Mesa Serenity Assisted Living Home LLC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of four sampled employees. The deficient practice posed a risk if the individual was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411(A) states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E3's personnel record revealed a fingerprint clearance card with the expiration date of February 27, 2024. There was no other documentation to reflect E3's compliance with A.R.S. \'a7 36-411(A) at the time of the inspection. 3. A review of the Arizona Department of Public Safety website revealed E3's fingerprint clearance card expired on February 27, 2024. 4. In an interview, E2 acknowledged E3's fingerprint clearance card was expired, and there was no documentation to reflect E3 had a valid fingerprint clearance card at the time of the inspection.

Based on documentation review, record review, and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Recording and Documentation." Under the title, "Procedures," the policy stated, "8. Errors in documentation will be corrected as follows: a. Mistakes will be corrected by drawing a line through the error and writing the word "error" above it with the initials of the person making the correction above it. No individual is allowed to correct another person's documentation." 2. A review of R1's medical record revealed a service plan dated June 23, 2024. The service plan indicated R1 received medication administration. 3. A review of R1's medical record revealed a medication administration record (MAR) dated June 2024. The MAR indicated R1 received the medication administration of Percocet 5 milligrams (mg)-325 mg, one tablet every six hours as needed. 4. A review of R1's MAR revealed white correction fluid had been used on every entry from June 12, 2024-June 27, 2024 when documenting the time and initials of the person that administered the Percocet. The white correction fluid rendered the initial entry illegible. 5. In an interview, E1 acknowledged all entries from June 12, 2024-June 27, 2024 for Percocet 5 mg-325 mg contained white correction fluid that made the initial entry illegible.

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officers observed when entering the facility's front door, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officers observed an alert system was installed on the front door; however, it was not functioning at the time of the inspection. 3. During a tour of the facility, the Compliance Officers observed when exiting the facility to the back yard, no alarm sounded to alert employees of the egress of a resident from the facility. The surveyor observed an alert system was installed on the patio door; however, it was not functioning at the time of the inspection. 4. In an interview, E2 acknowledged when opening the front door and the back patio door, no alarm sounded to alert employees of the egress of a resident from the facility. 5. Technical assistance was provided regarding this rule during the on-site complaint inspection conducted on May 2, 2023.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk of a potential adverse reaction or outcome with an error in administering a residents medication. Findings include: 1. A review of R1's medical record revealed a service plan dated June 23, 2024. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication list signed by a medical practitioner, dated March 1, 2024. The medication list included one tablet of Percocet 5 milligrams (mg)-325 mg every 6 hours as needed. 3. A review of R1's medical record revealed a "Narcotic Record" that documented the medication administration of Percocet 5 mg-325 mg. The Narcotic Record contained documentation of the date, time of administration, the dosage, name of caregiver who administered the medication, and the number of tablets remaining in the bubble pack. The Narcotic Record indicated there were 16 Percocet tablets remaining. Upon closer review, it was found that due to a documentation error, there should be 15 Percocet tablets remaining according to the Narcotic Record. 4. A review of R1's bubble pack containing Percocet 5 mg-325 mg revealed there were 14 Percocet tablets remaining. 5. In an interview, the Compliance Officers asked for clarification regarding the discrepancy between the number of tablets available according to the Narcotic Record and the number of tablets that were actually available. E1 and E2 determined that R1 received one tablet of Percocet last night; however the medication administration did not get documented as required. 6. In an interview, E1 and E2 acknowledged the administration of Percocet 5 mg-325 mg did not get documented as required.

Based on observation and interview, the manager failed to ensure the facility had an outside activity space with an available shaded area. The deficient practice posed a risk to residents who wanted access to the outside. Findings include: 1. During a tour of the facility, the Compliance Officers observed the facility did not have a back covered patio. When walking out the back sliding glass door, there was a three foot sidewalk (approximately) that extended along the back side of the home. The Compliance Officers also observed approximately half of the sidewalk area was overgrown with weeds. The roof of the home extended approximately one foot past the home; however, the roof of the home did not extend far enough to provide any shade. The Compliance Officers also observed several folding chairs in the yard for resident seating. 2. The Compliance Officers observed a blue patio umbrella; however, the umbrella was closed and lying on the concrete sidewalk. 3. In an interview, E2 and E3 reported the facility had one resident that smoked outside daily. While on-site, the Compliance Officers observed ambulatory residents during the inspection going in and out of the back door. 4. In an interview, E2 acknowledged the outside space did not have an available shaded area. E2 reported the facility planned to secure the umbrella in the ground with concrete; however, that project had not been completed.