Meadow Hills Assisted Living

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1. The Compliance Officer observed a posting in the dining room which designated caregivers to be accountable for the facility when the manager was not present. However, E2 was not designated. 2. In an interview, E1 acknowledged E2 is present in the facility at times when the manager is not present and had not designated to be accountable for the assisted living facility when the manager was not present.

Based on record review and interview, the manager failed to ensure the record for a resident who was receiving services from a hospice service agency contained documentation of the information provided by the agency. Findings include: 1. A review of R1's medical record revealed a service plan updated October 16, 2024. The service plan indicated R1 received hospice services. 2. A review of R1's medical record revealed information provided to the facility by a hospice service agency was not available for review. 3. In an interview, E1 acknowledged the resident's record lacked documentation of the information provided by a hospice agency, such as the plan of care and documentation of follow up orders provided by the hospice nurse.

Based on record review and interview, the manager failed to ensure, for one of one sampled resident receiving home health services, care instructions were documented in the resident's service plan. Findings include: 1. A review of R1's medical record revealed a service plan, dated October 16, 2024, for directed care services. The service plan stated R1 received hospice services. However, no hospice care instructions were included the service plan. 2. A review of R1's medical record revealed documentation of home health care instructions were not available for review. 3. During the on-site inspection, E1 contacted R1's home health agency and received care instructions from the hospice. The Compliance Officer was able to review these care instructions on E1's phone and noted care instructions had been provided and updated each month throughout R1's residency at the facility. 4. In an interview, E1 acknowledged R1's service plan did not include the care instructions provided to the facility by R1's home health agency.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, evidence of freedom from infections tuberculosis (TB), the individual's completed orientation and in-service education required by policies and procedures, and compliance with the requirements in A.R.S. \'a7 36-411(C); for two of two personnel records sampled. The deficient practice posed a risk if a staff member was not able to meet the needs of residents. Findings include: 1. A review of E1's personnel record revealed E1 was hired as a manager in June of 2022. However, E1's personnel record did not include the following documentation: - a current fingerprint clearance card. E1's personnel file included a fingerprint clearance card with an expiration date of January 29, 2025; - verification of the current status of E1's fingerprint clearance card; - continued competency training in fall prevention and fall recovery; and - annual training in recognizing the symptoms of tuberculosis. 2. A review of E2's personnel record revealed E2 was hired as a caregiver in May of 2023. However, E2's personnel record did not include the following documentation: - orientation; - a second-step Mantoux skin test or blood test for tuberculosis; - a caregiver certificate; - continued competency training in fall prevention and fall recovery; and - annual training in recognizing the symptoms of tuberculosis. 3. In an interview, E1 acknowledged the personnel records provided for E1 and E2 did not include all required documents.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled who received medication administration. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 2, 2024, for personal care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders, dated January 9, 2025, which included the following: - "Oxymetazoline HCL 0.05%, Spray 2 spray by intranasal route 2 times every day in each nostril in the morning and evening"; - "Aspirin EC, 325 MG, take 1 tablet by oral route every day"; and - "Cepacol sore throat 15 mg - 3.6 mg chew 1 lozenge by oral route every 6 hours for 10 days." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated January 2025. However the MAR did not include Oxymetazoline, Aspirin, or Cepacol. 4. In an interview, E1 reported the pharmacy is not filling the three aforementioned medications because they are available over the counter. E1 reported R2's responsible party has not provided the medications and the facility is not willing to pay for them per policy. E1 reporting having requested the primary care physician modify the order, however, as of the day of the inspection, E1 reported the medications were still ordered and not available. 5. In an interview, E1 acknowledged medications had not been administered to R2 as ordered. This is a repeat deficiency from the on-site compliance inspection conducted on October 19, 2023.

Based on observation, record review, 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 an environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen. Inside the refrigerator, the Compliance Officer observed two lockable containers used for storing resident medications. However, both containers had been left unlocked. Inside the containers, the Compliance Officer observed morphine, insulin, and diazepam. 2. In an interview, E1 acknowledged medications stored by the assisted living facility had not been stored in a separate locked area.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility evacuation drills revealed an evacuation drill conducted in September, 2024. However a second evacuation drill conducted in March 2024 was not provided for review. 2. In an interview, E1 acknowledged the facility's documentation of evacuation drills for employees and residents, conducted at least once every six months, had not been provided for review.

Based on documentation review and interview, the manager failed to ensure documentation of monthly smoke detector tests were maintained. Findings include: 1. During the on-site inspection, the Compliance Officer requested documentation of monthly smoke detector testing. However, documentation of monthly smoke detector testing was not available for review. 2. In an interview, E1 acknowledged documentation of monthly smoke detector tests had not been provided for review.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a the garage door had a keyed lock, however, the door had been left unlocked. Inside the garage, the Compliance Officer observed multiple household cleaning chemicals including the following: - "Multi Use CLR"; - "Ajax"; - "WD-40"; - "Mean Green Super Strength Degreaser"; and - "Great Value" toilet bowl cleaner. 2. In an interview, E1 acknowledged poisonous or toxic materials had not been maintained in a locked area and inaccessible to residents.

Based on record review, documentation review, observation, and interview, the manager failed to ensure for one of two personnel members sampled, before providing assisted living services to a resident, a caregiver provided current documentation of first aid training certification. Findings include: 1. A review of E3's personnel record revealed E3 was hired as a caregiver in April of 2020. 2. The Compliance Officer observed E3 was working in the facility as a caregiver during the on-site inspection. 3. A review of E3's personnel record revealed a current First Aid training certification was not available for review. E3's personnel record included documentation of First Aid and Cardiopulmonary Resuscitation (CPR) training dated February 28, 2021 with a marked expiration date of February 2023. E3's personnel record also included documentation of current CPR training, a "BLS - Basic Life Support," training. 4. In an interview, E3 reported E3 had taken a "combo" class which included both CPR and First Aid training, however, E3 reported E3 was only sent the "BLS" card via E-mail. 5. In an interview, E1 acknowledged E3's personnel file did not contain documentation of current first aid training certification. E1 reported being unaware the, "BLS" training did not include First Aid Training.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when updated, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan updated June 1, 2023. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 2. A review of R2's medical record revealed a service plan updated September 20, 2023. However, the service plan was not signed and dated by the resident or the resident's representative or the manager. 3. In an interview, E1 acknowledged the provided service plan updates for R1 and R2 had not been signed and dated by the resident or the resident's representative or the manager when updated.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication, and the Department was provided with false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan, updated June 1, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders, dated August 12, 2023, which included the following orders: - "Aspirin 81 mg oral delayed release tablet, 1 tab, Oral, Once every day for 90 days"; - "Atorvastatin 80 mg oral tablet, 1 tab, Oral, once every day"; - "Calcitriol 0.25 mcg oral capsule, 1 cap Oral every Monday/Wednesday/Friday for 90 days"; - "Dilitiazem 240 mg/ 24 hours oral capsule, 1 cap oral once every day, hold for SBP < 110"; and - "Sertraline 25 milligram Oral once every day." 3. A review of R1's medical record revealed a Medication Administration Records (MARs) dated October 2023. The MAR documented the following medication had been administered to R1 in October 2023: - "Aspirin 81 mg" was not included on the MAR; - "Atorvastatin 40 mg, 1 tab by mouth nightly," was on the MAR, however, it was for the incorrect dosage, and had been marked, "Out" on every day between October 1, 2023 and October 18, 2023; - "Calcitriol 0.25 mcg" was not included on the MAR; - "Dilitiazem 240 mg, 1 cap by mouth every Sun, Tue, Thursday," had been administered on October 1,3,5,8,10,12,17, and October 19, 2023. However, the frequency of administration was not daily as ordered, and R1's blood pressure had not been documented prior to each administered dose; - "Sertraline 25 mg, 1 tab oral daily, " was on the MAR, however, it was marked, "Out," between October 9, 2023 and October 19, 2023; - "Triaminolone Acetonide, apply QHD 5 days then off 2 days," had been marked administered on October 1-5, October 9-11, and October 15-19, however, this medication was not ordered; - "Lokelma, Take 10 grams Tuesday, Thursday, Saturday, and Sunday," had been marked administered on October 1, 3, 5, 7, 8, 19, 14, 15, 17, and October 19, 2023. However, this medication was not ordered and the MAR was false and misleading because the facility did not have a current supply of this medication to administer and had not administered this medication to R1; - "Loratadine 10 mg, 1 tab by mouth daily," had been administered to R1 on each day between October 1 and October 19, 2023, however, this medication was not ordered; - "Dilitiazem 120 mg, 1 cap by mouth every Monday, Wednesday, and Friday," had been administered to R1 on October 2,4,6,9,11,13,16,and October 18, 2023. However, this medication was not ordered; and - "Docusate 100mg, one tab by oral twice daily," had been administered one time per day betwee

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked on two shifts per day. 2. A review of facility disaster drills conducted during the previous twelve months revealed documentation of the following drills conducted during the previous twelve months: - No drills conducted between October 2022 and February 2023; - First shift drills were conducted on February 1, 2023 and July 1, 2023; - Second shift drills were conducted on February 1, 2023 and July 1, 2023; and - No drills conducted after July 1, 2023. 3. In an interview, E1 acknowledged documentation of disaster drills conducted on each shift at least once every three months for the previous twelve months had not been provided to the Compliance Officer upon request.