E3 acknowledged E2's first aid and CPR training had expired.

Based on record review and interview, the manager failed to ensure a personnel record for one of four personnel records sampled, included the individual's starting date of employment. Findings include: 1. A review of E2's personnel record revealed no starting date of employment. 2. In an interview, E1, E2, and E3 acknowledged the personnel record did not include the individual's starting dates of employment.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for three of three residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of the papers provided as R1's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 2. A review of the papers provided as R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 3. A review of the papers provided as R3's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 4. In an interview, E2 reported that it did not seem like R3 was appropriate for assisted living and that E2 thought R3 required a higher level of care. 5. In an interview, E1, E2, and E3 acknowledged documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints was not provided for R1, R2, and R3.

Based on record review and interview, the manager failed to ensure a resident had a written service plan included the level of service the resident was expected to receive, for one of three residents reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of the printed service plan provided for review for R1 revealed it did not contain the level of service R1 was expected to receive. No other service plans were provided. 2. In an interview, E2 reported that R1 received directed care services. E1, E2, and E3 acknowledged that R1's service plan did not identify R1's level of care.

Based on record review and interview, the manager failed to ensure a written service plan included the level of medication assistance provided to one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A review of the printed service plan provided for review for R1 revealed it did not include the level of medication services needed by R1. No other service plans were provided. 2. In an interview, E2 reported R1 received medication administration. E1, E2, and E3 acknowledged R1's service plan did not include the level of medication assistance provided.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for three of three residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's record revealed the most recent written service plan. However, this service plan did not include a signature and date from the resident or representative. 2. Review of R2's record revealed the most recent written service plan for personal care services. However, this service plan did not include a signature and date from the resident or representative. 3. Review of R3's record revealed the most recent written service plan for personal care services. However, this service plan did not include a signature and date from the resident or representative. 4. In an interview, E2 reported that only the manager has access to the signature pages, and that manager's designees were unable to provide the signature pages during the inspection. E1, E2, and E3 acknowledged R1's, R2's and R3's service plans did not include a signature and date from the resident or representative.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for three of three residents reviewed. The deficient practice posed a risk if the service plans were not developed to articulate decisions and agreements. Findings include: 1. Review of R1's record revealed the most recent written service plan. However, this service plan did not include a signature and date from the manager. 2. Review of R2's record revealed the most recent written service plan for personal care services. However, this service plan did not include a signature and date from the manager. 3. Review of R3's record revealed the most recent written service plan for personal care services. However, this service plan did not include a signature and date from the manager. 4. In an interview, E2 reported that only the manager has access to the signature pages, and that manager's designees were unable to provide the signature pages during the inspection. E1, E2, and E3 acknowledged R1's, R2's and R3's service plans did not include a signature and date from the manager.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of three residents reviewed. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. Review of R3's medical record revealed a current written service plan for personal care services dated September 24, 2024. This service plan stated the following service was needed: "Toileting-Full Assistance-Monitor & Check Every 4 hrs- Pull Up Briefs." However, documentation was not available indicating this service was provided. 2. Review of Department documentation revealed an intake that reported that the facility was not providing incontinence care. 3. In a phone interview, O1 reported that R3's pull-up briefs were not being changed when needed while R3 was in the facility. 4. In an interview, E2 reported that the service was provided, and acknowledged that documentation was not available showing that a caregiver provided a resident with the assisted living services in the resident's service plan.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents receiving medication administration reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan. This service plan did not include the level of medication services that R1 received, however, E2 reported that R1 received directed care services and medication administration. 2. Review of R1's October 2024 medication administration record (MAR) indicated the following: -Senna 8.6 mg tablet was administered twice a day October 1-October 24; -Aspirin 81mg tablet, delayed release was administered once a day October 1-October 24; -Metoprolol Tartrate 50mg tablet was administered at 6 am October 1-October 24; -Metoprolol Tartrate 50mg tablet was administered at 4 pm October 1st, 21st, and 22nd; -Lisinopril 40 mg tablet was administered once a day October 1-October 24. 3. The Compliance Officers requested to review medications orders for the medications administered to R1, however, the only medication order provided was for "Sarna 1 lotion Topical 4 times a day as Needed for itching." 4. In an interview, E2 reported the medications were administered per the MAR. E1, E2, and E3 acknowledged the medications were not administered in compliance with an available medication order.