Mesa Elder Care INC

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a health and safety risk to residents if the facility did not maintain staffing schedules, with documentation of facility staffing coverage for residents, and an identification of the caregivers who provided services. Findings include: 1. When the Compliance Officer arrived, E2 and E5 were working at the facility. 2. In observation, the Compliance officer did not observe a current personnel schedule conspicuously posted. 3. Review of the personnel schedule provided by E2 was titled “Work Schedule 2/21/2025-3/01/2025”. No further documentation was provided for review. 4. During an interview, E2 acknowledged the facility did not maintain current documentation of the caregivers who worked each day, including the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R3's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Based on R3's date of acceptance, this documentation was required. 3. In an interview, E2 acknowledged R3’s medical record did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if R3 had signs or symptoms of TB. Technical assistance was provided on this rule during the inspection conducted on November 1, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), to one of one resident records reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states "The department shall: 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. In record review, R2's medical record did not include documentation of notification of the resident or representative of the availability of the vaccination for pneumonia. Based on R2's acceptance date, this documentation was required. 3. During an interview, E2 acknowledged R2’s medical record did not include current documentation showing the pneumonia vaccination was offered or received.

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9) for two of two sampled residents. The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of R2's and R3's medical records revealed a standardized form that failed to include a copy of the resident's health insurance portability and accountability act (HIPAA) release. 3. In an interview, E1 acknowledged the facility failed to maintain a standardized form for each resident that included the information required in A.R.S. 36-420.04.A.

Based on observation, documentation review, and interview, the manager failed ensure a personnel record for each employee or volunteer included the requirements in R9-10-806(C)(1) for one of five personnel sampled. The deficient practice posed a risk as required information could not be verified for O1. Findings include: 1. Upon arrival to the facility, the compliance officer observed O1 on-site preparing food in the kitchen. 2. A review of the facility's policies and procedures revealed a policy titled, "Staffing and Record Keeping." The policy stated, "1. The facility manager shall insure that a personnel record for each employee and volunteer: a. Includes: i. The individual's name, date of birth, and contact telephone number; ii. The starting date of employment or volunteer service and, if applicable, the ending date; and iii. Documentation of: -The individuals qualifications, including skills and knowledge applicable to the individual's job duties; -The individuals education and experience applicable to the individual's job duties; -The individual's completed orientation and in-service education required by policies and procedures; -If the individual is a behavioral health technician, clinical oversight required in R9-10-114; -Evidence of freedom from infectious tuberculosis, if infectious tuberculosis screening for the individual is required in this Article; -Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; -First aid training, if required for the individual in this Article or policies and procedures; -Documentation of compliance with the requirements in \'a7 36-41 l(A) and (C) [DPS fingerprinting clearance requirements]" 3. The Compliance Officer requested all personnel records. However, O1's personnel record was not made available for review. 4. In an interview, E1 reported O1 was a family member and "cook" and assisted E1 when needed. 5. In an interview, E1 acknowledged O1 did not have a personnel record available for review. E1 reported O1 arrived approximately a week ago and planned to stay until next month.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk as the (former) resident's health information was not protected. Findings include: 1. In a record review, the Compliance Officer observed, on the back side of E3's and E4's personnel record paperwork, medical record information that appeared to be from residents of the facility. The Compliance Officer observed names, dates of birth, medication orders, medical history, and hospice information of several residents. 2. In an interview, E1 reported the medical information belonged to former residents of the facility. 3. In an interview, E1 acknowledged the medical records were not protected from loss, damage, or unauthorized use. E1 reported E1 used the medical records in an effort to recycle and acknowledged the medical records of former residents should not be used in this manner.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the on-site compliance inspection, the Compliance Officer observed several personnel members going in and out of a door located in the common area. The Compliance Officer observed a key in the lock. The key was not removed during the course of the inspection. 2. During a tour of the facility, the Compliance Officer observed the residents' medications were stored in the room behind the aforementioned door. 3. In an interview, E1 acknowledged the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.